Michael Kohn is Clinical Professor of Emergency Medicine at Stanford and Professor Emeritus of Epidemiology and Biostatistics at UCSF. He was an attending emergency physician at Mills-Peninsula Medical Center in Burlingame until May of 2018. For the past 20 years, he has taught in UCSF’s Training in Clinical Research (TICR) Program, directing or co-directing courses on research methods, clinical epidemiology, and database management. He also co-directs (with Steven Goodman) Stanford’s Epi 219, “Evaluating Technologies for Diagnosis, Prediction, and Screening”. He provides consultations to clinical investigators who need help with study design, sample size calculations, data management, and statistical analysis. His primary research interest is testing for diagnosis and prediction. He co-authored (with Thomas Newman) the clinical epidemiology textbook “Evidence-Based Diagnosis,” is a contributing author to Hulley et al, “Designing Clinical Research,” and created the UCSF CTSI’s online sample size calculators (

Academic Appointments

All Publications

  • Assessing the Presence of Positive Pancreatic Autoantibodies in Patients with a Clinical Diagnosis of Type 2 Diabetes Mellitus in a Pediatric Diabetes Clinic Ferrell, J., Kohn, M. A., Srinivasan, S. KARGER. 2021: 44-45
  • Key concepts in clinical epidemiology: reporting on the accuracy of continuous tests. Journal of clinical epidemiology Kohn, M. A. 2021


    Many clinical diagnostic tests, such as the joint fluid white blood cell count, produce results on a continuous scale, rather than a mere positive or negative. The accuracy of such tests is often reported as a positive and negative likelihood ratio at each of several potential cutoff points (e.g., ≥ 25,000/muL vs. not, ≥ 50,000/muL vs not; ≥ 100,000/muL vs. not). This Key Concepts article reviews the definition of a likelihood ratio and explains why the practice of dichotomizing the test is problematic. Instead, it proposes that such continuous scales be divided into multiple intervals (e.g., 0-25,000, >25,000-50,000, >50,000-100,000, >100,000) and each interval be given its own likelihood ratio. This practice does not only align with clinical common sense and practice, but also enables a more accurate estimate of the updated risk of disease, given a pre-test risk.

    View details for DOI 10.1016/j.jclinepi.2021.07.012

    View details for PubMedID 34298090

  • Utilization of Point-of-care Echocardiography in Cardiac Arrest: A Cross-sectional Pilot Study WESTERN JOURNAL OF EMERGENCY MEDICINE Wolfe, Y., Duanmu, Y., Lobo, V., Kohn, M. A., Anderson, K. L. 2021; 22 (4): 803-809
  • Optimal gestational age and birth-weight cutoffs to predict neonatal morbidity. Medical decision making : an international journal of the Society for Medical Decision Making Kohn, M. A., Vosti, C. L., Lezotte, D. n., Jones, R. H. ; 20 (4): 369–76


    Gestational age (GA) and birth weight (BW) criteria are used to identify newborns at risk for neonatal morbidity. Currently, preterm is GA less than 37 weeks; low birth weight is BW less than 2,500 grams; and small for gestational age (SGA) is BW less than the tenth percentile weight for the infant's GA. The optimal classification system balances the misclassification cost of false negatives against the cost of false positives.To calculate the relative misclassification costs implied by the current 37-week and 2,500-gram cutoffs, and to test the validity of the current definition of SGA as a predictor of term morbidities.GA, BW, and morbidity information were collected for 22,606 infants born between July 1981 and December 1992. Using this dataset, logistic regression coefficients were obtained modeling GA or BW as predictors of morbidities associated with prematurity. For a subset of 18,813 infants with GAs between 37 and 41 weeks, coefficients were obtained modeling both GA and BW as independent predictors of term morbidities. The logistic regression coefficients were used to calculate optimal birth weight, gestational age, and birth-weight-for-gestational-age cutoffs.The current definitions of low birth weight and preterm imply that it is 18 to 28 times more costly to misclassify a sick infant as low-risk than to misclassify a well infant as high-risk.Gestational age alone is better than birth weight alone at predicting preterm morbidities. No birth-weight cutoff can adequately predict term morbidities. A single weight-percentile cutoff for all gestational ages should not be used to identify newborns at high risk for neonatal morbidity.

    View details for DOI 10.1177/0272989X0002000401

    View details for PubMedID 11059470

  • What white blood cell count should prompt antibiotic treatment in a febrile child? Tutorial on the importance of disease likelihood to the interpretation of diagnostic tests. Medical decision making : an international journal of the Society for Medical Decision Making Kohn, M. A., Newman, M. P. ; 21 (6): 479–89


    Most diagnostic tests are not dichotomous (negative or positive) but, rather, have a range of possible results (very negative to very positive). If the pretest probability of disease is high, the test result that prompts treatment should be any value that is even mildly positive. If the pretest probability of disease is low, the test result needed to justify treatment should be very positive. Simple decision rules that fix the cutpoint separating positive from negative test results do not take into account the individual patient's pretest probability of disease. Allowing the cutpoint to change with the pretest probability of disease increases the value of the test. This is primarily an issue when the pretest probability of disease varies widely between patients and depends on characteristics that are not measured by the test. It remains an issue for decision rules based on multiple test results if these rules fail to account for important determinants of patient-specific risk. This tutorial demonstrates how the value of a diagnostic test depends on the ability to vary the cutpoint, using as an example the white blood cell count in febrile children at risk for bacteremia.

    View details for DOI 10.1177/0272989X0102100606

    View details for PubMedID 11760105

  • SARS-CoV-2 IgG Seropositivity and Acute Asymptomatic Infection Rate Among Firefighter First Responders in an Early Outbreak County in California. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors Newberry, J. A., Gautreau, M., Staats, K., Carrillo, E., Mulkerin, W., Yang, S., Kohn, M. A., Matheson, L., Boyd, S. D., Pinsky, B. A., Blomkalns, A. L., Strehlow, M. C., D'Souza, P. A. 2021: 1–10


    Objective: Firefighter first responders and other emergency medical services (EMS) personnel have been among the highest risk healthcare workers for illness during the SARS-CoV-2 pandemic. We sought to determine the rate of seropositivity for SARS-CoV-2 IgG antibodies and of acute asymptomatic infection among firefighter first responders in a single county with early exposure in the pandemic.Methods: We conducted a cross-sectional study of clinically active firefighters cross-trained as paramedics or EMTs in the fire departments of Santa Clara County, California. Firefighters without current symptoms were tested between June and August 2020. Our primary outcomes were rates of SARS-CoV-2 IgG antibody seropositivity and SARS-CoV-2 RT-PCR swab positivity for acute infection. We report cumulative incidence, participant characteristics with frequencies and proportions, and proportion positive and associated relative risk (with 95% confidence intervals).Results: We enrolled 983 out of 1339 eligible participants (response rate: 73.4%). Twenty-five participants (2.54%, 95% CI 1.65-3.73) tested positive for IgG antibodies and 9 (0.92%, 95% CI 0.42-1.73) tested positive for SARS-CoV-2 by RT-PCR. Our cumulative incidence, inclusive of self-reported prior positive PCR tests, was 34 (3.46%, 95% CI 2.41-4.80).Conclusion: In a county with one of the earliest outbreaks in the United States, the seroprevalence among firefighter first responders was lower than that reported by other studies of frontline health care workers, while the cumulative incidence remained higher than that seen in the surrounding community.

    View details for DOI 10.1080/10903127.2021.1912227

    View details for PubMedID 33819128

  • Pupillary unrest, opioid intensity, and the impact of environmental stimulation on respiratory depression. Journal of clinical monitoring and computing McKay, R. E., Kohn, M. A., Larson, M. D. 2021


    Opioid-induced respiratory depression (OIRD) confers significant morbidity, but its onset can be challenging to recognize. Pain or stimulation effects of conversation may mask or attenuate common clinical manifestations of OIRD. We asked whether pupillary unrest could provide an objective signal of opioid exposure, and whether this signal would be independent from the confounding influence of extrinsic stimulation. We conducted a cross-over trial of healthy volunteers using identical remifentanil infusions separated by a washout period; in both, pupillary unrest in ambient light (PUAL) was measured at 2.5-min intervals. During one infusion, investigators continuously engaged the subject in conversation, while in the other, a quiet environment was maintained; measures of respiratory depression were compared under each condition. We tested PUAL's relationship to estimated opioid concentration under quiet conditions, measured PUAL's discrimination of lower versus higher opioid exposure using receiver operating characteristic (ROC) analysis, and assessed the effect of stimulation on PUAL versus opioid using mixed effects regression. Respiratory depression occurred more frequently under quiet conditions (p < 0.0001). Under both conditions, PUAL declined significantly over the course of the remifentanil infusion and rose during recovery (p < 0.0001). PUAL showed excellent discrimination in distinguishing higher versus absent-moderate opioid exposure (AUROC = 0.957 [0.929 to 0.985]), but was unaffected by interactive versus quiet conditions (mean difference, interactive - quiet = - 0.007, 95% CI - 0.016 to 0.002). PUAL is a consistent indicator of opioid effect, and distinguishes higher opioid concentrations independently of the stimulating effects of conversational interaction. Under equivalent opioid exposure, conversational interaction delayed the onset and minimized the severity of OIRD.Clinical trial registration: NCT04301895.

    View details for DOI 10.1007/s10877-021-00675-3

    View details for PubMedID 33651243

  • Prehospital Identification of Large Vessel Occlusions Using Modified National Institutes of Health Stroke Scale: A Pilot Study. Frontiers in neurology Mulkerin, W. D., Spokoyny, I., Francisco, J. T., Lima, B., Corry, M. D., Nudelman, M. J., Niknam, K., Brown, I. P., Kohn, M. A., Govindarajan, P. 2021; 12: 643356


    Stroke identification is a key step in acute ischemic stroke management. Our objectives were to prospectively examine the agreement between prehospital and hospital Modified National Institutes of Health Stroke Scale (mNIHSS) assessments as well as assess the prehospital performance characteristics of the mNIHSS for identification of large vessel occlusion strokes. Method: In this prospective cohort study conducted over a 20-month period (11/2016-6/2018), we trained 40 prehospital providers (paramedics) in Emergency Neurological Life Support (ENLS) curriculum and in mNIHSS. English-speaking patients aged 18 and above transported for an acute neurological deficit were included. Using unique identifiers, we linked the prehospital assessment records to the hospital record. We calculated the agreement between prehospital and hospital mNIHSS scores using the Bland-Altman analysis and the sensitivity and specificity of the prehospital mNIHSS. Results: Of the 31 patients, the mean difference (prehospital mNIHSS-hospital mNIHSS) was 2.4, 95% limits of agreement (-5.2 to 10.0); 10 patients (32%) met our a priori imaging definition of large vessel occlusion and the sensitivity of mNIHSS ≥ 8 was 6/10 or 0.60 (95% CI: 0.26-0.88) and the specificity was 13/21 or 0.62 (95% CI: 0.38-0.82), respectively. Conclusions: We were able to train prehospital providers to use the prehospital mNIHSS. Prehospital and hospital mNIHSS had a reasonable level of agreement and and the scale was able to predict large vessel occlusions with moderate sensitivity.

    View details for DOI 10.3389/fneur.2021.643356

    View details for PubMedID 34054691

  • Lack of association between either outpatient or inpatient glycemic control and COVID-19 illness severity or mortality in patients with diabetes. BMJ open diabetes research & care Mehta, P. B., Kohn, M. A., Koliwad, S. K., Rushakoff, R. J. 2021; 9 (1)


    INTRODUCTION: To evaluate whether outpatient insulin treatment, hemoglobin A1c (HbA1c), glucose on admission, or glycemic control during hospitalization is associated with SARS-CoV-2 (COVID-19) illness severity or mortality in hospitalized patients with diabetes mellitus (DM) in a geographical region with low COVID-19 prevalence.RESEARCH DESIGN AND METHODS: A single-center retrospective study of patients hospitalized with COVID-19 from January 1 through August 31, 2020 to evaluate whether outpatient insulin use, HbA1c, glucose on admission, or average glucose during admission was associated with intensive care unit (ICU) admission, mechanical ventilation (ventilator) requirement, or mortality.RESULTS: Among 111 patients with DM, 48 (43.2%) were on outpatient insulin and the average HbA1c was 8.1% (65 mmol/mol). The average glucose on admission was 187.0±102.94 mg/dL and the average glucose during hospitalization was 173.4±39.8 mg/dL. Use of outpatient insulin, level of HbA1c, glucose on admission, or average glucose during hospitalization was not associated with ICU admission, ventilator requirement, or mortality among patients with COVID-19 and DM.CONCLUSIONS: Our findings in a region with relatively low COVID-19 prevalence suggest that neither outpatient glycemic control, glucose on admission, or inpatient glycemic control is predictive of illness severity or mortality in patients with DM hospitalized with COVID-19.

