Emergency Medicine Commons^™

Examining Clinical Decision Support Integrity: Is Clinician Self-Reported Data Entry Accurate?, A. Gupta, A. S. Raja, R. Khorasani

Journal Articles

The aim of this study was to assess the accuracy of clinician-entered data in imaging clinical decision support (CDS). We used CDS-guided CT angiography (CTA) for pulmonary embolus (PE) in the emergency department as a case example because it required clinician entry of d-dimer results which could be unambiguously compared with actual laboratory values. Of 1296 patients with CTA orders for suspected PE during 2011, 1175 (90.7%) had accurate d-dimer values entered. In 55 orders (4.2%), incorrectly entered data shielded clinicians from intrusive computer alerts, resulting in potential CTA overuse. Remaining data entry errors did not affect user workflow. We …

The Hmgb1/Rage Inflammatory Pathway Promotes Pancreatic Tumor Growth By Regulating Mitochondrial Bioenergetics, R. Kang, D. Tang, N. E. Schapiro, T. Loux, K. M. Livesey, T. R. Billiar, H. Wang, B. Van Houten, M. T. Lotze, H. J. Zeh

Journal Articles

Tumor cells require increased adenosine triphosphate (ATP) to support anabolism and proliferation. The precise mechanisms regulating this process in tumor cells are unknown. Here, we show that the receptor for advanced glycation endproducts (RAGE) and one of its primary ligands, high-mobility group box 1 (HMGB1), are required for optimal mitochondrial function within tumors. We found that RAGE is present in the mitochondria of cultured tumor cells as well as primary tumors. RAGE and HMGB1 coordinately enhanced tumor cell mitochondrial complex I activity, ATP production, tumor cell proliferation and migration. Lack of RAGE or inhibition of HMGB1 release diminished ATP production …

A Consensus Parameter For The Evaluation And Management Of Angioedema In The Emergency Department, J. J. Moellman, J. A. Bernstein, C. Lindsell, A. Banerji, P. J. Busse, C. A., Jr. Camargo, S. P. Collins, R. L. Campbell, S. Schneider, R. Sinert, +10 Additional Authors

Journal Articles

Despite its relatively common occurrence and life-threatening potential, the management of angioedema in the emergency department (ED) is lacking in terms of a structured approach. It is paramount to distinguish the different etiologies of angioedema from one another and more specifically differentiate histaminergic-mediated angioedema from bradykinin-mediated angioedema, especially in lieu of the more novel treatments that have recently become available for bradykinin-mediated angioedema. With this background in mind, this consensus parameter for the evaluation and management of angioedema attempts to provide a working framework for emergency physicians (EPs) in approaching the patient with angioedema in terms of diagnosis and management …

Hmgb1 In Health And Disease, R. Kang, R. C. Chen, Q. H. Zhang, W. Hou, S. Wu, X. G. Fan, Z. W. Yan, X. F. Sun, H. C. Wang, D. L. Tang, +8 Additional Authors

Journal Articles

Complex genetic and physiological variations as well as environmental factors that drive emergence of chromosomal instability, development of unscheduled cell death, skewed differentiation, and altered metabolism are central to the pathogenesis of human diseases and disorders. Understanding the molecular bases for these processes is important for the development of new diagnostic biomarkers, and for identifying new therapeutic targets. In 1973, a group of non-histone nuclear proteins with high electrophoretic mobility was discovered and termed high-mobility group (HMG) proteins. The HMG proteins include three superfamilies termed HMGB, HMGN, and HMGA. High-mobility group box 1 (HMGB1), the most abundant and well-studied HMG …

Gender Differences In Acute And Chronic Pain In The Emergency Department: Results Of The 2014 Academic Emergency Medicine Consensus Conference Pain Section, P. I. Musey, S. D. Linnstaedt, T. F. Platts-Mills, J. R. Miner, A. V. Bortsov, D. C. Lee, C. S. Nam, R. G. Patel, R. B. Fillingim, S. A. Mclean, +12 Additional Authors

Journal Articles

Pain is a leading public health problem in the United States, with an annual economic burden of more than $630 billion, and is one of the most common reasons that individuals seek emergency department (ED) care. There is a paucity of data regarding sex differences in the assessment and treatment of acute and chronic pain conditions in the ED. The Academic Emergency Medicine consensus conference convened in Dallas, Texas, in May 2014 to develop a research agenda to address this issue among others related to sex differences in the ED. Prior to the conference, experts and stakeholders from emergency medicine …

