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Biomedical subjects

Brian H Rowe

Publications and source records attributed to Brian H Rowe.

At least 73 records · Page 4Linked to original sources
PubMed2003

Methylxanthines for exacerbations of chronic obstructive pulmonary disease: meta-analysis of randomised trials.

OBJECTIVE: To evaluate the addition of methylxanthines to standard treatments in patients presenting with acute exacerbations of chronic obstructive pulmonary disease (COPD). DESIGN: Meta-analysis of randomised controlled trials. DATA SOURCE: The Cochrane airways review group's COPD register. Two reviewers independently selected articles for inclusion, assessed methodological quality, and extracted data. SELECTION OF STUDIES: Four trials met the inclusion criteria, with 169 patients. MAIN OUTCOME MEASURES: Mean change in spirometry, clinical end points, symptom scores, and adverse events. RESULTS: Mean change in forced expiratory volume at one second at two hours was similar in methylxanthine and placebo groups but transiently increased with methylxanthines at three days. Non-significant reductions in admissions to hospital and length of stay were offset by a non-significant increase in relapses at one week. Changes in symptom scores did not reach significance. Methylxanthines caused more nausea and vomiting than placebo (odds ratio 4.6, 95% confidence interval 1.7 to 12.6), and non-significant increases in tremor, palpitations, and arrhythmias were also observed. CONCLUSIONS: The available data do not support the use of methylxanthines for the treatment of exacerbations of chronic obstructive pulmonary disease. Potential benefits of methylxanthines for lung function and symptoms were generally not confirmed at standard levels of significance, whereas the potentially important adverse events of nausea and vomiting were significantly increased in patients receiving methylxanthines.

Administration, Oral↗
PubMed2003

Outpatient oral prednisone after emergency treatment of chronic obstructive pulmonary disease.

BACKGROUND: In this randomized, double-blind, placebo-controlled trial, we studied the effectiveness of prednisone in reducing the risk of relapse after outpatient exacerbations of chronic obstructive pulmonary disease (COPD). METHODS: We enrolled 147 patients who were being discharged from the emergency department after an exacerbation of COPD and randomly assigned them to 10 days of treatment with 40 mg of oral prednisone once daily or identical-appearing placebo. All patients received oral antibiotics for 10 days, plus inhaled bronchodilators. The primary end point was relapse, defined as an unscheduled visit to a physician's office or a return to the emergency department because of worsening dyspnea, within 30 days after randomization. RESULTS: The overall rate of relapse at 30 days was lower in the prednisone group than in the placebo group (27 percent vs. 43 percent, P=0.05), and the time to relapse was prolonged in those taking prednisone (P=0.04). After 10 days of therapy, patients in the prednisone group had greater improvements in forced expiratory volume in one second than did patients in the placebo group (mean [+/-SD] increase from base line, 34+/-42 percent vs. 15+/-31 percent; P=0.007). Patients in the prednisone group also had significant improvements in dyspnea, as measured by the transitional dyspnea index (P=0.04) and by the dyspnea domain of the Chronic Respiratory Disease Index Questionnaire (P=0.02), but not in health-related quality of life (P=0.14). CONCLUSIONS: Outpatient treatment with oral prednisone offers a small advantage over placebo in treating patients who are discharged from the emergency department with an exacerbation of COPD.

Acute Disease↗
PubMed2003

Zones of prevention: the geography of fall injuries in the elderly.

Our investigation of the geography of fall injuries considers the relationship between injury prevention and contextual approaches to health research. We use a geographic information system (GIS) to describe the pattern of emergency department reported falls of the elderly in the Capital Health Region, an administrative health area in Alberta, Canada. We used empirical Bayes estimates to obtain a geographic measure of fall incidence over the study area and a cluster detection statistic to measure the presence of a significant spatial cluster in the region. Inner-city Edmonton had the highest incidence of risk, suburban Edmonton the lowest, and surrounding rural regions and smaller communities had more moderate fall incidence. We argue that descriptive geography can enhance the effectiveness of injury prevention programs by identifying zones of high risk, even when the individual-level and contextual factors that explain the underlying patterns are unknown.

Accidental Falls↗
PubMed2003

The epidemiology of traumatic spinal cord injury in Alberta, Canada.

