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Article ; Online: Outpatient treatment of emergency department patients diagnosed with venous thromboembolism.

Stubblefield, William B / Kline, Jeffrey A

2021 Volume 133, Issue sup1, Page(s) 11–19

Abstract: Venous thromboembolism (VTE) includes the diagnosis of either deep venous thrombosis (DVT) and/or pulmonary embolism (PE). This review discusses an evidence-based approach to the outpatient treatment of VTE in the emergency care setting. Main findings: ... ...

Abstract	Venous thromboembolism (VTE) includes the diagnosis of either deep venous thrombosis (DVT) and/or pulmonary embolism (PE). This review discusses an evidence-based approach to the outpatient treatment of VTE in the emergency care setting. Main findings: The majority of patients diagnosed with VTE in the acute care setting are at low risk for an adverse event. Outpatient treatment for patients deemed low-risk by validated clinical decision tools leads to safe, efficacious, patient-centered, and cost-effective care. From a patient perspective, outpatient treatment of VTE can been simplified by the use of direct oral anticoagulant (DOACs) medications, and is supported by clinical trial evidence, and clinical practice guidelines from international societies. Outpatient treatment of patients with DVT has been more widely accepted as a best practice, while adoption of outpatient treatment of low-risk patients with acute PE has lagged. Many acute care clinicians remain wary of discharging patients with PE, concerned about drug access, adherence, and follow-up. Patients with VTE should be risk stratified identically as emerging evidence has demonstrated efficacy and safety in the interdependence of acute care protocols for the outpatient treatment of low-risk DVT and PE. Clinicians who practice in the acute care setting should be comfortable with risk stratification, anticoagulation, and discharge of low-risk VTE.
MeSH term(s)	Ambulatory Care/methods ; Anticoagulants/therapeutic use ; Emergency Medical Services/methods ; Evidence-Based Practice/methods ; Humans ; Risk Assessment/methods ; Venous Thromboembolism/complications ; Venous Thromboembolism/physiopathology ; Venous Thromboembolism/therapy
Chemical Substances	Anticoagulants
Language	English
Publishing date	2021-04-27
Publishing country	England
Document type	Journal Article ; Review
ZDB-ID	410138-8
ISSN	1941-9260 ; 0032-5481
ISSN (online)	1941-9260
ISSN	0032-5481
DOI	10.1080/00325481.2021.1916299
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Article ; Online: Is It Time to Adjust D-dimer Thresholds to Our Clinical Pretest Probability? An Analysis of the PEGeD Study: June 2020 Annals of Emergency Medicine Journal Club.

Stubblefield, William B / Kabrhel, D Christopher

Annals of emergency medicine

2019 Volume 75, Issue 6, Page(s) 778–780

Language	English
Publishing date	2019-12-21
Publishing country	United States
Document type	Journal Article
ZDB-ID	603080-4
ISSN	1097-6760 ; 0196-0644
ISSN (online)	1097-6760
ISSN	0196-0644
DOI	10.1016/j.annemergmed.2020.04.034
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Zs.A 1344: Show issues

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Article ; Online: Addressing the rising trend of high-risk pulmonary embolism mortality: Clinical and research priorities.

Casey, Scott D / Stubblefield, William B / Luijten, Dieuwke / Klok, Frederikus A / Westafer, Lauren M / Vinson, David R / Kabrhel, Christopher

Academic emergency medicine : official journal of the Society for Academic Emergency Medicine

2024 Volume 31, Issue 3, Page(s) 288–292

Abstract: Background: Deaths from high-risk pulmonary embolism (PE) appear to have increased in the US over the last decade. Modifiable risks contributing to this worrisome trend present opportunities for physicians, researchers, and healthcare policymakers to ... ...

Abstract	Background: Deaths from high-risk pulmonary embolism (PE) appear to have increased in the US over the last decade. Modifiable risks contributing to this worrisome trend present opportunities for physicians, researchers, and healthcare policymakers to improve care. Methods: We sought to contextualize contemporary, high-risk PE epidemiology and examine clinical trials, quality improvement opportunities, and healthcare policy initiatives directed at reducing mortality. Results: We observed significant and modifiable excess mortality due to high-risk PE. We identified several opportunities to improve care including: (1) rapid translation of forthcoming data on reperfusion strategies into clinical practice; (2) improved risk stratification tools; (3) quality improvement initiatives to address presumptive anticoagulation practice gaps; and (3) adoption of health policy initiatives to establish pulmonary embolism response teams and address the social determinants of health. Conclusion: Addressing knowledge and practice gaps in intermediate and high-risk PE management must be prioritized and informed by forthcoming high-quality data. Implementation efforts are needed to improve acute PE management and resolve treatment disparities.
MeSH term(s)	Humans ; Fibrinolytic Agents/therapeutic use ; Thrombolytic Therapy ; Treatment Outcome ; Pulmonary Embolism/drug therapy ; Research
Chemical Substances	Fibrinolytic Agents
Language	English
Publishing date	2024-02-21
Publishing country	United States
Document type	Journal Article
ZDB-ID	1329813-6
ISSN	1553-2712 ; 1069-6563
ISSN (online)	1553-2712
ISSN	1069-6563
DOI	10.1111/acem.14859
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Zs.A 4479: Show issues

