William R Mower

Publications (44)183.36 Total impact

• Source

  Available from: PubMed Central

  Article: Association Between Appendectomy and Clostridium difficile Infection.

  Rashida Merchant, William R Mower, Ariel Ourian, Fredrick M Abrahamian, Gregory J Moran, Anusha Krishnadasan, David A Talan
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  ABSTRACT: Recent theory proposes that the appendix functions as a reservoir for commensal bacteria, and serves to re-inoculate the colon with normal flora in the event of pathogen exposure or purging of intestinal flora. If true, we reasoned that flora from a normal appendix could provide protection against Clostridium difficile. We conducted this investigation to examine the protective effect of an intact appendix and test the hypothesis that prior appendectomy will be more common among patients with a positive test for C. difficile as compared with patients who test negative. We contacted patients who had undergone C. difficile testing and asked them whether or not they had a prior appendectomy. Using their responses and results from Toxin A & B EIA tests, we calculated the difference in appendectomy rates between those who tested positive for C. difficile, and those who tested negative. We considered a positive 15% absolute difference to represent a significant increase in appendectomy rate. We enrolled 257 patients. Among the 136 who tested positive for C. difficile, 27 (19.9%) had prior appendectomies, while among 121 patients testing negative for C. difficile, 38 (31.4%) had prior appendectomies, yielding a difference in appendectomy rates of -11.6% (95% Confidence Interval: -21.6% to -0.9%). The rate of prior appendectomy was actually lower among patients with a positive C. difficile test as compared to those with a negative test. Conversely, patients who tested positive for C. difficile were more likely to have an intact appendix than those who tested negative. These results suggest that rather than being protective, an intact appendix appears to promote C. difficile acquisition, carriage, and disease. Clostridium difficile; Appendix; Appendectomy; Microbial reservoir; Infection.
  Journal of Clinical Medicine Research 02/2012; 4(1):17-9.
• Article: Prevalence of herniation and intracranial shift on cranial tomography in patients with subarachnoid hemorrhage and a normal neurologic examination.

  Larry J Baraff, Richard L Byyny, Marc A Probst, Noriko Salamon, Michael Linetsky, William R Mower
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  ABSTRACT: Patients frequently present to the emergency department (ED) with headache. Those with sudden severe headache are often evaluated for spontaneous subarachnoid hemorrhage (SAH) with noncontrast cranial computed tomography (CT) followed by lumbar puncture (LP). The authors postulated that in patients without neurologic symptoms or signs, physicians could forgo noncontrast cranial CT and proceed directly to LP. The authors sought to define the safety of this option by having senior neuroradiologists rereview all cranial CTs in a group of such patients for evidence of brain herniation or midline shift. This was a retrospective study that included all patients with a normal neurologic examination and nontraumatic SAH diagnosed by CT presenting to a tertiary care medical center from August 1, 2001, to December 31, 2004. Two neuroradiologists, blinded to clinical information and outcomes, rereviewed the initial ED head CT for evidence of herniation or midline shift. Of the 172 patients who presented to the ED with spontaneous SAH diagnoses by cranial CT, 78 had normal neurologic examinations. Of these, 73 had initial ED CTs available for review. Four of the 73 (5%; 95% confidence interval [CI] = 2% to 13%) had evidence of brain herniation or midline shift, including three (4%; 95% CI = 1% to 12%) with herniation. In only one of these patients was herniation or shift noted on the initial radiology report. Awake and alert patients with a normal neurologic examination and SAH may have brain herniation and/or midline shift. Therefore, cranial CT should be obtained before LP in all patients with suspected SAH.
  Academic Emergency Medicine 04/2010; 17(4):423-8. · 1.86 Impact Factor
• Article: Predictors of 30-day serious events in older patients with syncope.