    View details for DOI 10.1136/bmjdrc-2021-002203

    View details for PubMedID 34059527

  • Concurrent validity of the Warner Initial Developmental Evaluation of Adaptive and Functional Skills and the Bayley Scales of Infant and Toddler Development, Third Edition. Developmental medicine and child neurology Peyton, C. n., Msall, M. E., Wroblewski, K. n., Rogers, E. E., Kohn, M. n., Glass, H. C. 2021; 63 (3): 349–54


    To determine the concurrent validity of the Warner Initial Developmental Evaluation of Adaptive and Functional Skills (WIDEA-FS), a criterion-specified questionnaire that assesses a child's adaptive skills in everyday contexts, and the Bayley Infant and Toddler Scales of Development, Third Edition (Bayley-III).In a prospective cohort study, 431 WIDEA-FS and Bayley-III assessments were completed among 341 children, aged 10 to 36 months corrected age (158 females, 183 males; median [interquartile range] gestational age at birth 32wks [29-38]), monitored in a high-risk neonatal intensive care unit follow-up clinic.WIDEA-FS scores were significantly associated with Bayley-III scores in all domains. Lower scores on the WIDEA-FS were significantly associated with an increased risk of adverse developmental performance on all Bayley-III scales. The association was strongest for motor and language Bayley-III scores when tested at <30 months of age, and for cognitive Bayley-III scores when tested at ≥30 months of age.The WIDEA-FS has concurrent validity with the Bayley-III and may be a useful tool in high-risk follow-up settings.WIDEA-FS mobility, communication, and social cognition domains are concurrently valid in infants at high-risk for neurodevelopmental disability. Bayley-III motor, language, and cognitive composite scores are concurrently valid in the same group. The WIDEA-FS mobility and communication domains may be most clinically useful in children <30 months.

    View details for DOI 10.1111/dmcn.14737

    View details for PubMedID 33206384

    View details for PubMedCentralID PMC7878347

  • Effect of emergency critical care nurses and emergency department boarding time on in-hospital mortality in critically ill patients. The American journal of emergency medicine Nesbitt, J., Mitarai, T., Chan, G. K., Wilson, J. G., Niknam, K., Nudelman, M. J., Cinkowski, C., Kohn, M. A. 2020; 41: 120–24


    STUDY HYPOTHESIS: We hypothesized that establishing a program of specialized emergency critical care (ECC) nurses in the ED would improve mortality of ICU patients boarding in the ED.METHODS: This was a retrospective before-after cohort study using electronic health record data at an academic medical center. We compared in-hospital mortality between the pre- and post-intervention periods and between non-prolonged (≤6h) boarding time and prolonged (>6h) boarding time. In-hospital mortality was stratified by illness severity (eccSOFA category) and adjusted using logistic regression.RESULTS: Severity-adjusted in-hospital mortality decreased from 12.8% pre-intervention to 12.3% post-intervention (-0.5% (95% CI, -3.1% to 2.1%), which was not statistically significant. This was despite a concurrent increase in ED and hospital crowding. The proportion of ECC patients downgraded to a lower level of care while still in the ED increased from 6.4% in the pre-intervention period to 17.0% in the post-intervention period. (+10.6%, 8.2% to 13.0%, p<0.001). Severity-adjusted mortality was 12.8% in the non-prolonged group vs. 11.3% in the prolonged group (p=0.331).CONCLUSIONS: During the post-intervention period, there was a significant increase in illness severity, hospital congestion, ED boarding time, and downgrades in the ED, but no significant change in mortality. These findings suggest that ECC nurses may improve the safety of boarding ICU patients in the ED. Longer ED boarding times were not associated with higher mortality in either the pre- or post-intervention periods.

    View details for DOI 10.1016/j.ajem.2020.12.067

    View details for PubMedID 33421675

  • The Effect of Chest Compression Location and Occlusion of the Aorta in a Traumatic Arrest Model. The Journal of surgical research Anderson, K. L., Morgan, J. D., Castaneda, M. G., Boudreau, S. M., Arana, A. A., Kohn, M. A., Bebarta, V. S. 2020; 254: 64–74


    BACKGROUND: Recent evidence demonstrates that closed chest compressions directly over the left ventricle (LV) in a traumatic cardiac arrest (TCA) model improve hemodynamics and return of spontaneous circulation (ROSC) when compared with traditional compressions. Resuscitative endovascular balloon occlusion of the aorta (REBOA) also improves hemodynamics and controls hemorrhage in TCA. We hypothesized that chest compressions located over the LV would result in improved hemodynamics and ROSC in a swine model of TCA using REBOA.MATERIALS AND METHODS: Transthoracic echo was used to mark the location of the aortic root (traditional location) and the center of the LV on animals (n=26), which were randomized to receive chest compressions in one of the two locations. After hemorrhage, ventricular fibrillation was induced to simulate TCA. After a period of 10min of ventricular fibrillation, basic life support (BLS) with mechanical cardiopulmonary resuscitation was initiated and performed for 10min followed by advanced life support for an additional 10min. REBOA balloons were inflated at 6 min into BLS. Hemodynamic variables were averaged during the final 2min of the BLS and advanced life support periods. Survival was compared between this REBOA cohort and a control group without REBOA (no-REBOA cohort) (n=26).RESULTS: There was no significant difference in ROSC between the two REBOA groups (P=0.24). Survival was higher with REBOA group versus no-REBOA group (P=0.02).CONCLUSIONS: There was no difference in ROSC between LV and traditional compressions when REBOA was used in this swine model of TCA. REBOA conferred a survival benefit regardless of compression location.

    View details for DOI 10.1016/j.jss.2020.03.026

    View details for PubMedID 32417498

  • Impact of Scribes with Flow Coordination Duties on Throughput in an Academic Emergency Department. The western journal of emergency medicine Thomas, K., Marcum, J., Wagner, A., Kohn, M. A. 2020; 21 (3): 653–59


    INTRODUCTION: With the increasing influence of electronic health records in emergency medicine came concerns of decreasing operational efficiencies. Particularly worrisome was increasing patient length of stay (LOS). Medical scribes were identified to be in a good position to quickly address barriers to treatment delivery and patient flow. The objective of this study was to investigate patient LOS in the mid- and low-acuity zones of an academic emergency department (ED) with and without medical scribes.METHODS: A retrospective cohort study compared patient volume and average LOS between a cohort without scribes and a cohort after the implementation of a scribe-flow coordinator program. Patients were triaged to the mid-acuity Vertical Zone (primarily Emergency Severity Index [ESI] 3) or low-acuity Fast Track (primarily ESI 4 and 5) at a tertiary academic ED. Patients were stratified by treatment zone, acuity level, and disposition.RESULTS: The pre-intervention and post-intervention periods included 8900 patients and 9935 patients, respectively. LOS for patients discharged from the Vertical Zone decreased by 12 minutes from 235 to 223 minutes (p<0.0001, 95% confidence interval [CI], -17,-7) despite a 10% increase in patient volume. For patients admitted from the Vertical Zone, volume increased 13% and LOS remained almost the same, increasing from 225 to 228 minutes (p=0.532, 95% CI, -6,12). For patients discharged from the Fast Track, volume increased 14% and LOS increased six minutes, from 89 to 95 minutes (p<0.0001, 95% CI, 4,9). Predictably, only 1% of Fast Track patients were admitted.CONCLUSION: Despite substantially increased volume, the use of scribes as patient flow facilitators in the mid-acuity zone was associated with decreased LOS. In the low-acuity zone, scribes were not shown to be as effective, perhaps because rapid patient turnover required them to focus on documentation.

    View details for DOI 10.5811/westjem.2020.2.46110

    View details for PubMedID 32421515

  • eccSOFA: SOFA illness severity score adapted to predict in-hospital mortality in emergency critical care patients. The American journal of emergency medicine Niknam, K. n., Nesbitt, J. n., Mitarai, T. n., Nudelman, M. J., Gordon, A. J., Wilson, J. G., Kohn, M. A. 2020; 41: 145–51


    Boarding of ICU patients in the ED is increasing. Illness severity scores may help emergency physicians stratify risk to guide earlier transfer to the ICU and assess pre-ICU interventions by adjusting for baseline mortality risk. Most existing illness severity scores are based on data that is not available at the time of the hospital admission decision or cannot be extracted from the electronic health record (EHR). We adapted the SOFA score to create a new illness severity score (eccSOFA) that can be calculated at the time of ICU admission order entry in the ED using EHR data. We evaluated this score in a cohort of emergency critical care (ECC) patients at a single academic center over a period of 3 years.This was a retrospective cohort study using EHR data to assess predictive accuracy of eccSOFA for estimating in-hospital mortality risk. The patient population included all adult patients who had a critical care admission order entered while in the ED of an academic medical center between 10/24/2013 and 9/30/2016. eccSOFA's discriminatory ability for in-hospital mortality was assessed using ROC curves.Of the 3912 patients whose in-hospital mortality risk was estimated, 2260 (57.8%) were in the low-risk group (scores 0-3), 1203 (30.8%) in the intermediate-risk group (scores 4-7), and 449 (11.5%) in the high-risk group (scores 8+). In-hospital mortality for the low-, intermediate, and high-risk groups was 4.2% (95%CI: 3.4-5.1), 15.5% (95% CI 13.5-17.6), and 37.9% (95% CI 33.4-42.3) respectively. The AUROC was 0.78 (95%CI: 0.75-0.80) for the integer score and 0.75 (95% CI: 0.72-0.77) for the categorical eccSOFA.As a predictor of in-hospital mortality, eccSOFA can be calculated based on variables that are commonly available at the time of critical care admission order entry in the ED and has discriminatory ability that is comparable to other commonly used illness severity scores. Future studies should assess the calibration of our absolute risk predictions.

    View details for DOI 10.1016/j.ajem.2020.12.018

    View details for PubMedID 33453549

  • Defining high-risk emergency chief complaints: data-driven triage for low- and middle-income countries. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Rice, B. n., Leanza, J. n., Mowafi, H. n., Thadeus Kamara, N. n., Mulogo, E. M., Bisanzo, M. n., Nikam, K. n., Kizza, H. n., Newberry, J. A., Strehlow, M. n., Kohn, M. n. 2020


    Emergency medicine in low- and middle-income countries (LMICs) is hindered by lack of research into patient outcomes. Chief complaints are fundamental to emergency care but have only recently been uniquely codified for an LMIC setting in Uganda. It is not known whether chief complaints independently predict emergency unit patient outcomes.Patient data collected in a Ugandan emergency unit between 2009-2018 were randomized into validation and derivation datasets. A recursive partitioning algorithm stratified chief complaints by three-day mortality risk in each group. The process was repeated in 10,000 bootstrap samples to create an averaged risk ranking. Based on this ranking, chief complaints were categorized as "high-risk" (>2x baseline mortality), "medium-risk" (between 2 and 0.5x baseline mortality) and "low-risk" (<0.5x baseline mortality). Risk categories were then included in a logistic regression model to determine if chief complaints independently predicted three-day mortality.Overall, the derivation dataset included 21,953 individuals with 7,313 in the validation dataset. In total, 43 complaints were categorized, and 12 chief complaints were identified as high-risk. When controlled for triage data including age, sex, HIV status, vital signs, level of consciousness, and number of complaints, high-risk chief complaints significantly increased three-day mortality odds (OR 2.39, 95% CI 1.95 - 2.93, p<0.001) while low-risk chief complaints significantly decreased three-day mortality odds (OR 0.16, 95% CI 0.09 - 0.29, p<0.001).High-risk chief complaints were identified and found to predict increased three-day mortality independent of vital signs and other data available at triage. This list can be used to expand local triage systems and inform emergency training programs. The methodology can be reproduced in other LMIC settings to reflect their local disease patterns.

    View details for DOI 10.1111/acem.14013

    View details for PubMedID 32416022

  • Risk Factors for Peri-intubation Cardiac Arrest in a Pediatric Emergency Department. Pediatric emergency care Pokrajac, N. n., Sbiroli, E. n., Hollenbach, K. A., Kohn, M. A., Contreras, E. n., Murray, M. n. 2020


    Cardiac arrest is a significant complication of emergent endotracheal intubation (ETI) within the pediatric population. No studies have evaluated risk factors for peri-intubation cardiac arrest (PICA) in a pediatric emergency department (ED) setting. This study identified risk factors for PICA among patients undergoing emergent ETI in a pediatric ED.We performed a nested case-control study within the cohort of children who underwent emergent ETI in our pediatric ED during a 9-year period. Cases were children with PICA within 20 minutes of ETI. Controls (4 per case) were randomly selected children without PICA after ETI. We analyzed potential risk factors based on published data and physiologic plausibility and created a simple risk model using univariate results, model fit statistics, and clinical judgment.In the cohort of patients undergoing ETI, PICA occurred in 21 of 543 subjects (3.9%; 95% confidence interval [CI], 2.2-5.9%), with return of spontaneous circulation in 16 of 21 (76.2%; 95% CI, 52.8-91.8%) and survival to discharge in 12 of 21 (57.1%; 95% CI, 34.0-78.2%). On univariate analysis, cases were more likely to be younger, have delayed capillary refill time, systolic or diastolic hypotension, hypoxia, greater than one intubation attempt, no sedative or paralytic used, and pulmonary disease compared with controls. Our 4-category risk model for PICA combined preintubation hypoxia (or an unobtainable pulse oximetry value) and younger than 1 year. The area under the receiver operating characteristic curve for this model was 0.87 (95% CI, 0.77-0.97).Hypoxia (or an unobtainable pulse oximetry value) was the strongest predictor for PICA among children after emergent ETI in our sample. A simple risk model combining pre-ETI hypoxia and younger than 1 year showed excellent discrimination in this sample. Our results require independent validation.