The Use Of Decision Support To Measure Documented Adherence To A National Imaging Quality Measure, A. S. Raja, A. Gupta, I. K. Ip, A. M. Mills, R. Khorasani

Journal Articles

RATIONALE AND OBJECTIVES: Present methods for measuring adherence to national imaging quality measures often require a resource-intensive chart review. Computerized decision support systems may allow for automated capture of these data. We sought to determine the feasibility of measuring adherence to a national quality measure (NQM) regarding computed tomography pulmonary angiograms (CTPAs) for pulmonary embolism using measure-targeted clinical decision support and whether the associated increased burden of data captured required by this system would affect the use and yield of CTs. MATERIALS AND METHODS: This institutional review board-approved prospective cohort study enrolled patients from September 1, 2009, through November 30, …

No Man Is An Island: Living In A Disadvantaged Neighborhood Influences Chronic Pain Development After Motor Vehicle Collision, J. C. Ulirsch, M. A. Weaver, A. V. Bortsov, A. C. Soward, R. A. Swor, D. A. Peak, J. S. Jones, N. K. Rathlev, D. C. Lee, S. A. Mclean, +2 Additional Authors

Journal Articles

Living in a lower socioeconomic status neighborhood has been shown to alter stress system function and is associated with a number of adverse health outcomes, but its influence on musculoskeletal pain (MSP) outcomes after traumatic stress exposures such as motor vehicle collision (MVC) has not been assessed. We performed a multicenter, prospective study that enrolled 948 European-American individuals within 24 hours of MVC who were discharged home after emergency department evaluation. Follow-up evaluations were completed via telephone or Internet survey 6 weeks, 6 months, and 1 year after MVC on 91%, 89%, and 91% of participants, respectively. A robust aggregate …

Targeting Hmgb1 In The Treatment Of Sepsis, H. C. Wang, M. F. Ward, A. E. Sama

Journal Articles

Introduction: Sepsis refers to the host's deleterious and non-resolving systemic inflammatory response to microbial infections and represents the leading cause of death in the intensive care unit. The pathogenesis of sepsis is complex, but partly mediated by a newly identified alarmin molecule, the high mobility group box 1 (HMGB1). Areas covered: Here we review the evidence that support extracellular HMGB1 as a late mediator of experimental sepsis with a wider therapeutic window and discuss the therapeutic potential of HMGB1-neutralizing antibodies and small molecule inhibitors (herbal components) in experimental sepsis. Expert opinion: It will be important to evaluate the efficacy of …

Pkm2 Regulates The Warburg Effect And Promotes Hmgb1 Release In Sepsis, L. C. Yang, M. Xie, M. H. Yang, Y. Yu, S. Zhu, M. T. Lotze, T. R. Billiar, H. C. Wang, L. Z. Cao, D. L. Tang, +2 Additional Authors

Journal Articles

Increasing evidence suggests the important role of metabolic reprogramming in the regulation of the innate inflammatory response, but the underlying mechanism remains unclear. Here we provide evidence to support a novel role for the pyruvate kinase M2 (PKM2)-mediated Warburg effect, namely aerobic glycolysis, in the regulation of high-mobility group box 1 (HMGB1) release. PKM2 interacts with hypoxia-inducible factor 1 alpha (HIF1 alpha) and activates the HIF-1 alpha-dependent transcription of enzymes necessary for aerobic glycolysis in macrophages. Knockdown of PKM2, HIF1 alpha and glycolysis-related genes uniformly decreases lactate production and HMGB1 release. Similarly, a potential PKM2 inhibitor, shikonin, reduces serum lactate …

Intraperitoneal Administration Of Fetuin-A Attenuates D-Galactosamine/Lipopolysaccharide-Induced Liver Failure In Mouse, P. Zhang, H. Shen, J. L. Huang, H. C. Wang, B. X. Zhang, R. R. Zhou, B. Y. Zhong, X. G. Fan

Journal Articles

Fulminant hepatic failure (FHF) is a devastating syndrome, which sometimes results in death or liver transplantation, in which inflammation would aggravate the development of fetuin-A which would act as an anti-inflammatory factor and may be an available approach to attenuate FHF. The purpose of this study was to investigate the effects of fetuin-A on d-galactosamine/lipopolysaccharide (d-GalN/LPS)-induced liver failure in mice. A mouse model of FHF induced by d-GalN/LPS was established and fetuin-A was injected intraperitoneally prior to d-GalN/LPS treatment. At different time points after d-GalN/LPS intervention, serum TNF-alpha and IL-6 levels were measured by ELISA. Fetuin-A mRNA and protein expression …