  Benjamin C Sun, Stephen F Derose, Li-Jung Liang, Gelareh Z Gabayan, Jerome R Hoffman, Alison A Moore, William R Mower, Carol M Mangione
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  ABSTRACT: We identify predictors of 30-day serious events after syncope in older adults. We reviewed the medical records of older adults (age > or =60 years) who presented with syncope or near syncope to one of 3 emergency departments (EDs) between 2002 and 2005. Our primary outcome was occurrence of a predefined serious event within 30 days after ED evaluation. We used multivariable logistic regression to identify predictors of 30-day serious events. Of 3,727 potentially eligible patients, 2,871 (77%) met all eligibility criteria. We excluded an additional 287 patients who received a diagnosis of a serious clinical condition while in the ED. In the final study cohort (n=2,584), we identified 173 (7%) patients who experienced a 30-day serious event. High-risk predictors included age greater than 90 years, male sex, history of an arrhythmia, triage systolic blood pressure greater than 160 mm Hg, abnormal ECG result, and abnormal troponin I level. A low-risk predictor was a complaint of near syncope rather than syncope. A risk score, generated by summing high-risk predictors and subtracting the low-risk predictor, can stratify patients into low- (event rate 2.5%; 95% confidence interval [CI] 1.4% to 3.6%), intermediate- (event rate 6.3%; 95% CI 5.1% to 7.5%), and high-risk (event rate 20%; 95% CI 15% to 25%) groups. We identified predictors of 30-day serious events after syncope in adults aged 60 years and greater. A simple score was able to stratify these patients into distinct risk groups and, if externally validated, might have the potential to aid ED decisionmaking.
  Annals of emergency medicine 09/2009; 54(6):769-778.e1-5. · 4.23 Impact Factor
• Source

  Available from: sjem.org

  Article: Clinical prediction rules for identifying adults at very low risk for intra-abdominal injuries after blunt trauma.

  James F Holmes, David H Wisner, John P McGahan, William R Mower, Nathan Kuppermann
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  ABSTRACT: We derive and validate clinical prediction rules to identify adult patients at very low risk for intra-abdominal injuries after blunt torso trauma. We prospectively enrolled adult patients (>or=18 years old) after blunt torso trauma for whom diagnostic testing for intra-abdominal injury was performed. In the derivation phase, we used binary recursive partitioning to create a rule to identify patients with intra-abdominal injury who were undergoing acute intervention (including therapeutic laparotomy or angiographic embolization) and a separate rule for identifying patients with any intra-abdominal injury present. We considered only clinical variables readily available with acceptable interrater reliability. The prediction rules were then prospectively validated in a separate cohort of patients. In the derivation phase, we enrolled 3,435 patients, including 311 (9.1%; 95% confidence interval [CI] 8.1% to 10.1%) with intra-abdominal injury and 109 (35.0%; 95% CI 29.7% to 40.6%) with intra-abdominal injury requiring acute intervention. In the validation study, we enrolled 1,595 patients, including 143 (9.0%; 95% CI 7.6% to 10.5%) with intra-abdominal injury. The derived rule for patients with intra-abdominal injuries who were undergoing acute intervention consisted of hypotension, Glasgow Coma Scale (GCS) score less than 14, costal margin tenderness, abdominal tenderness, hematuria level greater than or equal to 25 red blood cells/high powered field, and hematocrit level less than 30% and identified all 44 patients in the validation phase with intra-abdominal injury who were undergoing acute intervention (sensitivity 44/44, 100%; 95% CI 93.4% to 100%). The derived rule for the presence of any intra-abdominal injury consisted of GCS score less than 14, costal margin tenderness, abdominal tenderness, femur fracture, hematuria level greater than or equal to 25 red blood cells/high powered field, hematocrit level less than 30%, and abnormal chest radiograph result (pneumothorax or rib fracture). In the validation phase, the rule for any intra-abdominal injury present had the following test performance: sensitivity 137 of 143 (95.8%; 95% CI 91.1% to 98.4%), specificity 434 of 1,452 (29.9%; 95% CI 27.5% to 32.3%), and negative predictive value 434 of 440 (98.6%; 95% CI 97.1% to 99.5%). These derived and validated clinical prediction rules can aid physicians in the evaluation of adult patients after blunt torso trauma. Patients without any of these variables are at very low risk for having intra-abdominal injury, particularly intra-abdominal injury requiring acute intervention, and are unlikely to benefit from abdominal computed tomography scanning.
  Annals of emergency medicine 06/2009; 54(4):575-84. · 4.23 Impact Factor
• Article: How (un)useful is the pelvic ring stability examination in diagnosing mechanically unstable pelvic fractures in blunt trauma patients?