    View details for DOI 10.1097/PEC.0000000000002171

    View details for PubMedID 32576791

  • Diagnostic Accuracy of Point-of-Care Ultrasound for Intussusception in Children Presenting to the Emergency Department: A Systematic Review and Meta-analysis. The western journal of emergency medicine Lin-Martore, M. n., Kornblith, A. E., Kohn, M. A., Gottlieb, M. n. 2020; 21 (4): 1008–16


    Ileocolic intussusception is a common cause of pediatric bowel obstruction in young children but can be difficult to diagnose clinically due to vague abdominal complaints. If left untreated, it may cause significant morbidity. Point-of-care ultrasound (POCUS) is a rapid, bedside method of assessment that may potentially aid in the diagnosis of intussusception. The purpose of this systematic review and meta-analysis was to determine the diagnostic accuracy of POCUS for children with suspected ileocolic intussusception by emergency physicians (EP).We conducted a systematic search on PubMed, Embase, CINAHL, LILACS, the Cochrane databases, Google Scholar, as well as conference abstracts, and assessed bibliographies of selected articles for all studies evaluating the accuracy of POCUS for the diagnosis of intussusception in children. We dual extracted data into a predefined worksheet and performed quality analysis with the QUADAS-2 tool. Data were summarized and a meta-analysis was performed.Six studies (n = 1303 children) met our inclusion criteria. Overall, 11.9% of children had intussusception. POCUS was 94.9% (95% confidence interval [CI], 89.9% to 97.5%) sensitive and 99.1% (95% CI, 94.7% to 99.8%) specific with a likelihood ratio (LR)+ of 105 (95% CI, 18 to 625) and a LR- of 0.05 (95% CI, 0.03 to 0.10).POCUS by EPs is highly sensitive and specific for the identification of intussusception for children presenting to the emergency department.

    View details for DOI 10.5811/westjem.2020.4.46241

    View details for PubMedID 32726276

    View details for PubMedCentralID PMC7390574

  • Identification of Generalized Convulsive Status Epilepticus from Emergency Medical Service Records: A Validation Study of Diagnostic Coding. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors Hart, L. n., Sanford, J. K., Sporer, K. A., Kohn, M. A., Guterman, E. L. 2020: 1–8


    Generalized convulsive status epilepticus (GCSE) is a neurologic emergency demanding prehospital identification and treatment. Evaluating real-world practice requires accurately identifying the target population; however, it is unclear whether emergency medical services (EMS) documentation accurately identifies patients with GCSE.To evaluate the validity of EMS diagnostic impressions for GCSE.This was an analysis of electronic medical records of a California county EMS system from 2013 to 2018. We identified all cases with a primary diagnostic impression of "seizure-active," "seizure-post," or "seizure-not otherwise specified (NOS)" and within each diagnostic category, we randomly selected 75 adult and 25 pediatric records. Two authors reviewed the provider narrative of these 300 charts to determine a clinical seizure diagnosis according to prespecified definitions. We calculated a kappa for interrater reliability of the clinical diagnosis. We then calculated the positive predictive value (PPV), sensitivity, and specificity of an EMS diagnosis of "seizure-active" diagnosis for identifying GCSE. Sensitivity and specificity calculations were weighted according to the distribution of seizure cases in the overall population. We performed a descriptive analysis of records with an incorrect EMS diagnosis of GCSE or seizure.Of 38,995 total records for seizure, there were 3401 (8.7%) seizure-active cases, 12,478 (32.0%) seizure-NOS cases, and 23,116 (59.4%) seizure-post cases. An EMS diagnosis of "seizure-active" had a PPV of 65.0% (95% CI 54.8-74.3), sensitivity of 54.6% (95% confidence interval [CI] 39.3-69.0), and specificity of 96.6% (95% CI 95.1-97.6) for capturing GCSE. Limiting the case definition to patients who received an EMS diagnosis of "seizure-active" and were treated with a benzodiazepine increased the PPV (80.2%; 95% CI 69.9-88.2) and specificity (99.3%; 95% CI 98.7-99.6) while the sensitivity decreased (25.1%; 95% CI 17.0-35.3). Across the 300 records reviewed, there were 19 (6.3%) patients who had a non-seizure related diagnosis including non-epileptic spells (7 records), altered mental status (8 records), tremors (2 records), anxiety (1 record), and stroke (1 record).EMS diagnostic impressions have reasonable PPV and specificity but low sensitivity for GCSE. Improved coding algorithms and training will allow for improved benchmarking, quality improvement, and research about this neurologic emergency.

    View details for DOI 10.1080/10903127.2020.1817214

    View details for PubMedID 32870726

    View details for PubMedCentralID PMC8032820

  • Evaluation of two portable pupillometers to assess clinical utility. Concussion (London, England) McKay, R. E., Kohn, M. A., Schwartz, E. S., Larson, M. D. 2020; 5 (4): CNC82


    Pupillometers have been proposed as clinical assessment tools. We compared two pupillometers to assess measurement agreement.We enrolled 30 subjects and simultaneously measured the pupil diameter and light reflex amplitude with an iPhone pupillometer and a portable infrared pupillometer. We then enrolled 40 additional subjects and made serial measurements with each device.Failure occurred in 30% of attempts made with the iPhone pupillometer compared with 4% of attempts made with the infrared pupillometer (Fisher's exact p = 0.0001). Method comparison of the two devices used simultaneously showed significant disagreement in dynamic measurements.The iPhone pupillometer had poor repeatability and suggests that it is not a practical tool to support clinical decisions.

    View details for DOI 10.2217/cnc-2020-0016

    View details for PubMedID 33204494

    View details for PubMedCentralID PMC7653507

  • Practice Variation in the Diagnosis of Aneurysmal Subarachnoid Hemorrhage: A Survey of US and Canadian Emergency Medicine Physicians NEUROCRITICAL CARE Kumar, A., Niknam, K., Lumba-Brown, A., Woodruff, M., Bledsoe, J. R., Kohn, M. A., Perry, J. J., Goyindarajan, P. 2019; 31 (2): 321–28
  • Patient safety and quality outcomes for ED patients admitted to alternative care area inpatient beds. The American journal of emergency medicine Lee, M. O., Arthofer, R., Callagy, P., Kohn, M. A., Niknam, K., Camargo, C. A., Shen, S. 2019


    BACKGROUND: Inpatient hallway beds are one solution to mitigate emergency department (ED) crowding due to boarding of admitted patients. Alternative Care Areas (AltCA) beds are located in inpatient hallways, cardiac catheterization lab, and endoscopy. We examined whether AltCA beds were associated with increased risk of patient safety and quality outcomes: transfer to Intensive Care Unit (ICU), mortality, hospital-acquired infections (HAI), falls, and 72-hour hospital readmission.METHODS: Retrospective cohort study of patients age >18 years admitted from the ED to non-ICU beds at an urban, academic hospital. AltCA bed exclusion criteria: dementia, frequent respiratory interventions, contact or airborne isolation, psychiatric admission, and inability to ambulate. The study periods were: pre-intervention 9/1/2014-3/31/2015, transition 9/1/2015-3/31/2016, and post-intervention 9/1/2016-3/31/2017. Data analysis used unadjusted and multivariable analyses which controlled for age, sex, race, ethnicity, insurance, ED triage Emergency Service Index (ESI) level, and telemetry order.RESULTS: The study included 16,801 patients, with 622 (3.7%) patients in AltCA beds. AltCA beds had younger patients than standard inpatient beds, 57.7 years and 61.7 years; fewer telemetry order, 48.4% and 59.3%; and fewer ESI level 2, 16.1% and 26.2%. AltCA beds had shorter hospital LOS than standard inpatient beds, 2.7 days and 3.4 days. AltCA beds had decreased risk of transfer to ICU -10.6 (95%CI: -18.3, -2.8) and HAI -13.4 (95%CI: -20.3, -6.5) compared to standard inpatient beds.CONCLUSION: Patients in AltCA beds did not have increased risk of patient safety and quality outcomes but rather decreased risk of transfer to ICU and HAI than standard inpatient beds.

    View details for PubMedID 31085010

  • Practice Variation in the Diagnosis of Aneurysmal Subarachnoid Hemorrhage: A Survey of US and Canadian Emergency Medicine Physicians. Neurocritical care Kumar, A., Niknam, K., Lumba-Brown, A., Woodruff, M., Bledsoe, J. R., Kohn, M. A., Perry, J. J., Govindarajan, P. 2019


    BACKGROUND AND AIMS: Spontaneous subarachnoid hemorrhage (SAH) from a brain aneurysm, if untreated in the acute phase, leads to loss of functional independence in about 30% of patients and death in 27-44%. To evaluate for SAH, the American College of Emergency Physicians (ACEP) Clinical Policy recommends obtaining a non-contrast brain computed tomography (CT) scan followed by a lumbar puncture (LP) if the CT is negative. On the other hand, current evidence from prospectively collected data suggests that CT alone may be sufficient to rule out SAH in patients who present within 6h of symptom onset while anecdotal evidence suggests that CT angiogram (CTA) may be used to detect aneurysms, which are the probable cause of SAH. Since many different options are available to emergency physicians, we examinedtheirpractice pattern variation by observing their diagnostic approaches andtheir adherence to the ACEP Clinical Policy.METHODS: We developed, validated, and distributed a survey to emergency physicians at three practice sites: (1) Stanford Healthcare, California, (2) Intermountain Healthcare (five emergency departments), Utah, and (3) Ottawa General Hospital, Toronto. The survey questions examined physician knowledge on CT and LP's test performance and used case-based scenarios to assess diagnostic approaches, variation in practice, and adherence to guidelines. Results were presented as proportions with 95% CIs.RESULTS: Of the 216 physicians surveyed, we received 168 responses (77.8%). The responses by site were: (1) (n=38, 23.2%), (2) (n=70, 42.7%), (3) (n=56, 34.1%). To the CT and LP test performance question, most physicians indicated that CT alone detects>90% of SAH in those with a confirmed SAH [n=150 (89.3%, 95% CI 83.6-93.5]. To the case-based questions, most physicians indicated that they would perform a CTA along with a CT [n=110 (65.5%, 95% CI 57.8-72.6)], some indicated a LP along with a CT [n=57, 33.9% 95% CI 26.8-41.6)], and a few indicated both a CTA and a LP [n=16, 9.5%, 95% CI 5.5-15.0]. We also observed practice site variation in the proportion of physicians who indicated that they would use CTA: (1) (n=25, 65.8%), (2) (n=54, 77.1%), and (3) (n=28, 50.0%) (p=0.006).CONCLUSIONS: Survey responses indicate that physicians use some or all of the imaging tests, with or without LP to diagnose SAH. We observed variation in the use of CTA by site and academic setting and divergence from ACEP Clinical Policy.

    View details for PubMedID 30790225

  • A Review of Predictive Low Glucose Suspend and Its Effectiveness in Preventing Nocturnal Hypoglycemia. Diabetes technology & therapeutics Chen, E. n., King, F. n., Kohn, M. A., Spanakis, E. K., Breton, M. n., Klonoff, D. C. 2019; 21 (10): 602–9


    To evaluate the effectiveness of predictive low glucose suspend (PLGS) systems within sensor-augmented insulin infusion pumps at preventing nocturnal hypoglycemia in patients with type 1 diabetes (DM1), we performed a systematic review and meta-analysis of randomized crossover trials. Pubmed and Google Scholar were searched for randomized crossover trials, published between January 2013 and July 2018, in nonpregnant outpatients with DM1, which compared event rates during PLGS overnight periods and non-PLGS overnight periods. The primary outcome was the proportion of overnight periods with one or more hypoglycemic measurement. When available, individual patient data were used to assess the effect of clustering measurements within patients. Four studies (272 patients, 10,735 patient-nights: 5422 PLGS and 5313 non-PLGS) were included in the meta-analysis. Two studies reported patient-level data that permitted assessment of the effect of clustering measurements within patients. The effect on the risk difference was minimal. The proportion of overnight periods with one or more episodes of hypoglycemia was 19.6% for the PLGS periods and 27.8% for the non-PLGS periods. Based on the pooled estimate, PLGS overnight periods were associated with an 8.8% lower risk of hypoglycemia (risk difference -0.088; 95% CI -0.119 to -0.056, I2 = 67.4%, τ2 = 0.0006, 4 studies). PLGS systems can reduce nocturnal hypoglycemic events in patients with DM1.

    View details for DOI 10.1089/dia.2019.0119

    View details for PubMedID 31335193

  • ED Chest Pain Rules: Follow Your HEART? Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Kohn, M. A., Worster, A. n. 2019; 26 (2): 261–62

    View details for DOI 10.1111/acem.13647

    View details for PubMedID 30375128

  • Validating laboratory defined chronic kidney disease in the electronic health record for patients in primary care. BMC nephrology Frigaard, M. n., Rubinsky, A. n., Lowell, L. n., Malkina, A. n., Karliner, L. n., Kohn, M. n., Peralta, C. A. 2019; 20 (1): 3


    Electronic health record (EHR) data is increasingly used to identify patients with chronic kidney disease (CKD). EHR queries used to capture CKD status, identify comorbid conditions, measure awareness by providers, and track adherence to guideline-concordant processes of care have not been validated.We extracted EHR data for primary-care patients with two eGFRcreat 15-59 mL/min/1.73 m^2 at least 90 days apart. Two nephrologists manually reviewed a random sample of 50 charts to determine CKD status, associated comorbidities, and physician awareness of CKD. We also assessed the documentation of a CKD diagnosis with guideline-driven care.Complete data were available on 1767 patients with query-defined CKD of whom 822 (47%) had a CKD diagnosis in their chart. Manual chart review confirmed the CKD diagnosis in 34 or 50 (68%) patients. Agreement between the reviewers and the EHR diagnoses on the presence of comorbidities was good (κ > 0.70, p < 0.05), except for congestive heart failure, (κ = 0.45, p < 0.05). Reviewers felt the providers were aware of CKD in 23 of 34 (68%) of the confirmed CKD cases. A CKD diagnosis was associated with higher odds of guideline-driven care including CKD-specific laboratory tests and prescriptions for statins. After adjustment, CKD diagnosis documentation was not significantly associated with ACE/ARB prescription.Identifying CKD status by historical eGFRs overestimates disease prevalence. A CKD diagnosis in the patient chart was a reasonable surrogate for provider awareness of disease status, but CKD awareness remains relatively low. CKD in the patient chart was associated with higher rates of albuminuria testing and use of statins, but not use of ACE/ARB.