Effect Of Pain Location And Duration On Life Function In The Year After Motor Vehicle Collision, A. V. Bortsov, T. F. Platts-Mills, D. A. Peak, J. S. Jones, R. A. Swor, D. C. Lee, N. K. Rathlev, P. L. Hendry, R. B. Fillingim, S. A. Mclean, +1 Additional Author

Journal Articles

Persistent musculoskeletal pain is common after motor vehicle collision (MVC) and often results in substantial disability. The objective of this study was to identify distributions of post-MVC pain that most interfere with specific life functions and that have the greatest interference with aggregate life function. Study data were obtained from a prospective longitudinal multicenter emergency department-based cohort of 948 European Americans experiencing MVC. Overall pain (0-10 numeric rating scale [NRS]), pain in each of 20 body regions (0-10 NRS), and pain interference (Brief Pain Inventory, 0-10 NRS) were assessed 6 weeks, 6 months, and 1 year after MVC. After adjustment …

Pediatric Emergency Medical Care In Yerevan, Armenia: A Knowledge And Attitudes Survey Of Out-Of-Hospital Emergency Physicians, Aline A. Baghdassarian, Ross I. Donaldson, Andrew D. Depiero, Nancy L. Chernett, Harsh Sule

Emergency Medicine Publications

Background

Out-of-hospital emergency care is at an early stage of development in Armenia, with the current emergency medical services (EMS) system having emergency physicians (EPs) work on ambulances along with nurses. While efforts are underway by the Ministry of Health and other organizations to reform the EMS system, little data exists on the status of pediatric emergency care (PEC) in the country. We designed this study to evaluate the knowledge and attitudes of out-of-hospital emergency physicians in pediatric rapid assessment and resuscitation, and identify areas for PEC improvement.

Methods

We distributed an anonymous, self-administered Knowledge and Attitudes survey to a …

High Dose Insulin Therapy, An Evidence Based Approach To Beta Blocker/Calcium Channel Blocker Toxicity, Christina Woodward, Ali Pourmand, Maryann Mazer-Amirshahi

Emergency Medicine Faculty Publications

Poison-induced cardiogenic shock (PICS) as a result of beta-blocker (?-blocker) or calcium channel blocker (CCB) overdose is a common and potentially life-threatening condition. Conventional therapies, including fluid resuscitation, atropine, cardiac pacing, calcium, glucagon, and vasopressors often fail to improve hemodynamic status. High-dose insulin (HDI) is an emerging therapeutic modality for PICS. In this article, we discuss the existing literature and highlight the therapeutic success and potential of HDI. Based on the current literature, which is limited primarily to case series and animal models, the authors conclude that HDI can be effective in restoring hemodynamic stability, and recommend considering its use …

Do Emergency Department Patients Receive A Pathological Diagnosis? A Nationally Representative Sample., Leana S. Wen, Janice A. Espinola, Joshua M. Kosowsky, Carlos A. Camargo Jr

Emergency Medicine Faculty Publications

No abstract provided.

Intracellular Hmgb1 Inhibits Inflammatory Nucleosome Release And Limits Acute Pancreatitis In Mice, R. Kang, Q. Zhang, W. Hou, Z. Yan, R. Chen, J. Bonaroti, P. Bansal, T. R. Billiar, A. Tsung, Q. Wang, D. L. Bartlett, D. C. Whitcomb, E. B. Chang, X. Zhu, H. Wang, B. Lu, K. J. Tracey, L. Cao, X. G. Fan, M. T. Lotze, H. J., 3rd Zeh, D. Tang

Journal Articles

BACKGROUND & AIMS: High mobility group box 1 (HMGB1) is an abundant protein that regulates chromosome architecture and also functions as a damage-associated molecular pattern molecule. Little is known about its intracellular roles in response to tissue injury or during subsequent local and systemic inflammatory responses. We investigated the function of Hmgb1 in mice after induction of acute pancreatitis. METHODS: We utilized a Cre/LoxP system to create mice with pancreas-specific disruption in Hmbg1 (Pdx1-Cre; HMGB1(flox/flox) mice). Acute pancreatitis was induced in these mice (HMGB1(flox/flox) mice served as controls) after injection of l-arginine or cerulein. Pancreatic tissues and acinar cells were …