OBJECTIVES: To describe the incidence and pattern of traumatic spinal cord injury and cauda equina injury (SCI) in a geographically defined region of Canada. METHODS: The study period was April 1, 1997 to March 31, 2000. Data were gathered from three provincial sources: administrative data from the Alberta Ministry of Health and Wellness, records from the Alberta Trauma Registry, and death certificates from the Office of the Medical Examiner. RESULTS: From all three data sources, 450 cases of SCI were identified. Of these, 71 (15.8%) died prior to hospitalization. The annual incidence rate was 52.5/million population (95% CI: 47.7, 57.4). For those who survived to hospital admission, the incidence rate was 44.3/million/year (95% CI: 39.8, 48.7). The incidence rates for males were consistently higher than for females for all age groups. Motor vehicle collisions accounted for 56.4% of injuries, followed by falls (19.1%). The highest incidence of motor vehicle-related SCI occurred to those between 15 and 29 years (60/million/year). Fall-related injuries primarily occurred to those older than 60 years (45/million/year). Rural residents were 2.5 times as likely to be injured as urban residents. CONCLUSION: Prevention strategies for SCI should target males of all ages, adolescents and young adults of both sexes, rural residents, motor vehicle collisions, and fall prevention for those older than 60 years.

Accidental Falls↗
PubMed2003

Emergency department management of acute exacerbations of chronic obstructive pulmonary disease in the elderly: the Multicenter Airway Research Collaboration.

OBJECTIVES: To determine adherence of emergency department (ED) management of acute exacerbation of chronic obstructive pulmonary disease (COPD) to current treatment guidelines. DESIGN: A prospective cohort study, as part of the Multicenter Airway Research Collaboration. SETTING: The study was performed at 29 EDs in 15 U.S. states and three Canadian provinces. PARTICIPANTS: ED patients, aged 55 and older, who presented with COPD exacerbation and underwent a structured interview in the ED and another by telephone 2 weeks later. MEASUREMENTS: Adherence of ED management of COPD exacerbation to that recommended in current treatment guidelines. RESULTS: The cohort consisted of 397 subjects, of whom 224 (56%) reported only COPD and 173 (44%) reported asthma and COPD. The average age was 70. Most (80%) patients had used rescue medications in the 6 hours before seeking emergency care. Only 31% were evaluated using spirometry and 48% using arterial blood gas measurement. ED treatment included inhaled short-acting beta-agonists for 91% of patients, inhaled anticholinergics for 77%, methylxanthines for 0.3%, systemic corticosteroids for 62%, and antibiotics for 28%. More than half the patients required hospitalization. At 2-week follow-up, 43% of patients reported a relapse event or ongoing exacerbation. Overall, adherence to national and international guidelines was low. CONCLUSION: Important differences exist between guideline recommendations and actual ED management of COPD exacerbations in older adults. Outcomes after ED treatment are poor and may be related to these shortcomings in quality of care. Better adherence to guideline recommendations when caring for elderly patients with COPD exacerbations may lead to improved clinical outcomes and better resource usage.

Acute Disease↗
PubMed2003

Medication use and falls in community-dwelling older persons.

BACKGROUND: The association between injurious falls requiring a visit to the emergency department and various classes of medications was examined in a case-control study of community living persons aged 66 years and older. METHODS: Administrative databases from an urban health region provided the information used. Five controls for each case were randomly selected from community dwelling older persons who had not reported an injurious fall to one of the six regional emergency departments in the study year. Two series of analyses on medication use within 30 days of the fall were conducted using logistic regression, the first controlling for age, sex, and median income, the second controlling for co-morbid diagnoses as well. RESULTS: During the study year there were 2,405 falls reported by 2,278 individuals to six regional emergency departments giving a crude fall rate of 31.6 per 1,000 population per year. The initial analysis identified seven medication classes that were associated with an increased risk of an injurious fall, while controlling for age, gender and income. However, with further analyses controlling for the additional effects of co-morbid disease, narcotic pain-killers (odds ratio 1.68), anti-convulsants (odds ratio 1.51) and anti-depressants (odds ratio 1.46) were significant independent predictors of sustaining an injurious fall. CONCLUSION: These results are based on a Canadian population-based study with a large community sample. The study found that taking certain medications were independent predictors of sustaining an injurious fall in our elderly population - in addition to the risk associated with their medical condition.

Accidental Falls↗
PubMed2003

Resident evaluation of clinical teachers based on teachers' certification.