    View details for DOI 10.1186/s12882-018-1156-2

    View details for PubMedID 30606109

    View details for PubMedCentralID PMC6318865

  • Randomized controlled trial to evaluate locally sourced two-component compression bandages for HIV-associated Kaposi sarcoma leg lymphedema in western Kenya: The Kenyan Improvised Compression for Kaposi Sarcoma (KICKS) study protocol. Contemporary clinical trials communications Chang, A. Y., Karwa, R. n., Busakhala, N. n., Fletcher, S. L., Tonui, E. C., Wasike, P. n., Kohn, M. A., Asirwa, F. C., Kiprono, S. K., Maurer, T. n., Goodrich, S. n., Pastakia, S. D. 2018; 12: 116–22


    HIV-associated Kaposi sarcoma (KS), among the most frequent cancers seen in sub-Saharan Africa, is associated with a high prevalence of lymphedema. Lymphedema causes progressive functional impairment marked by swelling, physical discomfort, disfiguring changes, skin hardening from fibrosis, poor wound healing, and recurrent skin infection. While compression therapy is considered a major component of lymphedema management, this intervention has never been evaluated in HIV-associated KS lymphedema.The Kenyan Improvised Compression for Kaposi Sarcoma (KICKS) study is a randomized, controlled trial. Due to variable lymphedema stage, we will use block randomization with a 1:1 allocation to assign participants to one of two groups: "Immediate compression" or "Delayed compression." Those randomized to "Immediate compression" intervention arm will receive weekly two-component compression bandages while receiving chemotherapy, whereas those in the "Delayed compression" control arm will be followed during chemotherapy and then receive compression after chemotherapy is completed. The primary outcome is change in Lower Extremity Lymphedema Index from enrollment at Week 0 to blinded outcome assessment at Week 14 between intervention and control arms. Secondary outcomes are change in leg lymphedema-specific quality of life (LYMQOL) and change in overall health quality of life in cancer (EORTC QLQ C30).This represents the first study in sub-Saharan Africa to assess a lymphedema-directed intervention for KS, and the intervention-locally sourced two-component compression bandages-is affordable and available. Thus, the KICKS study is an important step towards developing an evidence-based path for regionally relevant management of HIV-associated KS lymphedema.This trial was registered at on January 19, 2018: identifier NCT03404297.

    View details for DOI 10.1016/j.conctc.2018.10.003

    View details for PubMedID 30402565

    View details for PubMedCentralID PMC6205322

  • Hospitalizations for Autoimmune Hepatitis Disproportionately Affect Black and Latino Americans. The American journal of gastroenterology Wen, J. W., Kohn, M. A., Wong, R. n., Somsouk, M. n., Khalili, M. n., Maher, J. n., Tana, M. M. 2018; 113 (2): 243–53


    The healthcare burden of autoimmune hepatitis (AIH) in the United States has not been characterized. We previously showed that AIH disproportionately affects people of color in a single hospital system. The current study aimed to determine whether the same disparity occurs nationwide.We analyzed hospitalizations with a primary discharge diagnosis corresponding to the ICD-9 code for AIH in the National Inpatient Sample between 2008 and 2012. For each racial/ethnic group, we calculated the AIH hospitalization rate per 100,000 population and per 100,000 all-cause hospitalizations, then calculated a risk ratio compared to the reference rate among whites. We used multivariable logistic regression models to assess for racial disparities and to identify predictors of in-hospital mortality during AIH hospitalizations.The national rate of AIH hospitalization was 0.73 hospitalizations per 100,000 population. Blacks and Latinos were hospitalized for AIH at a rate 69% (P<0.001) and 20% higher (P<0.001) than whites, respectively. After controlling for age, gender, payer, residence, zip code income, region, and cirrhosis, black race was a statistically significant predictor for mortality during AIH hospitalizations (odds ratio (OR) 2.81, 95% confidence interval (CI) 1.43, 5.47).Hospitalizations for AIH disproportionately affect black and Latino Americans. Black race is independently associated with higher odds of death during hospitalizations for AIH. This racial disparity may be related to biological, genetic, environmental, socioeconomic, and healthcare access and quality factors.

    View details for DOI 10.1038/ajg.2017.456

    View details for PubMedID 29380822

    View details for PubMedCentralID PMC6522224

  • Effect of park prescriptions with and without group visits to parks on stress reduction in low-income parents: SHINE randomized trial. PloS one Razani, N. n., Morshed, S. n., Kohn, M. A., Wells, N. M., Thompson, D. n., Alqassari, M. n., Agodi, A. n., Rutherford, G. W. 2018; 13 (2): e0192921


    Exposure to nature may reduce stress in low-income parents. This prospective randomized trial compares the effect of a physician's counseling about nature with or without facilitated group outings on stress and other outcomes among low-income parents.Parents of patients aged 4-18 years at a clinic serving low-income families were randomized to a supported park prescription versus independent park prescription in a 2:1 ratio. Parents in both groups received physician counseling about nature, maps of local parks, a journal, and pedometer. The supported group received additional phone and text reminders to attend three weekly family nature outings with free transportation, food, and programming. Outcomes measured in parents at baseline, one month and three months post-enrollment included: stress (using the 40-point Perceived Stress Scale [PSS10]); park visits per week (self-report and journaling); loneliness (modified UCLA-Loneliness Scale); physical activity (self-report, journaling, pedometry); physiologic stress (salivary cortisol); and nature affinity (validated scale).We enrolled 78 parents, 50 in the supported and 28 in the independent group. One-month follow-up was available for 60 (77%) participants and three-month follow up for 65 (83%). Overall stress decreased by 1.71 points (95% CI, -3.15, -0.26). The improvement in stress did not differ significantly by group assignment, although the independent group had more park visits per week (mean difference 1.75; 95% CI [0.46, 3.04], p = 0.0085). In multivariable analysis, each unit increase in park visits per week was associated with a significant and incremental decrease in stress (change in PSS10-0.53; 95% CI [-0.89, -0.16]; p = 0.005) at three months.While we were unable to demonstrate the additional benefit of group park visits, we observed an overall decrease in parental stress both overall and as a function of numbers of park visits per week. Paradoxically the park prescription without group park visits led to a greater increase in weekly park visits than the group visits. To understand the benefits of this intervention, larger trials are NCT02623855.

    View details for DOI 10.1371/journal.pone.0192921

    View details for PubMedID 29447248

    View details for PubMedCentralID PMC5814008

  • Investigation of the Accuracy of 18 Marketed Blood Glucose Monitors. Diabetes care Klonoff, D. C., Parkes, J. L., Kovatchev, B. P., Kerr, D. n., Bevier, W. C., Brazg, R. L., Christiansen, M. n., Bailey, T. S., Nichols, J. H., Kohn, M. A. 2018; 41 (8): 1681–88


    Cleared blood glucose monitors (BGMs) for personal use may not always deliver levels of accuracy currently specified by international and U.S. regulatory bodies. This study's objective was to assess the accuracy of 18 such systems cleared by the U.S. Food and Drug Administration representing approximately 90% of commercially available systems used from 2013 to 2015.A total of 1,035 subjects were recruited to have a capillary blood glucose (BG) level measured on six different systems and a reference capillary sample prepared for plasma testing at a reference laboratory. Products were obtained from consumer outlets and tested in three triple-blinded studies. Each of the three participating clinical sites tested a different set of six systems for each of the three studies in a round-robin. In each study, on average, a BGM was tested on 115 subjects. A compliant BG result was defined as within 15% of a reference plasma value (for BG ≥100 mg/dL [5.55 mmol/L]) or within 15 mg/dL (0.83 mmol/L) (for BG <100 mg/dL [5.55 mmol/L]). The proportion of compliant readings in each study was compared against a predetermined accuracy standard similar to, but more lenient than, current regulatory standards. Other metrics of accuracy included the overall compliance proportion; the proportion of extreme outlier readings differing from the reference value by >20%; modified Bland-Altman analysis including average bias, coefficient of variation, and 95% limits of agreement; and proportion of readings with no clinical risk as determined by the Surveillance Error Grid.The different accuracy metrics produced almost identical BGM rankings. Six of the 18 systems met the predetermined accuracy standard in all three studies, 5 systems met it in two studies, and 3 met it in one study. Four BGMs did not meet the accuracy standard in any of the three studies.Cleared BGMs do not always meet the level of analytical accuracy currently required for regulatory clearance. This information could assist patients, professionals, and payers in choosing products and regulators in evaluating postclearance performance.

    View details for DOI 10.2337/dc17-1960

    View details for PubMedID 29898901

  • The Epidemiology of Vestibular Migraine: A Population-based Survey Study. Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology Formeister, E. J., Rizk, H. G., Kohn, M. A., Sharon, J. D. 2018; 39 (8): 1037–44


    1. Describe the epidemiology of vestibular migraine (VM) in the United States, using data from the 2008 National Health Interview Survey (NHIS). 2. Characterize the sociodemographic and clinical attributes of people with VM.Population-based nationwide survey study of US adults.Adult respondents to the 2008 NHIS.The responses of participants in the 2008 NHIS balance and dizziness supplement (n = 21,781) were analyzed using statistical software. A case definition for VM was generated based on consensus criteria for diagnosis, and this was applied to the dataset to ascertain the prevalence, demographic, and clinical characteristics of VM.The 1-year prevalence of a dizziness or balance problem in the United States was 11.9% (2,490 respondents). Of respondents with dizziness, 584 (23.4%) met our case definition of VM, which represents a prevalence of VM in 2.7% of adults. There was a female preponderance (64.1%) and a slightly younger mean age (40.9 yr) for those with VM as compared with all respondents (51.7% females and 46.0 yr, respectively). Multivariate analysis showed that age less than 40, female sex, anxiety, depression, and prior head trauma were all associated with significantly increased odds of experiencing VM. Only 10% of subjects meeting criteria for VM were told that migraine was the cause of their dizziness.Using a representative database, we found a much higher prevalence of VM in the United States than previously reported. Results from this study indicate likely under-diagnosis of VM.

    View details for DOI 10.1097/MAO.0000000000001900

    View details for PubMedID 30020261

  • Association Between a Virtual Glucose Management Service and Glycemic Control in Hospitalized Adult Patients: An Observational Study. Annals of internal medicine Rushakoff, R. J., Sullivan, M. M., MacMaster, H. W., Shah, A. D., Rajkomar, A. n., Glidden, D. V., Kohn, M. A. 2017; 166 (9): 621–27


    Inpatient hyperglycemia is common and is linked to adverse patient outcomes. New methods to improve glycemic control are needed.To determine whether a virtual glucose management service (vGMS) is associated with improved inpatient glycemic control.Cross-sectional analyses of three 12-month periods (pre-vGMS, transition, and vGMS) between 1 June 2012 and 31 May 2015.3 University of California, San Francisco, hospitals.All nonobstetric adult inpatients who underwent point-of-care glucose testing.Hospitalized adult patients with 2 or more glucose values of 12.5 mmol/L or greater (≥225 mg/dL) (hyperglycemic) and/or a glucose level less than 3.9 mmol/L (<70 mg/dL) (hypoglycemic) in the previous 24 hours were identified using a daily glucose report. Based on review of the insulin/glucose chart in the electronic medical record, recommendations for insulin changes were entered in a vGMS note, which could be seen by all clinicians.Proportion of patient-days classified as hyperglycemic, hypoglycemic, and at-goal (all measurements ≥3.9 and ≤10 mmol/L [≥70 and ≤180 mg/dL] during the pre-vGMS, transition, and vGMS periods).The proportion of hyperglycemic patients decreased by 39%, from 6.6 per 100 patient-days in the pre-vGMS period to 4.0 per 100 patient-days in the vGMS period (difference, -2.5 [95% CI, -2.7 to -2.4]). The hypoglycemic proportion in the vGMS period was 36% lower than in the pre-vGMS period (difference, -0.28 [CI, -0.35 to -0.22]). Forty severe hypoglycemic events (<2.2 mmol/L [<40 mg/dL]) occurred during the pre-vGMS period compared with 15 during the vGMS period.Information was not collected on patients' concurrent illnesses and treatment or physicians' responses to the vGMS notes.Implementation of the vGMS was associated with decreases in hyperglycemia and hypoglycemia.National Institutes of Health, the Wilsey Family Foundation, and the UCSF Clinical & Translational Science Institute.