Hmgb1-Dna Complex-Induced Autophagy Limits Aim2 Inflammasome Activation Through Rage, L. Y. Liu, M. H. Yang, R. Kang, Y. P. Dai, X. J. Sun, X. L. Li, J. H. Li, H. C. Wang, L. Z. Cao, D. L. Tang, +3 Additional Authors

Journal Articles

High mobility group box 1 (HMGB1) is a prototype damage-associated molecular pattern (DAMP) that can induce inflammatory and immune responses alone as well as in combination with other molecules such as DNA. However, the intricate molecular mechanisms underlying HMGB1-DNA complex-mediated innate immune response remains largely elusive. In this study, we demonstrated that HMGB1-DNA complex initially induced absent in melanoma 2 (AIM2)-dependent inflammasome activation, and promoted rapid release of inflammasome-dependent early proinflammatory cytokines such as interleukin 10 (IL-1 beta). Subsequently, HMGB1 - DNA complex stimulated an ATG5-dependent cellular degradation process, autophagy, which was paralleled by a cessation of AIM2 inflammasome activation …

Molecular Mechanism And Therapeutic Modulation Of High Mobility Group Box 1 Release And Action: An Updated Review, B. Lu, C. Wang, M. Wang, W. Li, F. P. Chen, K. J. Tracey, H. C. Wang

Journal Articles

High mobility group box 1 (HMGB1) is an evolutionarily conserved protein, and is constitutively expressed in virtually all types of cells. Infection and injury converge on common inflammatory responses that are mediated by HMGB1 secreted from immunologically activated immune cells or passively released from pathologically damaged cells. Herein we review the emerging molecular mechanisms underlying the regulation of pathogen-associated molecular patterns (PAMPs)-induced HMGB1 secretion, and summarize many HMGB1-targeting therapeutic strategies for the treatment of infection- and injury-elicited inflammatory diseases. It may well be possible to develop strategies that specifically attenuate damage-associated molecular patterns (DAMPs)-mediated inflammatory responses without compromising the PAMPs-mediated …

Mirror Image Artifact Mimicking Heterotopic Pregnancy On Transvaginal Ultrasound: Case Series, R. Malhotra, R. M. Bramante, M. Radomski, M. Nelson

Journal Articles

Vaginal bleeding in early pregnancy is a common emergency department complaint. Point-of-care ultrasound is a useful tool to evaluate for intrauterine ectopic pregnancy. Emergency physicians performing these studies need to be cognizant of artifacts produced by ultrasound technology, as they can lead to misdiagnosis. We present two cases where mirror-image artifacts initially led to a concern for heterotopic pregnancies but were excluded on further imaging.

Patients In A Private Hospital In India Leave The Emergency Department Against Medical Advice For Financial Reasons, S. Naderi, J. R. Acerra, K. Bailey, P. Mukherji, T. Taraphdar, T. Mukherjee, A. Pal, M. F. Ward, K. Miele, M. Mathias, R. Tan, M. Kline, K. Alagappan, R. Silverman

Journal Articles

BACKGROUND: Some reports indicate financial concerns as a factor affecting ED patients leaving the acute care setting against medical advice (AMA). In India, no person is supposed to be denied urgent care because of inability to pay. Since a large proportion of the Indian health care system is financed by out-of-pocket expenses, we investigate the role of financial constraints for ED patients at a private hospital in India in leaving AMA. METHODS: A prospective ED-based cross-sectional survey of patients leaving AMA was conducted at a private hospital in India from 1 October 2010 to 31 December 2010. Descriptive statistics and …

Case Report: Transient Small Bowel Intussusception Presenting As Right Lower Quadrant Pain In A 6-Year-Old Male, M. J. Nelson, T. Paterson, C. Raio

Journal Articles

In children presenting to the emergency room with right lower quadrant pain, ultrasound is the preferred initial modality. In our patient, a 6-year-old male with a sudden onset of severe right lower quadrant pain, the differential is broad, including appendicitis and intussusception. In order to narrow our differential and secure the diagnosis, our first modality was ultrasonography. With the increased use of point-of-care ultrasound in the emergency department, the diagnosis of appendicitis and ileo-colic intussusception has been made more frequently. In addition, other entities such as transient small bowel intussusception may be identified. As in our case, obstruction secondary to …