  Gil Z Shlamovitz, William R Mower, Jonathan Bergman, Kenneth R Chuang, Jonathan Crisp, David Hardy, Martine Sargent, Sunil D Shroff, Eric Snyder, Marshall T Morgan
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  ABSTRACT: Our goal was to evaluate the utility of the pelvic ring stability examination for detection of mechanically unstable pelvic fractures in blunt trauma patients. Retrospective chart review. We enrolled 1,502 consecutive blunt trauma patients and found 115 patients with pelvic fractures including 34 patients with unstable pelvic fractures (Tile classification B and C). Unstable pelvic ring on physical examination had a sensitivity and specificity of 8% (95% CI 4-14) and 99% (95% CI 99-100), respectively, for detection of any pelvic fracture and 26% (95% CI 15-43) and 99.9% (95% 99-100), respectively, for detection of mechanically unstable pelvic fractures. The sensitivity and specificity of pelvic pain or tenderness in patients with Glasgow Coma Scale >13 were 74% (95% CI 64-82) and 97% (95% CI 96-98), respectively for diagnosing any pelvic fractures, and 100% (95% CI 85-100) and 93% (95% CI 92-95), respectively for diagnosing of mechanically unstable pelvic fractures. The sensitivity and specificity of the presence of pelvic deformity were 30% (95% CI 22-39) and 98% (95% CI 98-99), respectively for detection of any pelvic fracture and 55% (95% CI 38-70) and 97% (95% CI 96-98), respectively for detection of mechanically unstable pelvic fractures. The presence of either pelvic deformity or unstable pelvic ring on physical examination has poor sensitivity for detection of mechanically unstable pelvic fractures in blunt trauma patients. Our study suggests that blunt trauma patients with Glasgow Coma Scale >13 and without pelvic pain or tenderness are unlikely to suffer an unstable pelvic fracture. A prospective study is needed to determine whether a set of clinical criteria can safely detect or exclude the presence of an unstable pelvic fracture.
  The Journal of trauma 03/2009; 66(3):815-20. · 2.48 Impact Factor
• Article: Can patients with brain herniation on cranial computed tomography have a normal neurologic exam?

  Marc A Probst, Larry J Baraff, Jerome R Hoffman, Allan B Wolfson, Ariel J Ourian, William R Mower
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  ABSTRACT: Herniation of the brain outside of its normal intracranial spaces is assumed to be accompanied by clinically apparent neurologic dysfunction. The authors sought to determine if some patients with brain herniation or significant brain shift diagnosed by cranial computed tomography (CT) might have a normal neurologic examination. This is a secondary analysis of the National Emergency X-Radiography Utilization Study (NEXUS) II cranial CT database compiled from a multicenter, prospective, observational study of all patients for whom cranial CT scanning was ordered in the emergency department (ED). Clinical information including neurologic examination was prospectively collected on all patients prior to CT scanning. Using the final cranial CT radiology reports from participating centers, all CT scans were classified into three categories: frank herniation, significant shift without frank herniation, and minimal or no shift, based on predetermined explicit criteria. These reports were concatenated with clinical information to form the final study database. A total of 161 patients had CT-diagnosed frank herniation; 3 (1.9%) had no neurologic deficit. Of 91 patients with significant brain shift but no herniation, 4 (4.4%) had no neurologic deficit. A small number of patients may have normal neurologic status while harboring significant brain shift or brain herniation on cranial CT.
  Academic Emergency Medicine 01/2009; 16(2):145-50. · 1.86 Impact Factor
• Article: Decision instrument for the isolation of pneumonia patients with suspected pulmonary tuberculosis admitted through US emergency departments.

  Gregory J Moran, Tyler W Barrett, William R Mower, Anusha Krishnadasan, Fredrick M Abrahamian, Samuel Ong, Janet Y Nakase, Robert W Pinner, Matthew J Kuehnert, William R Jarvis, David A Talan
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  ABSTRACT: Many patients with pneumonia are admitted to respiratory isolation for possible tuberculosis (TB), but most do not have active TB. We created a decision instrument to predict which pneumonia patients do not need admission to a TB isolation bed. The design was a prospective case series conducted in 11 university-affiliated, urban, US emergency departments (EDs) (EMERGEncy ID NET). Participants were patients admitted to the hospital through the ED with a diagnosis of pneumonia or suspected TB. The main outcome measure was derivation and validation of a sensitive decision instrument to identify patients not having TB (and not requiring isolation) according to clinical data and chest radiographs. Of 5,079 pneumonia patients, 224 (4.4%) had pulmonary TB according to sputum cultures or tissue staining. The instrument derived to predict which patients did not have pulmonary TB included no TB history or previous positive tuberculin skin test result, nonimmigrant, not homeless, not recently incarcerated, no recent weight loss, and no apical infiltrate or cavitary lesion on plain chest radiograph. When tested on the validation subgroup, the decision instrument exhibited a negative predictive value of 99.7% (95% confidence interval [CI] 99.1% to 99.9%), and a sensitivity of 96.4% (95% CI 91.1% to 99.0%). A decision instrument can accurately predict which patients with pneumonia do not require admission to TB isolation rooms.
  Annals of emergency medicine 09/2008; 53(5):625-32. · 4.23 Impact Factor
• Article: Clinically suspected coagulopathy in blunt head trauma.