    View details for DOI 10.7326/M16-1413

    View details for PubMedID 28346946

  • D-dimer Interval Likelihood Ratios for Pulmonary Embolism. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Kohn, M. A., Klok, F. A., van Es, N. n. 2017; 24 (7): 832–37


    The objective was to estimate D-dimer interval likelihood ratios (iLRs) for diagnosing pulmonary embolism (PE).The authors used pooled patient-level data from five PE diagnostic management studies to estimate iLRs for the eight D-dimer intervals with boundaries 250, 500, 750, 1,000, 1,500, 2,500, and 5,000 ng/mL. Logistic regression was used to fit the data so that an interval increase corresponds to increasing the likelihood ratio by a constant factor.The iLR for the D-dimer interval 1,000-1,499 ng/mL was essentially 1.0 (0.98 with 95% confidence interval [CI] = 0.82-1.18). In the logistic regression model, the constant between-interval factor was 2.0 (95% CI = 1.9-2.1). Using these iLR estimates, if the pre-D-dimer probability of PE is 15%, only a D-dimer less than 500 ng/mL will result in a posttest probability below 3%; if the pretest probability is 5%, the threshold for a "negative" D-dimer is 1,000 ng/mL.A decision strategy based on these approximate iLRs agrees with several published strategies.

    View details for DOI 10.1111/acem.13191

    View details for PubMedID 28370759

  • In suspected PE, 2% of patients with a Wells score > 4 and negative CT pulmonary angiography had VTE at 3 months. Annals of internal medicine Kohn, M. A. 2017; 167 (10): JC59

    View details for DOI 10.7326/ACPJC-2017-167-10-059

    View details for PubMedID 29159385

  • Changes in Motor Unit Number Estimate and Forced Vital Capacity as Predictors of ALS Progression Olney, N., Kohn, M., Lomen-Hoerth, C., Olney, R. LIPPINCOTT WILLIAMS & WILKINS. 2016
  • Design and evaluation of a park prescription program for stress reduction and health promotion in low-income families: The Stay Healthy in Nature Everyday (SHINE) study protocol. Contemporary clinical trials Razani, N. n., Kohn, M. A., Wells, N. M., Thompson, D. n., Hamilton Flores, H. n., Rutherford, G. W. 2016; 51: 8–14


    Contact with nature improves human health; stress reduction is a mediating pathway. Stay Healthy in Nature Everyday (SHINE) is a stress reduction and health promotion intervention for low-income families at an urban Federally Qualified Health Center. We plan to evaluate two service-delivery models for SHINE and present here the intervention design and evaluation protocol.Behavioral change theory and environmental education literature informed the intervention. Outcomes were selected after review of the literature and field tested procedures to determine what was feasible and ethical in a busy clinic serving vulnerable populations.We designed a randomized controlled trial to examine two levels of intensity in behavioral counseling about the health benefits of nature. Dyads consisting of a caregiver and a child aged 4 to 18 who access our pediatric primary care center are eligible. All dyads receive a pediatrician's recommendation to visit parks to experience nature and written resources (a "park prescription"). The intervention group receives added case management and an invitation to three group outings into nature with transportation, meals and activities provided. Primary outcomes measured at baseline, one month and three months post-enrollment are caregiver stress measured by PSS-10 score and salivary α-amylase; secondary outcomes are park prescriptions adherence, physical activity recorded by pedometer and journaling, loneliness, family cohesion and affinity to nature as measured by a validated scales. Both groups receive incentives to participation.Our intervention represents a feasible integration of recent research findings on the health benefits of nature and primary care practice.

    View details for DOI 10.1016/j.cct.2016.09.007

    View details for PubMedID 27693759

  • Broadcasting Not Properly: Using B-type Natriuretic Peptide Interval Likelihood Ratios and the Results of Other Emergency Department Tests to Diagnose Acute Heart Failure in Dyspneic Patients. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Kohn, M. A., Steinhart, B. n. 2016; 23 (3): 347–50

    View details for DOI 10.1111/acem.12918

    View details for PubMedID 26836437

  • Early Cumulative Supplemental Oxygen Predicts Bronchopulmonary Dysplasia in High Risk Extremely Low Gestational Age Newborns. The Journal of pediatrics Wai, K. C., Kohn, M. A., Ballard, R. A., Truog, W. E., Black, D. M., Asselin, J. M., Ballard, P. L., Rogers, E. E., Keller, R. L. 2016; 177: 97–102.e2


    To assess the prognostic accuracy of early cumulative supplemental oxygen (CSO) exposure for prediction of bronchopulmonary dysplasia (BPD) or death, and to evaluate the independent association of CSO with BPD or death.We performed a secondary analysis of the Trial of Late Surfactant, which enrolled 511 infants born at ≤28 weeks gestational age who were mechanically ventilated at 7-14 days of life. Our primary outcome was BPD or death at 36 weeks postmenstrual age, as determined by a physiological oxygen/flow challenge. Average daily supplemental oxygen (fraction of inspired oxygen - 0.21) was calculated. CSO was calculated as the sum of the average daily supplemental oxygen over time periods of interest up to 28 days of age. Area under the receiver operating curve (AUROC) values were generated to evaluate the accuracy of CSO for prediction of BPD or death. The independent relationship between CSO and BPD or death was assessed in multivariate modeling, while adjusting for mean airway pressure.In the study infants, mean gestational age at birth was 25.2 ± 1.2 weeks and mean birth weight was 700 ± 165 g. The AUROC value for CSO at 14 days was significantly better than that at earlier time points for outcome prediction (OR, 0.70; 95% CI, 0.65-0.74); it did not increase with the addition of later data. In multivariate modeling, a CSO increase of 1 at 14 days increased the odds of BPD or death (OR, 1.7; 95% CI, 1.3-2.2; P < .0001), which corresponds to a 7% higher daily supplemental oxygen value.In high-risk extremely low gestational age newborns, the predictive accuracy of CSO plateaus at 14 days. CSO is independently associated with BPD or death. This index may identify infants who could benefit from early intervention to prevent BPD.

    View details for DOI 10.1016/j.jpeds.2016.06.079

    View details for PubMedID 27470692

    View details for PubMedCentralID PMC5037007

  • 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


    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

  • Outpatient Versus Hospitalization Management for Uncomplicated Diverticulitis. Annals of surgery Kohn, M. A. 2015; 262 (2): e86

    View details for DOI 10.1097/SLA.0000000000000633

    View details for PubMedID 24646551

  • 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


    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

  • HINTS to identify stroke in ED patients with dizziness. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Kohn, M. A. 2014; 21 (3): 347

    View details for DOI 10.1111/acem.12339

    View details for PubMedID 24524556

  • Understanding evidence-based diagnosis. Diagnosis (Berlin, Germany) Kohn, M. A. 2014; 1 (1): 39–42


    The real meaning of the word "diagnosis" is naming the disease that is causing a patient's illness. The cognitive process of assigning this name is a mysterious combination of pattern recognition and the hypothetico-deductive approach that is only remotely related to the mathematical process of using test results to update the probability of a disease. What I refer to as "evidence-based diagnosis" is really evidence-based use of medical tests to guide treatment decisions. Understanding how to use test results to update the probability of disease can help us interpret test results more rationally. Also, evidence-based diagnosis reminds us to consider the costs and risks of testing and the dangers of over-diagnosis and over-treatment, in addition to the costs and risks of missing serious disease.

    View details for DOI 10.1515/dx-2013-0003

    View details for PubMedID 29539978

  • Understanding the direction of bias in studies of diagnostic test accuracy. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Kohn, M. A., Carpenter, C. R., Newman, T. B. 2013; 20 (11): 1194–1206


    Ordering and interpreting diagnostic tests is a critical part of emergency medicine (EM). In evaluating a study of diagnostic test accuracy, emergency physicians (EPs) need to recognize whether the study uses case-control or cross-sectional sampling and account for common biases. The authors group biases in studies of test accuracy into five categories: incorporation bias, partial verification bias, differential verification bias, imperfect gold standard bias, and spectrum bias. Other named biases are either equivalent to these biases or subtypes within these broader categories. The authors go beyond identifying a bias and predict the direction of its effect on sensitivity and specificity, providing numerical examples from published test accuracy studies. Understanding the direction of a bias may permit useful inferences from even a flawed study of test accuracy.

    View details for DOI 10.1111/acem.12255

    View details for PubMedID 24238322

  • Determination of bone age in pediatric patients with Crohn's disease should become part of routine care. Inflammatory bowel diseases Gupta, N. n., Lustig, R. H., Kohn, M. A., Vittinghoff, E. n. 2013; 19 (1): 61–65


    Impaired growth and delayed puberty are common in pediatric Crohn's disease (CD). Bone age (BA) is important for interpretation of statural growth. Our aims were to 1) determine the distribution of BA-Z scores; 2) identify clinical factors associated with BA-Z scores; and 3) compare anthropometric Z scores based on chronological age (CA) (CA-Z) versus BA-Z in pediatric CD.CD patients ≤ CA 15 in females and 17 years in males were enrolled in a cross-sectional study. BA was determined with left hand/ wrist x-ray. In all, 49 patients (65% male; 84% Caucasian; mean CA 13 years) examined between January 2007 and July 2009 qualified for the study.Mean BA-Z score was -1.40 ± 1.50 (standard deviation). 41% had BA-Z score < -2.0. Mean BA-Z scores were lower in females (P = 0.02), Caucasians (P = 0.006), Tanner stage 1-3 children (P = 0.004), and patients with colonic disease (P = 0.0006), past corticosteroid exposure (P = 0.01), current azathioprine/6-mercaptopurine treatment (P = 0.003), or lower height (P = 0.006), weight (P < 0.001), or body mass index (BMI) (P = 0.01) CA-Z scores. Mean height, weight, and BMI BA-Z scores were 0.73 units (P < 0.0001), 0.51 units (P < 0.0001), and 0.23 units (P < 0.0001) greater than mean height, weight, and BMI CA-Z scores.Low BA occurs frequently in CD. Determination of BA should become the standard of care in pediatric CD patients, allowing clinically meaningful interpretation of growth in the context of skeletal maturation, leading to improved treatment recommendations, as growth is a dynamic marker of disease status. Prospective longitudinal studies are required to clarify determinants of BA and patterns of BA advancement in CD.

    View details for DOI 10.1002/ibd.22979

    View details for PubMedID 22552908

  • Rotational malreduction of the syndesmosis: reliability and accuracy of computed tomography measurement methods. Foot & ankle international Knops, S. P., Kohn, M. A., Hansen, E. N., Matityahu, A. n., Marmor, M. n. 2013; 34 (10): 1403–10


    Computed tomography (CT)-based indices may be superior to plain radiographs in determining the adequacy of reduction following operative fixation of the syndesmosis in unstable ankle fractures. This study assessed the reliability and accuracy of four CT-based methods for measurement of rotational malreduction of the fibula.A simulated Weber C ankle fracture was created by performing an osteotomy in 9 cadaver ankles. The fibula was rotated and fixed in neutral (0 degrees) and 10 to 30 degrees of internal and external rotation. Fifty-two CT images at the level of the syndesmosis were obtained in neutral and rotated positions and presented in random order to 3 independent observers. Measurements were made using commercial imaging software and 4 methods for interpreting CT scans. Interobserver reliability and accuracy were assessed and compared.Methods 1 and 4 showed high anatomic variability. Methods 1, 2, and 4 had a test-retest repeatability of about 15 degrees. Method 1 varied erratically with direction and degree of malrotation (R (2) = 0.15) and did not permit specification of a neutral range. Method 2 varied consistently and systematically with direction and degree of malrotation (R (2) = 0.88). Receiver operating characteristic curve analysis indicated that method 2 identified malrotation better than did the other methods. Methods 3 and 4 were somewhat more difficult to perform.Method 2, the angle between the tangent of the anterior tibial surface and the bisection of the vertical midline of the fibula at the level of the incisura, was fairly reliable and accurate and had greater ease of measurement compared with the other methods that were tested.This study demonstrated that assessment of malrotation of fibular fractures by CT scan can be difficult. We believe that of the 4 methods tested in this study, method 2, the angle between the tangent of the anterior tibial surface and the bisection of the vertical midline of the fibula at the level of the incisura, was the most useful.

    View details for DOI 10.1177/1071100713489286

    View details for PubMedID 23667049

  • Menarche in pediatric patients with Crohn's disease. Digestive diseases and sciences Gupta, N. n., Lustig, R. H., Kohn, M. A., Vittinghoff, E. n. 2012; 57 (11): 2975–81


    The timing of menarche in Crohn's disease (CD) is poorly described. Our objectives were to study age at menarche onset in CD, and factors associated with this.We compared the age at menarche of 34 CD patients with that for 545 controls, using data in the National Health and Nutrition Examination Survey (NHANES).Mean chronological age (CA) of CD patients (15.6 years) did not differ from that of the NHANES cohort (15.7 years; P = 0.91). The median CA at menarche (13.9 years) in CD was older than in the NHANES sample (12.0 years) (P < 0.00005). In CD patients, the cumulative incidence of menarche was 10 % at CA 12 years, 51 % at CA 14 years, and 100 % at CA 16 years. Sixty-eight percent reached menarche by bone age (BA) 13.5 years and 100 % by BA greater than 14.0 years. Menarche occurred earliest in South Asians, followed by East Asians, and then Caucasians (P = 0.02).CA at menarche is delayed in CD compared with the NHANES cohort. BA at menarche in CD is similar to BA at menarche reported for healthy children. CA at menarche in CD differs by race. If menarche has not occurred by BA greater than 14.0 years, endocrinology referral should be considered.

