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ABSTRACT: BACKGROUND: Given that orbital fractures are found in only one of every eight patients receiving computed tomography for acute orbital trauma, we sought to prospectively identify clinical predictors of orbital fracture that may obviate the need for exposing low-risk patients to ionizing radiation. METHODS: Prospective cohort study conducted from July 2007 through October 2009 at two urban emergency departments. Consecutive patients undergoing computed tomography for acute blunt orbital trauma were evaluated on 15 clinical findings before imaging. The primary outcome of interest was presence of any acute orbital fracture. The secondary outcome was a fracture requiring emergent operative intervention. Multivariable logistic regression analysis with multiple imputation was used to derive a predictive risk score. RESULTS: A total of 2,262 patients with acute orbital trauma were enrolled. Median age was 38 years with male predominance (68.3%). Acute orbital fractures were found in 360 patients (15.9%). The derived risk score included orbital rim tenderness, periorbital emphysema, subconjunctival hemorrhage, pain with extraocular movement, impaired extraocular movement, and epistaxis. Across 10 multiply imputed data sets, a mean of 660 patients (29.2%) lacked all six equally weighted predictors, of which 6.3% (95% confidence interval, 4.3-8.2) experienced an acute orbital fracture and only 0.5% (95% confidence interval, 0.0-1.0) required emergent operative intervention. CONCLUSION: Six clinical predictors identify patients with blunt orbital trauma at increased risk for acute orbital fracture. A risk score of 0 identifies patients at very low risk for emergent operative intervention. Multicenter studies are needed to validate these findings and derive a clinical decision instrument to reduce orbital imaging without compromising patient safety. LEVEL OF EVIDENCE: Diagnostic study, level II.
The Journal of trauma 11/2012; 73(5):1313–1318. · 2.48 Impact Factor
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ABSTRACT: In preparation for development of a clinical decision rule (CDR) to promote more efficient use of computed tomography (CT) for diagnosing orbital fractures, the authors sought to estimate the annual incidence of orbital fractures in emergency departments (EDs) and the usage of CT to make these diagnoses. The authors also sought to evaluate a mandatory electronic data collection instrument (EDCI) administered to providers to facilitate CDR data collection.
National estimates were made by analyzing the 2007 National Hospital Ambulatory Medical Care Survey (NHAMCS) database, while hospital billing system and coding data were used to make local estimates. An EDCI was integrated into the CT ordering system such that providers had to complete the form to perform a CT. Because the EDCI had to be filled out for every CT ordered, data collection efficiency was measured by compliance (counting the number of unrealistic data collection instrument answers) and by timing a convenience sample of providers completing the EDCI.
Out of 116.8 million ED visits in the United States in 2007, 4.1 million patients were treated for injuries of the eye and face. Of those, 820,252 patients underwent CT imaging, with 102,999 patients (12.5%) diagnosed with an orbital fracture. In our local hospital system with 122,500 annual ED visits, 752 CTs of orbits were performed, with 172 (23%) orbital fractures. The EDCI compliance rate was 94.9% and took less than 5 minutes to complete.
National and local data demonstrate a low yield for CT imaging in identifying orbital fractures. Data collection using a mandatory EDCI linked to computerized provider order entry can provide prospective, consecutive patient data that are needed to develop a CDR for the selective use of CT imaging in orbital trauma. Such a decision rule could increase the efficiency in diagnosing orbital fractures, thereby improving patient care, reducing radiation exposure, and decreasing costs.