  Ron Medzon, Mark Bracken, Niels K Rathlev, William R Mower, Allan B Wolfson, Steven Go, Jerome R Hoffman
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  ABSTRACT: Patients with moderate to severe head injury and abnormal coagulation studies have a significantly higher risk of brain injury. The objective of this study was to determine the association of clinical suspicion of coagulopathy and intracranial injury (ICI) among patients sustaining blunt head trauma, including minor injuries. As part of the NEXUS II blunt head injury study, enrolled patients were prospectively evaluated for ICI and suspicion of coagulopathy. We examined the relationship between suspicion of coagulopathy and the presence of any clinically significant or "therapeutically inconsequential" ICI based on head computed tomography (CT) scan results. The NEXUS II study enrolled 13,728 patients, including 493 with suspicion of coagulopathy. Significant ICI was present in 46 (9.3%; 95% confidence interval [CI] 6.9-12.2) patients with suspected coagulopathy, and in 460 of 9863 (4.7%; 95% CI 4.3-5.1) patients without such suspicion. "Therapeutically inconsequential" findings were found on head CT scan in 74 patients, and 7 of these had suspected coagulopathy. Interventions including intubation, intracranial pressure monitoring, or craniotomy were performed in 5 of these 7 (71%; 95% CI 29-96) individuals, compared with only 3 of 67 (4%; 95% CI 1-12) patients without suspicion of coagulopathy. Initial clinical suspicion of coagulopathy, independent of laboratory confirmation, is associated with a greater prevalence of significant ICI injury after blunt head trauma; it also substantially increases the risk of morbidity despite the presence of an apparent "therapeutically inconsequential" injury. CT scanning of the head should be performed initially based on clinical suspicion of coagulopathy.
  Journal of Emergency Medicine 07/2008; 39(4):399-405. · 1.31 Impact Factor
• Source

  Available from: calgaryem.com

  Article: Sensitivity of noncontrast cranial computed tomography for the emergency department diagnosis of subarachnoid hemorrhage.

  Richard L Byyny, William R Mower, Natalie Shum, Gelareh Z Gabayan, Shanna Fang, Larry J Baraff
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  ABSTRACT: Emergency physicians use noncontrast cranial computed tomographic (CT) imaging of headache patients to identify subarachnoid hemorrhage caused by aneurysms or arteriovenous malformations. Given sufficiently high sensitivity, CT imaging could be used as a definitive diagnostic study in these patients. The purpose of this study is to determine the sensitivity of noncontrast cranial CT in detecting all spontaneous subarachnoid hemorrhages and those caused by aneurysm or arteriovenous malformation. This was a retrospective review performed at an urban tertiary academic emergency department (ED). Using a combination of noncontrast cranial CT radiology coding, lumbar puncture results, International Classification of Diseases, Ninth Revision discharge diagnosis, and medical record review, we identified all patients who presented to a tertiary care academic ED from August 1, 2001, to December 31, 2004, with spontaneous subarachnoid hemorrhage. We determined whether patients were diagnosed by cranial CT or lumbar puncture, the presence of headache and level of consciousness at ED presentation, and whether or not they had an aneurysm or arteriovenous malformation. We identified 149 patients who were diagnosed with spontaneous subarachnoid hemorrhage during the study period. Noncontrast cranial CT scan diagnosed 139 patients, and 10 were diagnosed with lumbar puncture. This yielded an overall CT scan sensitivity of 93% (95% confidence interval [CI] 88% to 97%). Of the 149 with subarachnoid hemorrhage, 117 (79%) had aneurysm or arteriovenous malformation; cranial CT scan demonstrated subarachnoid hemorrhage in 110 of the 117, for a sensitivity of 94% (95% CI 88% to 98%). For the 67 patients presenting with headache and normal mental status who had a subarachnoid hemorrhage and vascular lesions (either aneurysm or arteriovenous malformation), the sensitivity of cranial CT scan was 91% (95% CI 82% to 97%). Noncontrast CT imaging exhibits inadequate sensitivity to serve as a sole diagnostic modality in detecting spontaneous subarachnoid hemorrhage caused by aneurysm or arteriovenous malformation.
  Annals of emergency medicine 07/2008; 51(6):697-703. · 4.23 Impact Factor
• Article: Radiation doses among blunt trauma patients: assessing risks and benefits of computed tomographic imaging.