    View details for DOI 10.1007/s10620-012-2235-z

    View details for PubMedID 22744430

  • Reduced lung-cancer mortality with CT screening. The New England journal of medicine Kohn, M. A. 2011; 365 (21): 2036–37; author reply 2037–38

    View details for DOI 10.1056/NEJMc1110293

    View details for PubMedID 22111731

  • Heightened pain perception in illicit substance-using patients in the ED: implications for management. The American journal of emergency medicine Neighbor, M. L., Dance, T. R., Hawk, M. n., Kohn, M. A. 2011; 29 (1): 50–56


    Substance users are commonly perceived to overstate their pain. Few data exist comparing pain intensity, perception, and related psychiatric comorbidities in the emergency department (ED) population.To compare pain severity, duration, interference with function, and psychiatric and mood disturbance in substance-using (SU) and non-substance-using (NSU) patients in the ED.This is a cross-sectional study. The setting is in an urban ED. Participants are SU and NSU patients in moderate to severe pain (numerical rating scale, 5-10). Outcome measures are as follows: pain intensity and duration, other painful conditions, pain-related functional interference (0-10), psychiatric disorders, and mood distress (profile of mood scale, 0-44).Of the 148 patients who enrolled, 28 (19%) reported recent illicit substance use (SU) and 120 (81%) did not (NSU). The SU patients' mean pain intensity was 8.96 (confidence interval [CI], 7.47-8.14) vs 7.81 (CI, 8.48-9.45) for NSU (P = .003). The SU patients reported higher levels of pain interference. Fifty-four percent of SU patients vs 31% of NSU patients reported a psychiatric illness (P = .02). Mean Profile of Mood State score was higher in SU (32.3; CI, 27.4-37.1) than in NSU (22.5; CI, 20.2-24.8; P < .001). Chronic pain was reported by 29% of SU patients vs 16% of NSU patients, and 75% of SU patients vs 58% of NSU patients reported another concurrent painful condition (P = .10).The SU patients report more severe pain and functional interference, more psychiatric illness and mood distress, and more chronically painful conditions. Given the complex interplay between pain, substance use, and mood disorders, increased attention should be paid to identifying patients with these associated conditions and to facilitating appropriate referrals. Effective treatment of this challenging patient population requires treating the entirety of their medical, psychiatric, and addictive diseases.

    View details for DOI 10.1016/j.ajem.2009.07.018

    View details for PubMedID 20825774

  • Sex differences in statural growth impairment in Crohn's disease: role of IGF-1. Inflammatory bowel diseases Gupta, N. n., Lustig, R. H., Kohn, M. A., McCracken, M. n., Vittinghoff, E. n. 2011; 17 (11): 2318–25


    Growth impairment in Crohn's disease (CD) is more common in males than females for unknown reasons. Since insulin-like growth factor-1 (IGF-1) is important for statural growth, we hypothesized that IGF-1 levels are lower in males with CD.Sex differences in hormone Z-scores based on chronological age (CA-Z) and bone age (BA-Z) were examined in a cross-sectional study of 82 CD patients <21 years of age (43% female).IGF-1 CA-Z and BA-Z-scores were 0.50 units (P = 0.04) and 1.24 units (P = 0.003) lower in males. Mean bone age (12.2 years) was lower than chronological age (13.1 years) (P < 0.0001). Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and albumin did not differ by sex (P ≥ 0.08), but were associated with IGF-1 CA-Z and BA-Z-scores (P ≤ 0.02). Insulin-like growth factor binding protein-3 (IGFBP-3) CA-Z and BA-Z-scores were 0.71 units (P = 0.004) and 1.26 units (P < 0.001) lower in males. Inflammatory markers were correlated with sex hormone CA-Z and BA-Z and pituitary hormone BA-Z-scores in males (P ≤ 0.03), but not females (P ≥ 0.25). IGF-1 BA-Z-scores were positively associated with height BA-Z-scores (P = 0.03). Mean height BA-Z-scores were lower in males (P = 0.03).Lower IGF-1 levels in males may explain sex differences in growth impairment in CD. Inflammation appears to more adversely affect hormone levels and statural growth in males. Prospective longitudinal studies are needed to further clarify the role of IGF-1 in sex differences in statural growth impairment in pediatric CD.

    View details for DOI 10.1002/ibd.21617

    View details for PubMedID 21287667

    View details for PubMedCentralID PMC3136638

  • Emergency physician ultrasonography for evaluating patients at risk for ectopic pregnancy: a meta-analysis. Annals of emergency medicine Stein, J. C., Wang, R. n., Adler, N. n., Boscardin, J. n., Jacoby, V. L., Won, G. n., Goldstein, R. n., Kohn, M. A. 2010; 56 (6): 674–83


    Ectopic pregnancy is a common concern in emergency departments (EDs) and remains the leading cause of first-trimester mortality. Pelvic ultrasonography by emergency physicians has been investigated as a diagnostic test for ectopic pregnancy. We present a meta-analysis of the use of emergency physician ultrasonography in the evaluation of patients at risk of ectopic pregnancy.A structured search was performed of both MEDLINE and EMBASE. Inclusion criteria were that (1) the study reported original research on ED patients at risk for ectopic pregnancy; (2) an emergency physician performed and interpreted the initial pelvic ultrasonography; and (3) follow-up was conducted on all patients. Sensitivity was defined as the proportion of patients with ectopic pregnancy for which ED ultrasonography demonstrated no intrauterine pregnancy. A random-effects model was used to obtain summary test characteristics.The initial search showed 576 publications, abstract review yielded 60 with potential relevance, and 10 studies were included. There was a total of 2,057 patients, of whom 152 (7.5%) had ectopic pregnancy. The pooled sensitivity estimate was 99.3% (95% confidence interval [CI] 96.6% to 100%), negative predictive value was 99.96% (95% CI 99.6% to 100%), and negative likelihood ratio was 0.08 (95% CI 0.025 to 0.25), all without significant heterogeneity.The results of this meta-analysis suggest that in a wide variety of clinical settings, the use of bedside ultrasonography performed by emergency physicians as a diagnostic test for ectopic pregnancy provides excellent sensitivity and negative predictive value. Visualization of an intrauterine pregnancy by an emergency physician is generally sufficient to rule out ectopic pregnancy.

    View details for DOI 10.1016/j.annemergmed.2010.06.563

    View details for PubMedID 20828874

  • Increasing discussions of intimate partner violence in prenatal care using Video Doctor plus Provider Cueing: a randomized, controlled trial. Women's health issues : official publication of the Jacobs Institute of Women's Health Humphreys, J. n., Tsoh, J. Y., Kohn, M. A., Gerbert, B. n. 2010; 21 (2): 136–44


    To report the effectiveness of a prenatal intervention and to provide evidence that prenatal visits provide an opportune time for health assessment and counseling with abused women.Fifty ethnically diverse pregnant women who presented for routine prenatal care and who also reported being at risk for intimate partner violence (IPV) were recruited to the study. Participants were assigned to either usual care or the Video Doctor plus Provider Cueing intervention. At baseline and 1 month later at another routine prenatal visit, intervention group participants received a 15-minute Video Doctor assessment and interactive tailored counseling. Their providers received a printed Cue Sheet alert and suggested counseling statements.Participants in the intervention group were significantly more likely to report provider-patient discussions of IPV compared with participants receiving usual care at baseline (81.8% vs. 16.7%; p < .001) and at the 1-month follow-up (70.0% vs. 23.5%; p = .005). Summing the number of patient-provider discussions across the two visits at baseline and 1 month later, intervention participants were significantly more likely to have IPV risk discussion with their providers at one or both visits (90.0% vs. 23.6%; p < .001) compared with the participants who received usual care. When specifically asked about the helpfulness of these IPV-related discussions, 20 out of 22 (90.9%) participants rated the discussion as helpful or very helpful at baseline and all 18 (100%) participants rated the discussion as helpful or very helpful at the 1-month follow-up.Video Doctor plus Provider Cueing intervention significantly increases the likelihood of provider-patient IPV discussion with pregnant women with a history of abuse.

    View details for DOI 10.1016/j.whi.2010.09.006

    View details for PubMedID 21185737

    View details for PubMedCentralID PMC3053017

  • Promoting smoking cessation in pregnancy with Video Doctor plus provider cueing: a randomized trial. Acta obstetricia et gynecologica Scandinavica Tsoh, J. Y., Kohn, M. A., Gerbert, B. n. 2010; 89 (4): 515–23


    This study examined the use of a Video Doctor plus provider cueing to promote provider advice and smoking cessation outcomes in pregnancy.A randomized clinical trial was conducted from 2006 to 2008.Five community prenatal clinics in the San Francisco Bay Area of the United States.A total of 410 pregnant patients completed screening for behavioral risks including tobacco use in the past 30 days. Pregnant smokers (n = 42) were randomized regardless of their intention to quit smoking.Participants were assigned to either usual care or intervention. Intervention participants received 15-minute Video Doctor sessions plus provider cueing, at baseline and one month, prior to their routine prenatal visit. The Video Doctor delivered interactive tailored messages, an educational worksheet for participants, and a cueing sheet for providers.Receipt of advice from the provider and 30-day smoking abstinence, both by self-report.Intervention participants were more likely to receive provider advice on tobacco use at both prenatal visits during the intervention period (60.9 vs. 15.8%, p = 0.003). The intervention yielded a significantly greater decrease in the number of days smoked and in cigarettes smoked per day. The 30-day abstinence rate at two months post baseline was 2.5 times greater in the intervention group; the difference was not significant (26.1 vs. 10.5%, p = 0.12).The Video Doctor plus provider cueing is an efficacious adjunct to routine prenatal care by promoting provider advice and smoking reduction among pregnant smokers.

    View details for DOI 10.3109/00016341003678419

    View details for PubMedID 20196678

    View details for PubMedCentralID PMC3312043

  • When is rapid testing for influenza useful? Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Hersh, A. L., Kohn, M. A., Newman, T. B. 2010; 50 (6): 935–36

    View details for DOI 10.1086/650737

    View details for PubMedID 20166825

  • Basal Cell Carcinoma Chemoprevention with Nonsteroidal Anti-inflammatory Drugs in Genetically Predisposed PTCH1(+/-) Humans and Mice CANCER PREVENTION RESEARCH Tang, J. Y., Aszterbaum, M., Athar, M., Barsanti, F., Cappola, C., Estevez, N., Hebert, J., Hwang, J., Khaimskiy, Y., Kim, A., Lu, Y., So, P., Tang, X., Kohn, M. A., McCulloch, C. E., Kopelovich, L., Bickers, D. R., Epstein, E. H. 2010; 3 (1): 25-34


    In vitro and epidemiologic studies favor the efficacy of nonsteroidal anti-inflammatory drugs (NSAID) in preventing skin squamous photocarcinogenesis, but there has been relatively little study of their efficacy in preventing the more common skin basal cell carcinoma (BCC) carcinogenesis. We first compared the relative anti-BCC effects of genetic deletion and NSAID pharmacologic inhibition of cyclooxygenase (COX) enzymes in the skin of Ptch1(+/-) mice. We then assessed the effects of celecoxib on the development of BCCs in a 3-year, double-blinded, randomized clinical trial in 60 (PTCH1(+/-)) patients with the basal cell nevus syndrome. In Ptch1(+/-) mice, genetic deletion of COX1 or COX2 robustly decreased (75%; P < 0.05) microscopic BCC tumor burden, but pharmacologic inhibition with celecoxib reduced microscopic BCCs less efficaciously (35%; P < 0.05). In the human trial, we detected a trend for oral celecoxib reducing BCC burden in all subjects (P = 0.069). Considering only the 60% of patients with less severe disease (<15 BCCs at study entry), celecoxib significantly reduced BCC number and burden: subjects receiving placebo had a 50% increase in BCC burden per year, whereas subjects in the celecoxib group had a 20% increase (P(difference) = 0.024). Oral celecoxib treatment inhibited BCC carcinogenesis in PTCH1(+/-) mice and had a significant anti-BCC effect in humans with less severe disease.

    View details for DOI 10.1158/1940-6207.CAPR-09-0200

    View details for Web of Science ID 000273295500006

    View details for PubMedID 20051370

    View details for PubMedCentralID PMC2894531

  • Result categories for ventilation-perfusion scintigraphy. Radiology Kohn, M. A., Fahimi, J. n., Newman, T. B., Sostman, H. D., Stein, P. D., Hull, R. D. 2009; 253 (2): 575; author reply 575

    View details for DOI 10.1148/radiol.2532091186

    View details for PubMedID 19864536

  • Universal primer polymerase chain reaction looks promising for newborns with low pretest probability of sepsis. Archives of pediatrics & adolescent medicine Newman, T. B., Kohn, M. A. 2009; 163 (7): 675–76; author reply 676

    View details for DOI 10.1001/archpediatrics.2009.121

    View details for PubMedID 19581557

  • Ascites improves upon [corrected] serum sodium plus [corrected] model for end-stage liver disease (MELD) for predicting mortality in patients with advanced liver disease. Alimentary pharmacology & therapeutics Somsouk, M. n., Guy, J. n., Biggins, S. W., Vittinghoff, E. n., Kohn, M. A., Inadomi, J. M. 2009; 30 (7): 741–48


    The clinical impact of ascites has historically been well recognized; however, its value is unclear in the context of current prognostic models.To determine whether ascites can improve risk discrimination beyond model for end-stage liver disease (MELD) and serum sodium (MELDNa).Consecutive cirrhotic patients were evaluated for ascites on the basis of an outpatient CT along with concurrent MELD and Na values. Cox models were used to determine the added value of ascites for predicting 1-year mortality. Increases in the C-index, integrated discrimination improvement (IDI) and the net reclassification index (NRI) were used to assess improvements in discrimination after the addition of ascites.A total of 1003 patients had Na and MELD scores available within 30 days of the CT scan. A total of 60 deaths occurred within 1 year, with mortality higher in patients with ascites (21.4% vs. 4.0%, HR 6.08, 95% CI 3.62-10.19, P < 0.0005). In the presence of ascites, the MELD and MELDNa scores underestimated mortality risk when the scores were less than 21. The addition of ascites to the MELDNa model substantially improved discrimination by the C-index (0.804 vs. 0.770, increase of 3.4%, 95% CI 0.2-9.9%), IDI (1.8%, P = 0.016) and NRI (15.8%, P = 0.0006).The incorporation of radiographic ascites significantly improves upon MELDNa for predicting 1-year mortality. The presence of ascites may help identify patients at increased risk for mortality, not otherwise captured by either MELD or MELDNa.