Academic Emergency Medicine 02/2011; 18(3):313-6. · 1.86 Impact Factor
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Journal of Emergency Medicine 09/2009; 41(2):187. · 1.31 Impact Factor
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ABSTRACT: New Centers for Disease Control and Prevention (CDC) guidelines recommend routine HIV screening in locations including emergency departments. This study evaluates a novel approach to HIV counseling and testing (C&T) in a high-volume inner-city emergency department in terms of the number of patients who can be recruited, tested, test positive, and are linked to care. This prospective evaluation was conducted for 26 months. Noncritically ill or injured patients presenting to an inner-city emergency department were recruited. Patients used a multimedia program that facilitated data entry and viewed previously evaluated HIV counseling videos. Demographic characteristics, risk factors, and sexual history were collected. Data were collected on the number of patients tested, number of HIV-positive patients identified, and number linked to care. Demographic characteristics of the participants were as follows: 48.7% males, mean age 32.6 +/- 11.3, 34.6% Hispanic, and 37.9 % African American. Of the 7109 eligible patients approached, 6214 (87.4%) agreed to be HIV tested. There were 57 newly diagnosed or confirmed HIV-positive patients, representing a seroprevalence of 0.92%. Of those testing positive, 49 (84.2%) were linked to care and had a mean initial CD4 count of 238 cells/mm(3). In conclusion, a video-assisted rapid HIV program in a busy inner-city hospital emergency department can effectively test a high volume of patients and successfully link HIV-positive individuals to care, while providing high-quality education and prevention messages for all those who test.
AIDS patient care and STDs 08/2009; 23(9):749-55. · 2.68 Impact Factor
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ABSTRACT: To test a model designed to increase willingness of patients presenting to the emergency department off hours to be tested for human immunodeficiency virus (HIV) by using a pretest counseling video as a substitute for face-to-face counseling.
We conducted a randomized controlled trial comparing the rate of testing in patients randomized to receive video counseling with immediate testing (video group) versus standard care, which was referral to counseling and testing the next day (standard referral group).
Fifty percent of 805 eligible patients consented to participate in the study, indicating willingness to be tested. The HIV testing rate was higher in the video group 92.6% (187 of 202) than in the standard referral group 4.5% (9 of 202) (difference = 88.1%, 95% confidence interval: 83.5%-92.7%). Thirty percent of 187 patients in the video group who were tested returned for their results; 8 of 9 patients in standard care returned to be tested and to get their results.
Half of the patients who were solicited for HIV testing agreed to be tested. When testing was immediate the patient was more likely to have the test completed.
Sex Transm Dis 01/2008; 34(12):1025-9. · 2.87 Impact Factor
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ABSTRACT: This study determined whether Spanish and English educational videos are superior to routine discussion for informing emergency department (ED) patients about risks, benefits, and alternatives to receiving intravenous contrast for computed tomography (CT).
A prospective randomized controlled trial was performed on a convenience sample of adult ED patients scheduled to receive intravenous contrast for CT. Patients randomized to the intervention group watched a video in Spanish or English explaining the procedure and its risks, benefits, and alternatives. The control group underwent routine discussion, receiving intravenous contrast information from their emergency physician. After their educational sessions, all participants completed a 10-question intravenous contrast knowledge measure and 1 question rating satisfaction with the informed consent process. Mean scores were compared to assess whether the videos were superior to routine discussion for educating patients about intravenous contrast. Secondary outcomes included the proportion of satisfied patients and refusals to sign consent.
Of the 112 patients enrolled, 56 were randomized to the video group and 56 to routine discussion. Five patients withdrew from the study, leaving 107 for analysis (video N=53; control N=54). Mean knowledge scores were higher in the video group (68.1%) compared to routine discussion (47.8%) (95% confidence interval [CI] for the difference 12.6% to 28.1%). Video-group patients exhibited greater satisfaction than routine-discussion patients (86.8% [95% CI 74.6% to 94.5%] versus 77.4% [95% CI 63.8% to 87.7%]). All patients signed consent to receive intravenous contrast.
Using Spanish and English educational videos yielded higher intravenous contrast knowledge scores compared with routine informed consent procedures.
Annals of emergency medicine 03/2007; 49(2):221-30, 230.e1-3. · 4.23 Impact Factor
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ABSTRACT: To develop software that categorizes electronic head computed tomography (CT) reports into groups useful for clinical decision rule research.