  William R Mower
  Annals of emergency medicine 04/2008; 52(2):99-100. · 4.23 Impact Factor
• Article: Low diagnostic yield of electrocardiogram testing in younger patients with syncope.

  Benjamin C Sun, Jerome R Hoffman, William R Mower, Gil Z Shlamovitz, Gelarah Z Gabayan, Carol M Mangione
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  ABSTRACT: Routine ECG testing is recommended in the evaluation of syncope, although the value of such testing in young patients is unclear. For ECG testing, we assess the diagnostic yield (frequency that ECG identified the reason for syncope) and predictive accuracy for 14-day cardiac events after an episode of syncope as a function of age. Adult patients with syncope or near-syncope were prospectively enrolled for 1 year at a single academic emergency department (ED). A 3-physician panel reviewed ED charts, hospital records, and telephone interview forms to identify predefined cardiac events. The primary outcome included all 14-day, predefined cardiac events including arrhythmia, myocardial ischemia, and structural heart disease. Of 592 eligible patients, 477 (81%) provided informed consent. Direct telephone contact or admission/outpatient records were successfully obtained for 461 (97%) patients, who comprised the analytic cohort. There were 44 (10%) patients who experienced a 14-day cardiac event. Overall diagnostic yield of ECG testing was 4% (95% confidence interval 2% to 6%). For patients younger than 40 years, ECG testing had a diagnostic yield of 0% (95% confidence interval 0% to 3%) and was associated with a 10% frequency of abnormal findings. ECG testing in patients younger than 40 years did not reveal a cardiac cause of syncope and was associated with a significant frequency of abnormal ECG findings unrelated to syncope. Although our findings should be verified in larger studies, it may be reasonable to defer ECG testing in younger patients who have a presentation consistent with a benign cause of syncope.
  Annals of emergency medicine 04/2008; 51(3):240-6, 246.e1. · 4.23 Impact Factor
• Article: Re: clinical decision rules and cervical spine injury.

  Jerome R Hoffman, William R Mower
  Journal of Emergency Medicine 02/2008; 34(1):99; author reply 99-100. · 1.31 Impact Factor
• Article: Lack of evidence to support routine digital rectal examination in pediatric trauma patients.

  Gil Z Shlamovitz, William R Mower, Jonathan Bergman, Jonathan Crisp, Heather K DeVore, David Hardy, Martine Sargent, Sunil D Shroff, Eric Snyder, Marshall T Morgan
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  ABSTRACT: Current advanced trauma life support guidelines recommend that a digital rectal examination (DRE) should be performed as part of the initial evaluation of all trauma patients. Our primary goal was to estimate the test characteristics of the DRE in pediatric patients for the following injuries: (1) spinal cord injuries, (2) bowel injuries, (3) rectal injuries, (4) pelvic fractures, and (5) urethral disruptions. We conducted a nonconcurrent, observational, chart review study of a consecutive series of pediatric trauma patients. We enrolled all patients younger than 18 years seen in our ED from January 2003 to February 2005, for whom the trauma team was activated and who had a documented DRE. For each patient, we reviewed all available clinical documents in a computerized medical record system to identify the DRE findings followed by review of radiological reports, operative reports, and discharge summaries to identify specific injuries. Two hundred thirteen patients met our selection criteria and were included in the analysis. We identified 3 patients with spinal cord injury (1% prevalence), 13 patients with bowel injury (6%), 5 patients with rectal injury (2%), 12 patients with a pelvic fracture (6%), and 1 patient with urethral disruption (0.5%). The DRE failed to diagnose (false-negative rate) 66% of spinal cord injuries, 100% of bowel injuries, 100% of rectal wall injuries, 100% of pelvic fractures, and 100% of urethral disruption injuries. The DRE has poor sensitivity for the diagnosis of spinal cord, bowel, rectal, bony pelvis, and urethral injuries. Our findings suggest that the DRE should not be routinely used in pediatric trauma patients.
  Pediatric emergency care 09/2007; 23(8):537-43. · 0.92 Impact Factor
• Article: Older age predicts short-term, serious events after syncope.