    View details for DOI 10.1111/j.1365-2036.2009.04096.x

    View details for PubMedID 19604177

    View details for PubMedCentralID PMC2742706

  • Arrhythmogenic right ventricular cardiomyopathy. The New England journal of medicine Kohn, M. A., Newman, T. B. 2009; 360 (26): 2784–85; author reply 2785–86

    View details for PubMedID 19557886

  • 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


    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

  • Interunit and intraunit reliability of the RT3 triaxial accelerometer. Journal of physical activity & health Krasnoff, J. B., Kohn, M. A., Choy, F. K., Doyle, J. n., Johansen, K. n., Painter, P. L. 2008; 5 (4): 527–38


    Interest in the quantification of physical activity is on the rise. Triaxial accelerometry has frequently been used; however, research on the reliability of these devices is limited. We examine the interunit and intraunit reliability of 22 RT3 triaxial accelerometers using a performance-documented laboratory agitator.The RT3 units were tested while moving in 2 directions (antero-posterior, medio-lateral) and speeds (150 and 275 RPM) on a shaker with simultaneous documented performance output for three 24-hour periods.Minimal shaker variance was recorded for all trials (coefficients of variation [CVs] < 0.52%). Our data demonstrate good reliability within RT3s (CVs < 1.81%) but poor reliability among the 22 units (CVs range = 9.5% to 34.7%).In longitudinal studies, each subject should use the same RT3 unit at each assessment. The use of multiple RT3 units in cross-sectional studies is not recommended because data interpretation would be compromised by the high between-unit variability.

    View details for DOI 10.1123/jpah.5.4.527

    View details for PubMedID 18648118

  • Cueing prenatal providers effects on discussions of intimate partner violence. American journal of preventive medicine Calderón, S. H., Gilbert, P. n., Jackson, R. n., Kohn, M. A., Gerbert, B. n. 2008; 34 (2): 134–37


    Intimate partner violence (IPV) during pregnancy poses a significant health risk to the mother and developing fetus. Practice guidelines recommend that prenatal providers screen for and counsel their patients about IPV, yet many physicians express reluctance or discomfort regarding such discussions. The Health in Pregnancy (HIP) computer program was designed to improve prenatal providers' counseling about behavioral risks.English-speaking women 18 years or older, less than 26-weeks pregnant, and receiving prenatal care at one of the five participating clinics in the San Francisco area, were randomized in parallel groups in a controlled trial (June 2006-present; data analyzed June 2007). Participants reporting one or more risks were randomized to intervention or control in stratified blocks. Providers received summary "cueing sheets" alerting them to their patient's risk(s) and suggesting counseling statements.Thirteen percent (37/286) of the sample reported current IPV. Provider cueing resulted in 85% of the IPV-intervention group reporting discussions with their provider, compared to 23.5% of the control group (p<0.001).IPV discussions were influenced strongly by cueing providers. Provider cueing is an effective and appropriate adjunct to routine risk counseling in prenatal care.

    View details for DOI 10.1016/j.amepre.2007.09.029

    View details for PubMedID 18201643

    View details for PubMedCentralID PMC2242423

  • Trends in opioid prescribing by race/ethnicity for patients seeking care in US emergency departments. JAMA Pletcher, M. J., Kertesz, S. G., Kohn, M. A., Gonzales, R. n. 2008; 299 (1): 70–78


    National quality improvement initiatives implemented in the late 1990s were followed by substantial increases in opioid prescribing in the United States, but it is unknown whether opioid prescribing for treatment of pain in the emergency department has increased and whether differences in opioid prescribing by race/ethnicity have decreased.To determine whether opioid prescribing in emergency departments has increased, whether non-Hispanic white patients are more likely to receive an opioid than other racial/ethnic groups, and whether differential prescribing by race/ethnicity has diminished since 2000.Pain-related visits to US emergency departments were identified using reason-for-visit and physician diagnosis codes from 13 years (1993-2005) of the National Hospital Ambulatory Medical Care Survey.Prescription of an opioid analgesic.Pain-related visits accounted for 156 729 of 374 891 (42%) emergency department visits. Opioid prescribing for pain-related visits increased from 23% (95% confidence interval [CI], 21%-24%) in 1993 to 37% (95% CI, 34%-39%) in 2005 (P < .001 for trend), and this trend was more pronounced in 2001-2005 (P = .02). Over all years, white patients with pain were more likely to receive an opioid (31%) than black (23%), Hispanic (24%), or Asian/other patients (28%) (P < .001 for trend), and differences did not diminish over time (P = .44), with opioid prescribing rates of 40% for white patients and 32% for all other patients in 2005. Differential prescribing by race/ethnicity was evident for all types of pain visits, was more pronounced with increasing pain severity, and was detectable for long-bone fracture and nephrolithiasis as well as among children. Statistical adjustment for pain severity and other factors did not substantially attenuate these differences, with white patients remaining significantly more likely to receive an opioid prescription than black patients (adjusted odds ratio, 0.66; 95% CI, 0.62-0.70), Hispanic patients (0.67; 95% CI, 0.63-0.72), and Asian/other patients (0.79; 95% CI, 0.67-0.93).Opioid prescribing for patients making a pain-related visit to the emergency department increased after national quality improvement initiatives in the late 1990s, but differences in opioid prescribing by race/ethnicity have not diminished.

    View details for DOI 10.1001/jama.2007.64

    View details for PubMedID 18167408

  • The effects of executive and behavioral dysfunction on the course of ALS. Neurology Olney, R. K., Murphy, J. n., Forshew, D. n., Garwood, E. n., Miller, B. L., Langmore, S. n., Kohn, M. A., Lomen-Hoerth, C. n. 2005; 65 (11): 1774–77


    To determine whether patients with ALS-frontotemporal lobar dementia (FTLD) have a shorter survival and are less compliant with recommended treatments than those with ALS who have normal executive and behavioral function (classic ALS).Survival analysis from ALS symptom onset to death included 81 of 100 consecutive patients who could be classified definitely as ALS with abnormal executive or behavioral function or as classic ALS. Criteria were defined for compliance with noninvasive positive-pressure ventilation (NPPV) and percutaneous endoscopic gastrostomy (PEG).Median survival was 2 years 4 months for the 28 patients with FTLD and 3 years 3 months for the 53 patients with classic ALS (relative hazard for death 1.93, CI 1.09 to 3.43; p = 0.024). However, the relative hazard associated with FTLD (1.49) in the multivariate model was diminished by the association of FTLD with bulbar onset and older age and was not significant in this sample size. With bulbar onset, median survival was 2 years 0 months for the 14 with ALS-FTLD and 2 years 10 months for the 10 with classic ALS (relative hazard for death 2.78, CI 1.02 to 7.55; p = 0.045), and older age was not a significant risk. Noncompliance with NPPV and PEG were 75% and 72% in ALS-FTLD, respectively, vs 38% and 31% in classic ALS (relative risks 2.00 and 2.34; p = 0.013 and 0.022).Survival is significantly shorter among patients with ALS-FTLD than with classic ALS. Furthermore, patients with ALS-FTLD are twice as likely to be noncompliant.

    View details for DOI 10.1212/01.wnl.0000188759.87240.8b

    View details for PubMedID 16344521

  • Changing opioid use for right lower quadrant abdominal pain in the emergency department. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Neighbor, M. L., Baird, C. H., Kohn, M. A. 2005; 12 (12): 1216–20


    To compare the use of opioid analgesia in the treatment of emergency department patients with acute right lower quadrant (RLQ) abdominal pain between 1998 and 2003 and to explore the relationship between opioid use and abdominal computed tomography (CT) scanning.This was a retrospective cohort study of patients presenting in 1998 and 2003 to an urban emergency department with a triage complaint of RLQ pain. The authors abstracted use and timing of abdominal CT scanning and opioid analgesia. Other predictor variables were patient demographics. Risk ratio for receiving opioids with CT scan versus without CT scan, stratifying by year, were calculated. Proportional-hazards analysis was used to control for time in the emergency department.Of the 187 patients seen in 1998, 38 (20%) underwent CT scanning and 43 (23%) received opioids. Of the 137 patients seen in 2003, 77 (56%) underwent CT scanning and 72 (53%) received opioids. In 1998, the risk ratio for receiving opioids in patients who underwent CT scanning (vs. without) was 3.7 (95% confidence interval [CI] = 2.3 to 6.1); in 2003, it was 1.5 (95% CI = 1.0 to 2.1). Opioids were overwhelmingly given before CT scanning in those patients who received both (81% in 1998 and 98% in 2003). The mean time to administration of the first opioid dose in 1998 was 155 minutes and in 2003 was 94 minutes. The proportional-hazards analysis confirmed a strong association between CT scanning and opioid administration in 1998 (relative hazard, 2.7; 95% CI = 1.5 to 5.1) and substantial attenuation of the association in 2003 (relative hazard, 1.3; 95% CI = 0.8 to 2.1). The hospitalization rate was not significantly different in 2003 (33%) versus 1998 (27%) (p = 0.28). The risk ratio of receiving opioids in admitted patients was 2.8 (95% CI = 1.7 to 4.6) in 1998 and 2.0 (95% CI = 1.5 to 2.7) in 2003.Opioid administration to patients with RLQ pain has dramatically increased between 1998 and 2003. During these five years, the number of patients receiving opioids more than doubled and the time to first administration of opioids decreased by one hour. The authors show that this cannot be attributed to an increased use of CT scanning.

    View details for DOI 10.1197/j.aem.2005.07.024

    View details for PubMedID 16293897

  • Prevalence of acute myocardial infarction and other serious diagnoses in patients presenting to an urban emergency department with chest pain. The Journal of emergency medicine Kohn, M. A., Kwan, E. n., Gupta, M. n., Tabas, J. A. 2005; 29 (4): 383–90


    A retrospective cohort study and chart review were performed to estimate the absolute and relative prevalence of the serious diagnoses that might cause a patient to present to the Emergency Department (ED) with a chief complaint of chest pain. In this study, we queried a database of 347,229 complete visits to the San Francisco General Hospital Emergency Department between July 1, 1993 and June 30, 1998 for visits by patients > 35 years old with a chief complaint of chest pain and no history of trauma. Visits for chest pain that resulted in hospitalization were assigned to one of nine diagnostic groups according to final diagnoses as coded in the database. Manual chart review by trained abstractors using explicit criteria was done when group assignment based on coded diagnoses was unclear and in all diagnoses of pulmonary embolism and aortic dissection. Of 8,711 visits (2.5% of all visits) with a chief complaint of non-traumatic chest pain, 3,271 (37.6%) resulted in hospitalization. Of the 3,078 (94.1% of those hospitalized) assigned a final diagnosis, 329 (10.7% of hospitalizations, 3.8% of all visits) had acute myocardial infarction, 693 (22.5%) had either unstable angina or stable coronary artery disease, and 345 (11.2%) had pulmonary causes (mainly bacterial pneumonia) deemed serious enough to require hospitalization. Pulmonary embolism and aortic dissection were diagnosed in only 12 (0.4%) and 8 (0.3%) patients, respectively. In 905 (29.4%) hospitalizations for chest pain, myocardial infarction was "ruled out" and no cardiac ischemia or other serious etiology for the chest pain was diagnosed. Among patients presenting with chest pain, those in older age groups had dramatically increased risk of acute myocardial infarction. Women presenting with chest pain had a lower risk of acute myocardial infarction than men. In conclusion, the prevalence of acute myocardial infarction in the undifferentiated ED patient with a chief complaint of chest pain is only about 4%. An equal number of patients will have a serious pulmonary cause as the etiology of their pain. Pulmonary embolism and aortic dissection are important but extremely rare causes of a chest pain presentation to the ED.