Data were obtained from the Second National Emergency X-Radiography Utilization Study, a cohort of head injury patients having received head CT. CT reports were reviewed manually for presence or absence of clinically important subdural or epidural hematoma, defined as greater than 1.0 cm in width or causing mass effect. Manual categorization was done by 2 independent researchers blinded to each other's results. A third researcher adjudicated discrepancies. A random sample of 300 reports with radiologic abnormalities was selected for software development. After excluding reports categorized manually or by software as indeterminate (neither positive nor negative), we calculated sensitivity and specificity by using manual categorization as the standard. System efficiency was defined as the percentage of reports categorized as positive or negative, regardless of accuracy. Software was refined until analysis of the training data yielded sensitivity and specificity approximating 95% and efficiency exceeding 75%. To test the system, we calculated sensitivity, specificity, and efficiency, using the remaining 1,911 reports.
Of the 1,911 reports, 160 had clinically important subdural or epidural hematoma. The software exhibited good agreement with manual categorization of all reports, including indeterminate ones (weighted kappa 0.62; 95% confidence interval [CI] 0.58 to 0.65). Sensitivity, specificity, and efficiency of the computerized system for identifying manual positives and negatives were 96% (95% CI 91% to 98%), 98% (95% CI 98% to 99%), and 79% (95% CI 77% to 80%), respectively.
Categorizing head CT reports by computer for clinical decision rule research is feasible.
Annals of emergency medicine 12/2006; 48(5):551-7, 557.e1-25. · 4.23 Impact Factor
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ABSTRACT: Multiple barriers to traditional pretest HIV counseling make HIV testing difficult to accomplish in the emergency department setting in off hours. This study compares the educational effectiveness of a 10-minute pretest counseling video with the usual practice of a session with an HIV counselor.
This was a prospective randomized controlled trial of adult patients presenting to the urgent care area of a busy inner-city hospital. Patients either viewed an HIV educational video or spoke with an HIV counselor for pretest counseling. The video was developed by 2 of the investigators (YC, MH) and covered essential educational elements for HIV testing, as required by the New York State Department of Health. All participants completed a measure of HIV knowledge after their intervention. An equivalence analysis was performed to assess whether the video was at least as good as counseling in terms of overall mean knowledge score.
Of 129 patients recruited for the study, 65 patients were randomized to the intervention and 64 patients to the control group. Five patients were unable to complete the study. The final analysis was based on 124 patients. Mean knowledge scores were higher in the intervention (85.3% versus 79.7%; 90% confidence interval for the difference 2.6% to 8.7%).
We conclude that the use of an educational video with an inner-city adult population was at least as effective as in-person pretest counseling in conveying information related to HIV testing.
Annals of emergency medicine 08/2006; 48(1):21-7. · 4.23 Impact Factor
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American Journal of Emergency Medicine 06/2005; 23(3):414-5. · 1.98 Impact Factor
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ABSTRACT: A decision instrument based on 5 clinical criteria has been shown to be highly sensitive in selecting patients who require cervical spine imaging after blunt trauma, while simultaneously reducing overall imaging. We examine the performance of this instrument in the elderly and explore some of the common features of geriatric cervical spine injury (CSI).
The National Emergency X-radiography Utilization Study (NEXUS) was a prospective, observational, multicenter study conducted at 21 geographically diverse centers. We analyzed the performance of the NEXUS decision instrument among patients at least 65 years of age.
The study group consisted of 2,943 (8.6%) geriatric patients, representing 8.6% of the entire NEXUS sample. The rate of CSI was twice as great in these patients as it was in nongeriatric patients (4.59% versus 2.19%). Odontoid fractures were particularly common in geriatric patients, accounting for 20% of geriatric fractures compared with 5% of nongeriatric fractures. The frequency of patients meeting NEXUS criteria was similar in the 2 groups, with 14% of geriatric patients and 12.5% of nongeriatric patient classified as low risk. CSI occurred in only 2 low-risk geriatric patients, and these patients' injuries met our preset definition of a clinically insignificant injury. The sensitivity of the NEXUS decision instrument for clinically significant injury in the geriatric group was therefore 100% (95% confidence interval 97.1% to 100%).
The prevalence of CSI, and especially odontoid fracture, is relatively increased among geriatric patients with blunt trauma. The NEXUS decision instrument can be applied safely to these patients, with an expected reduction in cervical imaging comparable with that achieved in nongeriatric patients.
Annals of Emergency Medicine 10/2002; 40(3):287-93. · 4.13 Impact Factor