OBJECTIVE: To examine the influence of emergency medicine (EM) certification of clinical teaching faculty on evaluations provided by residents. METHODS: A prospective cohort analysis was conducted of assessments between July 1994 and July 2000 on residents' evaluations of EM faculty at the University of Alberta, Edmonton, Canada. Resident- and faculty-related variables were entered anonymously using the validated evaluation tool (ER Scale). Credentialing and demographic information on EM faculty was supplemented by data obtained through a nine-question survey. Groups were compared using ANOVA. RESULTS: The 562 residents returned 705 (91%) valid evaluation sheets on 115 EM faculty members. The four domains of didactic teaching, clinical teaching, approachability, and helpfulness were assessed. The majority of ratings were in the very good or superb categories for each domain. Instructors with certification in EM had higher scores in didactic, clinical teaching compared with others, and teachers without national certification scored lower in the helpful and approachable categories (p < 0.05). The route of obtaining EM certifications either through training or practice eligibility did not affect scores. Instructors under the age of 40 years had higher scores than the older age groups in three of four categories (p < 0.05). Instructors working at the teaching sites on a half-time basis received higher scores than those working full-time, and scores varied based on site. Overall, teaching ratings improved over the study period (p < 0.05). CONCLUSIONS: Significant differences exist among instructors in the EM setting that affect their teaching rating scores. National certification in EM, academic track, rotation year, and site are all correlated with better teaching performance.

Adult↗
PubMed2002

Adherence to practice guidelines for transient ischemic attacks in an emergency department.

OBJECTIVE: To evaluate the investigation and treatment of patients with a diagnosis of transient ischemic attacks (TIA) in the emergency department (ED) a tertiary care teaching hospital with a neuroscience referral program. METHODS: A chart review was conducted in the hospital. Consecutive ED charts with a diagnosis of TIA were included; each was reviewed by independent coders using a standardized data form. RESULTS: Two hundred and ninety-three TIA charts were reviewed; the gender ratio was 1:1 with a mean age of 66 years. Most patients (75%; 95% CI: 70, 80) were evaluated by ED physicians; the remaining patients were seen directly by referral services. The median time from symptom onset to ED arrival was 29 hours and the duration of symptoms was 4.6 hours. Most patients received CT scans (81%; 95% CI: 73, 85), complete blood counts (74%; 95% CI: 68, 79), and electrocardiograms (75%; 95% CI: 70, 80) in the ED. In 16% (95% CI: 13, 22) a carotid doppler was performed and in 26% (95% CI: 21, 31) an outpatient doppler was booked. Among those who were discharged (75%; 95% CI: 70, 80), antithrombotic medications were not prescribed to 28% (95% CI: 22, 34). CONCLUSION: Practice variation exists with respect to the investigation and treatment of TIAs in this tertiary-care teaching hospital. Carotid doppler investigation and use of anti-platelet therapy for patients with TIA are suboptimal. Clinical practice guidelines and rapid assessment TIA clinics may change these results.

Aged↗
PubMed2002

Evaluation of patient satisfaction and outcomes after assessment for acute ankle injuries.

Physicians argue that patient preferences influence their test ordering and their potential for compliance with clinical practice guidelines (CPG). This study was conducted to evaluate patient satisfaction with clinical practice in emergency department (ED) settings using a validated and widely publicized set of CPGs. Patients presenting to 4 hospital EDs were eligible if they had sustained acute ankle or foot injuries. All sites were involved with the dissemination of radiography CPG, and use of radiography was determined by treating physicians. Telephone follow-up was attempted for all patients who did not receive ankle or foot radiography (Group 1). A random sample of 25% of patients who had a normal radiograph interpretation (Group 2) was also chosen for follow-up. Structured telephone interviews were administered and included information on post-encounter health care utilization, subsequent radiography, and patient satisfaction. A structured questionnaire was administered to all ED physicians (N = 60) to elicit their perspectives on the clinical practice guidelines. In Group 1, 342 (69%) of 494 non-radiographed patients were successfully contacted. In Group 2, 623 (77%) of 812 patients with normal ED radiographs, were successfully contacted. After ED discharge, 86 (25%) Group 1 and 191 (31%) Group 2 patients had visited another physician within 2 weeks of the initial ED encounter (P =.07). Subsequent ankle radiography was similar between the groups (38 [11%] in Group 1 vs. 59 [10%] in Group 2; P =.38). Patients appeared to be similarly highly satisfied with physician care (P =.58) and with discharge instructions (P =.12) in both groups. Overall, 76% of physicians supported the use of CPGs; however, 78% reported that patient expectations influenced their application of the Ottawa Ankle Rules. This study suggests that patients are equally satisfied with care, access additional health care services similarly and obtain the same percentage of radiographs irrespective of the initial ED ankle/foot radiograph ordering. These results may help physicians in re-evaluating their perceptions that patient expectation influence utilization and have important implications in guideline development.