  Benjamin C Sun, Jerome R Hoffman, Carol M Mangione, William R Mower
  [show abstract] [hide abstract]
  ABSTRACT: To assess the relationship between age and 14-day serious events after an emergency department (ED) visit for syncope. One-year prospective cohort study. Single academic ED. Adult patients with an ED complaint of syncope or near-syncope. Treating physicians prospectively recorded the presence or absence of potential risk factors for serious clinical events. Patients were contacted by telephone at 14 days for a structured interview. A three-physician panel reviewed ED charts, hospital records, and telephone interview forms to identify predefined events. The primary outcome included any 14-day predefined event. A secondary outcome included any 14-day predefined event that was first diagnosed after the initial ED visit. Age was analyzed in 20-year intervals. Multivariate logistic regression controlled for baseline demographic, comorbidity, and electrocardiogram data. Of 592 eligible patients, 477 (81%) provided informed consent. Follow-up was successfully obtained for 463 (97%) patients. The age range was 18 to 96, and 47% of patients were aged 60 and older. There were 80 (17%) patients who had a 14-day event, including 18 (4%) with a delayed diagnosis. Compared with patients aged 18 to 39, the adjusted odds ratio (OR) of a serious outcome was 2.7 (95% confidence interval (CI)=0.9-8.4) for patient aged 40 to 59, 3.8 (95% CI=1.3-12) for patients aged 60 to 79, and 3.8 (95% CI=1.2-12) for patients aged 80 and older. Age of 60 and older is strongly associated with short-term serious events after an ED visit for syncope.
  Journal of the American Geriatrics Society 07/2007; 55(6):907-12. · 3.74 Impact Factor
• Article: Poor test characteristics for the digital rectal examination in trauma patients.

  Gil Z Shlamovitz, William R Mower, Jonathan Bergman, Jonathan Crisp, Heather K DeVore, David Hardy, Martine Sargent, Sunil D Shroff, Eric Snyder, Marshall T Morgan
  [show abstract] [hide abstract]
  ABSTRACT: Current advanced trauma life support guidelines recommend that a digital rectal examination be performed as part of the initial evaluation of all trauma patients. Our goal is to estimate the test characteristics of the digital rectal examination in trauma patients. We conducted a retrospective medical record review study of consecutive trauma patients treated in our emergency department from January 2003 to February 2005 for whom the trauma team was activated and who had a documented digital rectal examination. One thousand four hundred one patients met our selection criteria and were included in the analysis. We estimated the composite sensitivity of the digital rectal examination (any abnormal finding) for detecting any of the index injuries to be 22.9% (95% confidence interval [CI] 16% to 30%) and the specificity to be 94.7% (95% CI 93% to 96%). The calculated sensitivity and specificity for the digital rectal examination were 37% (95% CI 23% to 50%) and 96% (95% CI 95% to 97%), respectively, for detection of spinal cord injury, 5.7% (95% CI 0% to 13%) and 98.9% (95% CI 98% to 99%) for detection of bowel injury, 33.3% (95% CI 0% to 87%) and 99.8% (95% CI 99% to 100%) for detection of rectal injury, 0% and 99.8% (95% CI 99% to 100%) for detection of pelvic fracture, and 20% (95% CI 0% to 55%) and 99% (95% CI 98% to 100%) for detection of urethral disruption. The digital rectal examination has poor sensitivity for the diagnosis of spinal cord, bowel, rectal, bony pelvis, and urethral injuries. Our findings suggest that the digital rectal examination should not be used as a screening tool for detecting injuries in trauma patients.
  Annals of emergency medicine 07/2007; 50(1):25-33, 33.e1. · 4.23 Impact Factor
• Source

  Available from: panaftosa.org.br

  Article: Epidemiology of animal exposures presenting to emergency departments.