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Article ; Online: Should Cancer Patients Receive Apixaban to Prevent Venous Thromboembolism? An Analysis of the AVERT Trial: January 2020 Annals of Emergency Medicine Journal Club.

Stubblefield, William B / Courtney, D Mark / Self, Wesley H

Annals of emergency medicine

2019 Volume 75, Issue 1, Page(s) 116–118

Language	English
Publishing date	2019-12-21
Publishing country	United States
Document type	Journal Article
ZDB-ID	603080-4
ISSN	1097-6760 ; 0196-0644
ISSN (online)	1097-6760
ISSN	0196-0644
DOI	10.1016/j.annemergmed.2019.11.010
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Article ; Online: Characteristics and outcomes of prehospital and emergency department surgical airways.

Mathews, Amanda C / McLeod, Kaitlin / Lacy, Aaron J / High, Kevin / Brywczynski, Jeremy / McKinney, Jared J / Wrenn, Jesse O / Jones, Ian D / Stubblefield, William B

Journal of the American College of Emergency Physicians open

2024 Volume 5, Issue 2, Page(s) e13136

Abstract: Objectives: The surgical airway is a high acuity, low occurrence procedure. Data on the complications and outcomes of surgical airways are limited. Our primary objective was to describe immediate complications, late complications, and clinical outcomes ... ...

Abstract	Objectives: The surgical airway is a high acuity, low occurrence procedure. Data on the complications and outcomes of surgical airways are limited. Our primary objective was to describe immediate complications, late complications, and clinical outcomes of patients who underwent a surgical airway procedure in the prehospital or emergency department (ED) setting. Methods: We conducted a retrospective chart review of patients ≥14 years at an academic medical center who underwent a surgical airway procedure in the ED, the prehospital setting, or at a referring ED prior to interfacility transfer. We identified cases from keyword searches of prehospital text pages and hospital electronic medical records from June 1, 2008 to July 1, 2022. Manual chart review was used to confirm inclusion and determine patient and procedure characteristics. Outcomes included immediate complications, delayed in-hospital complications, and neurologic disability as defined by Modified Rankin Score (mRS) at discharge. Results: We identified 63 patients (34 prehospital, 11 ED, and 18 referring ED). Immediate complications included mainstem intubation (46.0%) and bleeding that required direct pressure (23.4%). Overall, 29 patients (46%) died after arrival to the hospital. Of the patients surviving to hospital admission, 25 (48%) had an airway-related complication. Nine complications were deemed directly related to technical components of the procedure. Of the patients who survived to discharge, 18 (52.9%) had poor neurologic function (mRS 4-5). Conclusion: Procedural complications, mortality, and poor neurologic function were common following a surgical airway procedure in the prehospital or ED setting. Most patients surviving to discharge had a moderate to severe neurologic disability.
Language	English
Publishing date	2024-03-21
Publishing country	United States
Document type	Journal Article
ISSN	2688-1152
ISSN (online)	2688-1152
DOI	10.1002/emp2.13136
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Article ; Online: Efficacy and Safety of Dapagliflozin in Patients With Acute Heart Failure.

Cox, Zachary L / Collins, Sean P / Hernandez, Gabriel A / McRae, A Thomas / Davidson, Beth T / Adams, Kirkwood / Aaron, Mark / Cunningham, Luke / Jenkins, Cathy A / Lindsell, Christopher J / Harrell, Frank E / Kampe, Christina / Miller, Karen F / Stubblefield, William B / Lindenfeld, JoAnn

Journal of the American College of Cardiology

2024 Volume 83, Issue 14, Page(s) 1295–1306

Abstract: Background: The primary goals during acute heart failure (AHF) hospitalization are decongestion and guideline-directed medical therapy (GDMT) optimization. Unlike diuretics or other GDMT, early dapagliflozin initiation could achieve both AHF goals.: ... ...