Adult↗
PubMed2002

How relevant are the systematic reviews in the cochrane library to emergency medical practice?

STUDY OBJECTIVES: The Cochrane Database of Systematic Reviews (CDSR), one of the databases in the Cochrane Library, is a compilation of regularly updated systematic reviews with meta-analytic summary statistics. We conducted a study of the CDSR to evaluate the relevance of this database to emergency medical practice. METHODS: Using criteria that were determined a priori, 2 reviewers independently screened the titles of 795 completed reviews from the April 2000 CDSR for possible relevance to emergency medicine practice. Five reviewers independently ranked summaries of these reviews for degree of relevance. Agreement was measured using kappa statistics. Disagreements were resolved by consensus or adjudication. RESULTS: Screening of 795 completed reviews identified 136 (17%) as "possibly" and 151 (19%) as "likely" relevant (simple agreement, 74%; kappa=0.82). Further independent assessment indicated 95 (12%) of the 151 "likely" systematic reviews were directly relevant to emergency medicine practice, whereas 44 (6%) were indirectly relevant (simple agreement, 77%; kappa=0.45). Cochrane Review Groups producing the most emergency medicine-relevant systematic reviews included acute respiratory infections (14 [10%]), injuries (14 [10%]), pregnancy and childbirth (13 [10%]), stroke (12 [10%]), and airways (11 [8%]). In contrast, only 1 (0.1%) of the reviews produced by the Heart Review Group was considered directly relevant to emergency medicine practice. CONCLUSION: More than one third of CDSR reviews have some relevance, and 12% are directly relevant, to emergency medical practice or discharge planning. Although certain conditions are well covered, other key emergency medicine areas are not. Emergency physicians should consider the Cochrane Library an important evidence-based resource for emergency medicine therapeutic interventions and should examine ways of increasing the number of reviews relevant to emergency medicine.

Databases, Factual↗
PubMed2002

The effectiveness of inhaled corticosteroids in the emergency department treatment of acute asthma: a meta-analysis.

STUDY OBJECTIVE: Inhaled corticosteroids (ICSs) are of proven benefit in the treatment of chronic asthma; however, their role in the management of acute asthma is unclear. METHODS: We performed a systematic review of randomized controlled trials involving children or adults treated in the emergency department for acute asthma with or without the addition of ICSs. Outcome measures included hospital admission, pulmonary function tests, and side effects. RESULTS: Seven trials were selected for inclusion in the primary analyses. ICSs versus placebo were compared; data were not available on 1 of these trials. In the remaining 6 trials, a total of 352 patients were studied (179 ICS-treated and 173 non-ICS-treated patients). Two trials compared ICSs plus systemic corticosteroids versus placebo plus systemic corticosteroids; 4 trials compared ICSs versus placebo. Patients treated with ICSs were less likely to be admitted to the hospital (odds ratio 0.30; 95% confidence interval [CI] 0.16 to 0.57) and showed small improvements in peak expiratory flows (weighted mean difference 8%; 95% CI 3% to 13%) Overall, the treatment was well tolerated, with few reports of adverse side effects. A secondary analysis compared ICSs alone versus systemic corticosteroids alone; in the 4 included trials, significant heterogeneity between the study results for admission rates precluded meaningful pooling of admission data. CONCLUSION: There is evidence of decreased admission rates for patients with acute asthma treated with ICSs. However, there is insufficient evidence that ICS therapy results in clinically important changes in pulmonary function when used in acute asthma, and there is insufficient evidence that ICSs alone are as effective as systemic corticosteroids.

Acute Disease↗
PubMed2002

The accuracy of the enzyme-linked immunosorbent assay D-dimer test in the diagnosis of pulmonary embolism: a meta-analysis.