  Mark T Steele, O John Ma, Janet Nakase, Gregory J Moran, William R Mower, Samuel Ong, Anusha Krishnadasan, David A Talan
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  ABSTRACT: To describe the epidemiology of emergency department mammalian animal exposures and to compare adult and pediatric exposure characteristics. This was a prospective case series of patients presenting with animal exposure-related complaints from July 1996 to July 1998. Eleven university-affiliated, geographically diverse, urban emergency departments (EMERGEncy ID NET) participated. A total of 1,631 exposures (80.5%) were from dogs, 267 (13.2%) from cats, 88 (4.3%) from rodents or rabbits, 18 (0.9%) from raccoons and wild carnivores, eight (0.4%) from livestock, nine (0.4%) from monkeys, and five (0.2%) from bats. Compared with adults, children were more likely to be bitten by dogs (odds ratio [OR], 2.9; 95% confidence interval [CI] = 2.2 to 3.8) or hamsters, gerbils, and rabbits (OR, 2.6; 95% CI = 0.79 to 9.2); to be bitten on the head, neck, or face (OR, 6.7; 95% CI = 5.2 to 8.6); and to be petting or playing with the animal at the time of exposure (OR, 2.6; 95% CI = 2.1 to 3.3). Animal exposures are a common source of injury seen in the emergency department. These findings have potentially important public health implications in terms of emphasizing the need to effectively implement education programs for parents and children.
  Academic Emergency Medicine 06/2007; 14(5):398-403. · 1.86 Impact Factor
• Source

  Available from: fasthost.net

  Article: External validation of the San Francisco Syncope Rule.

  Benjamin C Sun, Carol M Mangione, Guy Merchant, Timothy Weiss, Gil Z Shlamovitz, Gelareh Zargaraff, Sharon Shiraga, Jerome R Hoffman, William R Mower
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  ABSTRACT: We externally validate the ability of the San Francisco Syncope Rule to accurately identify syncope patients who will experience a 7-day serious clinical event. Patients who presented to a single academic emergency department (ED) between 8 am and 10 pm with syncope or near-syncope were prospectively enrolled. Treating physicians recorded the presence or absence of all San Francisco Syncope Rule risk factors. Patients were contacted by telephone at 14 days for a structured interview. A 3-physician panel, blinded to the San Francisco Syncope Rule score, reviewed ED medical records, hospital records, and telephone interview forms to identify predefined serious clinical events. The primary outcome was the ability of the San Francisco Syncope Rule to predict any 7-day serious clinical event. A secondary outcome was the ability of the San Francisco Syncope Rule to predict 7-day serious clinical events that were not identified during the initial ED evaluation. Of 592 eligible patients, 477 (81%) provided informed consent. Direct telephone contact or admission/outpatient records were successfully obtained for 463 (97%) patients. There were 56 (12%) patients who had a serious 7-day clinical event, including 16 (3%) who received a diagnosis after the initial ED evaluation. Sensitivity and specificity of the San Francisco Syncope Rule for the primary outcome were 89% (95% confidence interval [CI] 81% to 97%) and 42% (95% CI 37% to 48%), respectively, and 69% (95% CI 46% to 92%) and 42% (95% CI 37% to 48%), respectively, for the secondary outcome. Estimates of sensitivity were minimally affected by missing data and most optimistic assumptions for missing follow-up information. In this external validation cohort, the San Francisco Syncope Rule had a lower sensitivity and specificity than in previous reports.
  Annals of emergency medicine 05/2007; 49(4):420-7, 427.e1-4. · 4.23 Impact Factor
• Source

  Available from: ers4kids.com

  Article: Evaluation of a modified prediction instrument to identify significant pediatric intracranial injury after blunt head trauma.

  Benjamin C Sun, Jerome R Hoffman, William R Mower
  [show abstract] [hide abstract]
  ABSTRACT: We evaluate the effect of a modification of the University of California-Davis Pediatric Head Injury Rule on the ability of the decision instrument for pediatric head injury to predict clinically important intracranial injury in an external cohort. We analyzed data prospectively recorded in 1,666 pediatric patients enrolled in the derivation set of the National Emergency X-Radiography Utilization Study II (NEXUS II). Treating physicians at 21 emergency departments recorded the presence or absence of clinical predictors on all patients who received a head computed tomography (CT) scan after experiencing blunt head trauma. Predictors included 3 exact elements of the University of California-Davis Rule (abnormal mental status, signs of skull fracture, and scalp hematoma in children < or = 2 years of age), some with different wording, and 2 modified elements with new definitions (the presence of high-risk vomiting or severe headache, rather than any vomiting or headache). A significant intracranial injury was identified by CT in 138 (8.3%) patients. Sensitivity of the modified instrument to detect significant intracranial injury was 90.4% (95% confidence interval [CI] 85.4% to 95.4%); 13 children with such an injury were misclassified as low risk. Specificity of the modified instrument was 42.7% (95% CI 40.1% to 45.3%). In the NEXUS II cohort, a modified version of the University of California-Davis Rule misclassified a substantial proportion of pediatric patients with clinically important blunt head injury. Although we cannot evaluate the exact University of California-Davis Rule, we demonstrate that using stricter definitions of "headache" and "vomiting" and different wording than in the original study may have unintended or negative consequences. We emphasize the importance of careful attention to precise definitions of clinical predictors when a decision instrument is used.
  Annals of emergency medicine 04/2007; 49(3):325-32, 332.e1. · 4.23 Impact Factor
• Article: Effect of intoxication among blunt trauma patients selected for head computed tomography scanning.