    View details for DOI 10.1016/j.jemermed.2005.04.010

    View details for PubMedID 16243193

  • White blood cell count intervals and likelihood ratios for appendicitis. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Kohn, M. A. 2005; 12 (5): 480; author reply 480–81

    View details for DOI 10.1197/j.aem.2004.12.003

    View details for PubMedID 15860704

  • Likelihood ratio reporting. Mayo Clinic proceedings Kohn, M. A., Michaels, A. D. 2005; 80 (4): 563; author reply 563–64

    View details for DOI 10.1016/S0025-6196(11)63211-4

    View details for PubMedID 15819297

  • 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


    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

  • Factors affecting emergency department opioid administration to severely injured patients. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Neighbor, M. L., Honner, S. n., Kohn, M. A. 2004; 11 (12): 1290–96


    Studies of emergency department (ED) pain management in patients with trauma have been mostly restricted to patients with fractures, yet the potential for undertreatment of more severely injured patients is great. The authors sought to identify factors associated with failure to receive ED opioid administration in patients with acute trauma who subsequently required hospitalization.At an urban Level 1 trauma center and teaching hospital, a retrospective cohort study of trauma team activation patients requiring hospitalization between January 1 and December 31, 1999, was conducted. The authors excluded patients receiving opioids only within ten minutes of chest tube insertion or fracture manipulation. The main outcome measure was ED opioid administration.A total of 540 charts of hospitalized first-tier trauma team activation patients were reviewed. A total of 258 (47.8%) received intravenous opioid analgesia within three hours of ED arrival. The median time to receiving the first dose of opioids was 95 minutes. Patients were independently less likely to receive opioids if they were younger or older, were intubated, had a lower Revised Trauma Score, or did not require fracture manipulation. Patients with these factors were less likely to receive opioids independent of the amount of time they spent in the ED.Many trauma activation patients requiring hospitalization do not receive opioid analgesia in the ED. Patients at particular risk for oligoanalgesia include those who are younger or older and those who are more seriously injured, as defined by a lower Revised Trauma Score, lower Glasgow Coma Scale score, and intubation.

    View details for DOI 10.1197/j.aem.2004.07.014

    View details for PubMedID 15576519

  • Trauma team activation criteria as predictors of patient disposition from the emergency department. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Kohn, M. A., Hammel, J. M., Bretz, S. W., Stangby, A. n. 2004; 11 (1): 1–9


    Many trauma centers use mainly physiologic, first-tier criteria and mechanism-related, second-tier criteria to determine whether and at what level to activate a multidisciplinary trauma team in response to an out-of-hospital call. Some of these criteria result in a large number of unnecessary team activations while identifying only a few additional patients who require immediate operative intervention.To separately evaluate the incremental predictive value of individual first-tier and second-tier trauma team activation criteria for severe injury as reflected by patient disposition from the emergency department (ED).This was a prospective cohort study in which activation criteria were collected prospectively on all adult patients for whom the trauma team was activated during a five-month period at an urban, Level 1 trauma center. Severe injury disposition ("appropriate" team activation) was defined as immediate operative intervention, admission to the intensive care unit (ICU), or death in the ED. Data analysis consisted of recursive partitioning and multiple logistic regression.Of the 305 activations for the mainly physiologic first-tier criteria, 157 (51.5%) resulted in severe injury disposition. The first-tier criterion that caused the greatest increase in "inappropriate" activations for the lowest increase in "appropriate" activations was "age > 65." Of the 34 additional activations due to this criterion, seven (20.6%) resulted in severe injury disposition. Of the 700 activations for second-tier, mechanism-related criteria, 54 (7.7%) resulted in ICU or operating room admissions, and none resulted in ED death. The four least predictive second-tier criteria were "motorcycle crash with separation of rider," "pedestrian hit by motor vehicle," "motor vehicle crash with rollover," and "motor vehicle crash with death of occupant." Of the 452 activations for these four criteria, only 18 (4.0%) resulted in ICU or operating room admission.The four least predictive second-tier, mechanism-related criteria added little sensitivity to the trauma team activation rule at the cost of substantially decreased specificity, and they should be modified or eliminated. The first-tier, mainly physiologic criteria were all useful in predicting the need for an immediate multidisciplinary response. If increased specificity of the first-tier criteria is desired, the first criterion to eliminate is "age > 65."

    View details for DOI 10.1111/j.1553-2712.2004.tb01364.x

    View details for PubMedID 14709422

  • Beta-human chorionic gonadotropin levels and the likelihood of ectopic pregnancy in emergency department patients with abdominal pain or vaginal bleeding. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Kohn, M. A., Kerr, K. n., Malkevich, D. n., O'Neil, N. n., Kerr, M. J., Kaplan, B. C. 2003; 10 (2): 119–26


    Strategies for diagnosing ectopic pregnancy that defer endovaginal ultrasound in women with suggestive symptoms and serum beta-human chorionic gonadotropin (beta-hCG) levels less than 1500 mIU/mL ignore the increased risk of ectopic pregnancy in these patients.To quantify this increased risk by establishing and comparing the beta-hCG distributions of symptomatic women with ectopic pregnancies, abnormal intrauterine pregnancies, and normal intrauterine pregnancies.The authors reviewed the records of a cohort of women who visited an urban emergency department (ED) during a 34-month period with abdominal pain or vaginal bleeding and non-zero quantitative beta-hCG levels. Explicit criteria were used to determine whether the pregnancy ultimately turned out to be intrauterine and normal, intrauterine and abnormal, or ectopic. Probability distributions were compared using frequency distributions, receiver operating characteristic (ROC) curves, and likelihood ratios.Of 730 ED patients included in the analysis, 96 (13%) had ectopic pregnancies, 253 (35%) had abnormal intrauterine pregnancies, and 381 (52%) had normal intrauterine pregnancies. The beta-hCG distributions of patients with ectopic pregnancies and abnormal intrauterine pregnancies were similar and much lower than the beta-hCG distribution of patients with normal intrauterine pregnancies. A beta-hCG level less than 1500 mIU/mL more than doubled the odds of ectopic pregnancy (likelihood ratio = 2.24). Of the 158 patients with beta-hCG below 1500 mIU/mL, 40 (25%; 95% confidence interval [CI] = 19% to 32%) had ectopic pregnancies, and only 25 (16%; CI = 11% to 22%) had normal intrauterine pregnancies.In women with pain or bleeding and serum beta-hCG levels less than 1500 mIU/mL, the risk of ectopic pregnancy is substantially increased, while the likelihood of normal intrauterine pregnancy is low.

    View details for DOI 10.1111/j.1553-2712.2003.tb00028.x

    View details for PubMedID 12574008

  • Lack of association between patient ethnicity or race and fracture analgesia. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Fuentes, E. F., Kohn, M. A., Neighbor, M. L. 2002; 9 (9): 910–15


    Ethnic and racial differences in the provision of emergency department (ED) analgesia for long-bone fractures have recently been reported in two large cities. The authors sought to determine, in a third city, whether nonwhite patients with long-bone fractures were less likely to receive analgesics than white patients with similar injuries.At an urban Level 1 trauma center and teaching hospital, a retrospective cohort study was conducted of all ED patients aged 18 to 55 years seen from July 1, 1998, through June 30, 1999, with an ED discharge diagnosis of isolated long-bone fracture identified by ICD-9 codes 812, 813, 821, and 823. Exclusion criteria included injury more than 12 hours prior to presentation or a Glasgow Coma Scale score of less than 14. The main outcome measure was ED analgesia administration.Three hundred twenty-three patients met inclusion criteria; 181 were white, 58 African American, 46 Hispanic, 38 Asian. All ethnic/racial groups were equally likely to receive no analgesia or no parenteral analgesia. The overall risk for no analgesia was 20% and for no parenteral analgesia was 31%. Stratification and multiple logistic regression to control for gender, bone fractured, and need for reduction failed to identify any trend toward reduced analgesia administration in any ethnic/racial group.In contrast to two recently reported studies, at this urban trauma center and teaching hospital ED, there was no difference in the administration of analgesics to white and nonwhite patients with long-bone fractures.

    View details for DOI 10.1111/j.1553-2712.2002.tb02192.x

    View details for PubMedID 12208680

  • Presenting complaint among patients with myocardial infarction who present to an urban, public hospital emergency department. Annals of emergency medicine Gupta, M. n., Tabas, J. A., Kohn, M. A. 2002; 40 (2): 180–86


    We determine the frequency of patients presenting without a primary complaint of chest pain who are admitted with acute myocardial infarction (AMI) and identify factors associated with an increased risk of a presentation without chest pain.This was a retrospective, cross-sectional study over a 5-year period (July 1, 1993, to June 30, 1998) of patients presenting to a large urban, public hospital emergency department who were admitted and determined to have an AMI based on International Classification of Diseases, 9th Revision, coding and chart review. Main outcome measures were prevalence of presentation without chest pain and prevalence of other predefined presentations (ie, shortness of breath, cardiac arrest, abdominal pain, dizziness/weakness/syncope) as determined by the primary chief complaint entered on arrival at the ED. We calculated univariate relative risks and multivariate odds ratios (ORs) for presentation without chest pain in women, nonwhite ethnic groups, and older age groups.Of the 721 cases of diagnosed AMI, 53% (380; 95% confidence interval [CI] 49% to 56%) of patients presented with chest pain. The frequency of other complaints were shortness of breath, 17% (121); cardiac arrest, 7% (50); dizziness/weakness/syncope, 4% (32); abdominal pain, 2% (14); and other, 17% (124). The risk of a presentation without chest pain in a patient with AMI increased with age. The characteristic with the highest risk for a presentation without chest pain in patients with AMI was age older than 84 years old (multivariate OR 5.76; 95% CI 3.06 to 10.83). Women were more likely than men to present without chest pain (multivariate OR 1.59; 95% CI 1.11 to 2.28).Our results demonstrate that patients with AMI commonly present to the ED without a primary initial complaint of chest pain and that the frequency of initial presentations without chest pain in our urban, public hospital is as high or higher than that reported in the general ED population. Heightened awareness of atypical presentations may affect assessment of patients with AMI and provide further focus for research into presentations of acute coronary syndrome other than chest pain.

    View details for DOI 10.1067/mem.2002.126396

    View details for PubMedID 12140497

  • Indications for computed tomography after minor head injury. The New England journal of medicine Kohn, M. A., Newman, T. B. 2000; 343 (21): 1571

    View details for DOI 10.1056/NEJM200011233432113

    View details for PubMedID 11184748

  • Missed diagnoses of acute cardiac ischemia. The New England journal of medicine Kohn, M. A. 2000; 343 (20): 1492–93; discussion 1493–94

    View details for DOI 10.1056/NEJM200011163432012

    View details for PubMedID 11184458

  • The effects of clinical case management on hospital service use among ED frequent users. The American journal of emergency medicine Okin, R. L., Boccellari, A. n., Azocar, F. n., Shumway, M. n., O'Brien, K. n., Gelb, A. n., Kohn, M. n., Harding, P. n., Wachsmuth, C. n. 2000; 18 (5): 603–8


    This study examined the impact of case management on hospital service use, hospital costs, homelessness, substance abuse, and psychosocial problems in frequent users of a public urban emergency department (ED). Subjects were 53 patients who used the ED five times or more in 12 months. Utilization, cost, and psychosocial variables were compared 12 months before and after the intervention. The median number of ED visits decreased from 15 to 9 (P < .01), median ED costs decreased from $4,124 to $2,195 (P < .01) and median medical inpatient costs decreased from $8,330 to $2,786 (P < .01). Homelessness decreased by -57% (P < .01), alcohol use by -22% (P = .05) and drug use by -26% (P = .05). Linkage to primary care increased 74% (P < .01). Fifty-four percent of medically indigent subjects obtained Medicaid (P < .01). There was a net cost savings, with each dollar invested in the program yielding a $1.44 reduction in hospital costs. Thus, case management appears to be a cost-effective means of decreasing acute hospital service use and psychosocial problems among frequent ED users.

    View details for DOI 10.1053/ajem.2000.9292

    View details for PubMedID 10999578

  • Epidemiologic analysis of an urban, public emergency department's frequent users. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Mandelberg, J. H., Kuhn, R. E., Kohn, M. A. 2000; 7 (6): 637–46


    To determine how the demographic, clinical, and utilization characteristics of emergency department (ED) frequent users differ from those of other ED patients.A cross-sectional and retrospective cohort study was performed using a database of all 348,858 visits to the San Francisco General Hospital ED during a five-year period (July 1, 1993, to June 30, 1998). A "frequent user" visited the ED five or more times in a 12-month period.Frequent users constituted 3.9% of ED patients but accounted for 20.5% of ED visits. The relative risk (RR) of frequent use was high among patients who were homeless (RR = 4.5), African American (RR = 1.8), and Medi-Cal sponsored (RR = 2.1). Frequent users were more likely to be seen for alcohol withdrawal (RR = 4.4), alcohol dependence (RR = 3.4), and alcohol intoxication (RR = 2.4). Frequent users were also more likely to visit for exacerbations of chronic conditions, including sickle cell anemia (RR = 8.0), renal failure (RR = 3.6), and chronic obstructive pulmonary disease (RR = 3.3). They were less likely to visit for all forms of trauma (RR = 0.43). Survival analysis showed that only 38% of frequent users for one year remained frequent users the next year. However, 56% of frequent users for two consecutive years remained frequent users in the third year.Frequent use of the ED reflects the urban social problems of homelessness, poverty, alcohol abuse, and chronic illness. Frequent use of the ED shows a high rate of decline from one year to the next. This rate of decline slows after the first year and suggests the existence of a smaller group of chronic frequent users.

    View details for DOI 10.1111/j.1553-2712.2000.tb02037.x

    View details for PubMedID 10905642

  • Diagnostic accuracy of ultrasound above and below the beta-hCG discriminatory zone. Obstetrics and gynecology Kohn, M. A. 2000; 95 (3): 475–76

    View details for DOI 10.1016/s0029-7844(99)00651-1

    View details for PubMedID 10711570