STUDY OBJECTIVE: We sought to determine the sensitivity and specificity of the enzyme-linked immunosorbent assay (ELISA) D -dimer test in the diagnosis of pulmonary embolism (PE) in the adult emergency department population. METHODS: A search of MEDLINE, EMBASE, and bibliographies of previous systematic reviews was conducted, with no language restriction. Experts in the field of PE research were contacted to identify unpublished studies. Prospective investigations involving a predominately outpatient population suspected of PE that used ELISA D -dimer tests were included. Two authors extracted data independently and assessed study quality on the basis of the patient spectrum and reference standard. Consensus was reached by means of conference. The analysis was based on a summary receiver operating characteristic curve and pooled estimates for sensitivity and specificity by using a random-effects model. RESULTS: The search yielded 52 publications. No unpublished studies were found. Eleven studies met the inclusion criteria and provided a sample of 2,126 patients. The summary receiver operating characteristic curve analysis found significant heterogeneity among the 11 studies. Subgroup analysis of the 9 studies that used traditional ELISA D -dimer methods yielded the most valid pooled estimates, with a sensitivity of 0.94 (95% confidence interval [CI] 0.88 to 0.97) and a specificity of 0.45 (95% CI 0.36 to 0.55). Advanced age resulted in a lower specificity. A prolonged duration of symptoms decreased the sensitivity and specificity. CONCLUSION: The ELISA D -dimer test is highly sensitive but nonspecific for the detection of PE in the clinical setting. This test might help clinicians safely rule out PE, especially in the face of low and low-to-moderate pretest probabilities.

Enzyme-Linked Immunosorbent Assay↗
PubMed2002

Analysis of prehospital transport of head-injured patients after consolidation of neurosurgery resources.

OBJECTIVES: Consolidation of neurosurgical (NS) services resulted in emergency medical services guidelines mandating transport of head-injured patients to the NS center if the Glasgow Coma Scale score is < 14 and prehospital index is > 3. This study determined what paramedic, system, or patient factors were associated with secondary head-injury transfer. METHODS: This study was a retrospective chart review from January 1996 to November 1998. RESULTS: Ninety-one patient charts were reviewed. The median transport delay to the NS site was 4 hours 22 minutes. After transfer, 79 (96%) patients were admitted, 25 (30%) underwent craniotomy, and 18 (22%) died. The final diagnosis in 35 (43%) cases was subdural hematoma. Triage guidelines were violated in five patients (6%) and the NS center was on diversion in three (4%) cases. Most delays were related to patient presentations; 17 (21%) patients had no history of head trauma. CONCLUSION: Unpredictable patient factors were the most frequent reasons patients required secondary transfer; few protocol violations or system factors were identified. No modifications to the current NS triage criteria are recommended.

Adolescent↗
PubMed2002

Replacement of oral corticosteroids with inhaled corticosteroids in the treatment of acute asthma following emergency department discharge: a meta-analysis.

OBJECTIVES: Oral corticosteroids (CS) are standard treatment for patients discharged from the emergency department (ED) after treatment for acute asthma. Several recent, relatively small trials have investigated the replacement of CS with inhaled corticosteroids (ICS), with varied results and conclusions. This systematic review examined the effect of using ICS in place of CS on outcomes in this setting. METHODS: Only randomized controlled trials were eligible for inclusion. Studies in which patients were treated for acute asthma in the ED or its equivalent, and on discharge compared ICS therapy to standard CS therapy, were eligible for inclusion. Trials were identified using the Cochrane Airways Review Group register, searching abstracts and bibliographies, and contacting primary authors and pharmaceutical companies. Data were extracted and methodologic quality assessed independently by two reviewers, and missing data were obtained from authors. RESULTS: Seven trials, involving a total of 1,204 patients, compared high-dose ICS therapy vs CS therapy after ED discharge. There were no significant differences demonstrated between the treatments for relapse rates (odds ratio, 1.00; 95% confidence interval, 0.66 to 1.52) or in the secondary outcomes of beta-agonist use, symptoms, or adverse events. However, the sample size was not adequate to prove equivalence between the treatments, and severe asthmatics were excluded from these trials. CONCLUSIONS: There is some evidence that high-dose ICS therapy alone may be as effective as CS therapy when used in mild asthmatics on ED discharge; however, there is a significant possibility of a type II error in drawing this conclusion.

Acute Disease↗