  Mark E Bracken, Ron Medzon, Niels K Rathlev, William R Mower, Jerome R Hoffman
  [show abstract] [hide abstract]
  ABSTRACT: We examine the prevalence and types of intracranial injuries sustained by intoxicated blunt trauma patients. The study was conducted as a secondary analysis of National Emergency X-Radiography Utilization Study II head injury database. Treating physicians prospectively assessed presenting signs and symptoms on all blunt trauma patients who underwent head computed tomography (CT). Intoxication status was determined by the examining physician and was based on a history of intoxication, positive toxicologic screen result, or physical evidence suggesting intoxication. Intracranial injury diagnoses were based on final CT interpretations provided by attending radiologists. Intracranial injury was detected in 1,193 of the 13,728 enrolled patients (8.7%), and intoxication was evident in 3,356 (24.4%) patients. Physicians were unable to assess intoxication status in 620 individuals. Intracranial injury was present in 231 intoxicated patients (231/3,356; 6.9%; 95% confidence interval [CI] 6.0 to 7.8), 789 of 9,752 nonintoxicated patients (8.1%; 95% CI 7.6% to 8.6%), and 173 of the 620 patients who could not be assessed for intoxication (prevalence 27.9%; 95% CI 24.4% to 31.6%). Intracranial injury was identified in only 5 of 299 intoxicated patients (1.7%) who had normal neurological examination results and no evidence of trauma to the calvarium. The prevalence of intracranial injury among intoxicated blunt trauma patients who are selected for head CT is lower than among nonintoxicated patients selected for imaging, which likely represents heightened concern in the presence of intoxication, even without other findings suggestive of intracranial injury. This conclusion is supported by the fact that few intoxicated patients with normal neurologic findings and no evidence of trauma to the calvarium had positive findings on CT imaging.
  Annals of emergency medicine 02/2007; 49(1):45-51. · 4.23 Impact Factor
• Article: Prevalence and prognosis of traumatic intraventricular hemorrhage in patients with blunt head trauma.

  Clare Atzema, William R Mower, Jerome R Hoffman, James F Holmes, Anthony J Killian, Allan B Wolfson
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  ABSTRACT: Most studies of traumatic intraventricular hemorrhage (tIVH) contain fewer than 25 subjects and are retrospective in design, providing minimal information about the entity and its clinical significance. We prospectively enrolled trauma patients from 18 centers in North America in the National Emergency X-Radiography Utilization Study (NEXUS) II if they received an emergent head computed tomography (CT) scan, as determined by the managing physician. Clinical data were collected at the time of enrollment and CT reports were compiled at least 1 month later. We calculated prevalence and demographics of tIVH from the 18 sites, while outcome data were gathered from medical records of patients with tIVH who were seen at any of six sites that participated in the follow-up portion of the study. We considered patients who underwent a neurosurgical intervention or who had a "poor outcome" (Glasgow Outcome Scale score of 1 to 3, death, persistent vegetative state, or severe disability) to have suffered a "combined outcome." Prevalence of tIVH among all trauma patients who received a head CT was 118 in 8,374, or 1.41%. Among tIVH patients, 70% had a "poor outcome" and 76% had a "combined outcome." A poor outcome appeared to be associated with an abnormal presenting Glasgow Coma Scale score and involvement of the third or fourth ventricle, whereas age appeared to be unrelated. Patients with tIVH and no major associated injury on CT tended to do well; only one patient with isolated tIVH had a poor outcome. Traumatic IVH is rare and is associated with poor outcomes that seem to be the consequence of associated injuries. Isolated tIVH patients who are clinically well appear to have a functional outcome; we were unable to identify a case of isolated tIVH, combined with a normal neurologic examination, resulting in a poor or combined outcome.
  The Journal of trauma 06/2006; 60(5):1010-7; discussion 1017. · 2.48 Impact Factor