Abstract	Background: The primary goals during acute heart failure (AHF) hospitalization are decongestion and guideline-directed medical therapy (GDMT) optimization. Unlike diuretics or other GDMT, early dapagliflozin initiation could achieve both AHF goals. Objectives: The authors aimed to assess the diuretic efficacy and safety of early dapagliflozin initiation in AHF. Methods: In a multicenter, open-label study, 240 patients were randomized within 24 hours of hospital presentation for hypervolemic AHF to dapagliflozin 10 mg once daily or structured usual care with protocolized diuretic titration until day 5 or hospital discharge. The primary outcome, diuretic efficiency expressed as cumulative weight change per cumulative loop diuretic dose, was compared across treatment assignment using a proportional odds model adjusted for baseline weight. Secondary and safety outcomes were adjudicated by a blinded committee. Results: For diuretic efficiency, there was no difference between dapagliflozin and usual care (OR: 0.65; 95% CI: 0.41-1.02; P = 0.06). Dapagliflozin was associated with reduced loop diuretic doses (560 mg [Q1-Q3: 260-1,150 mg] vs 800 mg [Q1-Q3: 380-1,715 mg]; P = 0.006) and fewer intravenous diuretic up-titrations (P ≤ 0.05) to achieve equivalent weight loss as usual care. Early dapagliflozin initiation did not increase diabetic, renal, or cardiovascular safety events. Dapagliflozin was associated with improved median 24-hour natriuresis (P = 0.03) and urine output (P = 0.005), expediting hospital discharge over the study period. Conclusions: Early dapagliflozin during AHF hospitalization is safe and fulfills a component of GDMT optimization. Dapagliflozin was not associated with a statistically significant reduction in weight-based diuretic efficiency but was associated with evidence for enhanced diuresis among patients with AHF. (Efficacy and Safety of Dapagliflozin in Acute Heart Failure [DICTATE-AHF]; NCT04298229).
MeSH term(s)	Humans ; Sodium Potassium Chloride Symporter Inhibitors/therapeutic use ; Acute Disease ; Heart Failure/drug therapy ; Diuretics ; Benzhydryl Compounds ; Glucosides
Chemical Substances	Sodium Potassium Chloride Symporter Inhibitors ; dapagliflozin (1ULL0QJ8UC) ; Diuretics ; Benzhydryl Compounds ; Glucosides
Language	English
Publishing date	2024-04-02
Publishing country	United States
Document type	Randomized Controlled Trial ; Multicenter Study ; Journal Article
ZDB-ID	605507-2
ISSN	1558-3597 ; 0735-1097
ISSN (online)	1558-3597
ISSN	0735-1097
DOI	10.1016/j.jacc.2024.02.009
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Zs.A 1846: Show issues			Location: Je nach Verfügbarkeit (siehe Angabe bei Bestand) bis Jg. 1994: Bestellungen von Artikeln über das Online-Bestellformular Jg. 1995 - 2021: Lesesall (1.OG) ab Jg. 2022: Lesesaal (EG)
Zs.MO 196: Show issues

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Article ; Online: Clinician gestalt estimate of pretest probability for acute coronary syndrome and pulmonary embolism in patients with chest pain and dyspnea.

Kline, Jeffrey A / Stubblefield, William B

Annals of emergency medicine

2014 Volume 63, Issue 3, Page(s) 275–280

Abstract: Study objective: Pretest probability helps guide diagnostic testing for patients with suspected acute coronary syndrome and pulmonary embolism. Pretest probability derived from the clinician's unstructured gestalt estimate is easier and more readily ... ...

Abstract	Study objective: Pretest probability helps guide diagnostic testing for patients with suspected acute coronary syndrome and pulmonary embolism. Pretest probability derived from the clinician's unstructured gestalt estimate is easier and more readily available than methods that require computation. We compare the diagnostic accuracy of physician gestalt estimate for the pretest probability of acute coronary syndrome and pulmonary embolism with a validated, computerized method. Methods: This was a secondary analysis of a prospectively collected, multicenter study. Patients (N=840) had chest pain, dyspnea, nondiagnostic ECGs, and no obvious diagnosis. Clinician gestalt pretest probability for both acute coronary syndrome and pulmonary embolism was assessed by visual analog scale and from the method of attribute matching using a Web-based computer program. Patients were followed for outcomes at 90 days. Results: Clinicians had significantly higher estimates than attribute matching for both acute coronary syndrome (17% versus 4%; P<.001, paired t test) and pulmonary embolism (12% versus 6%; P<.001). The 2 methods had poor correlation for both acute coronary syndrome (r(2)=0.15) and pulmonary embolism (r(2)=0.06). Areas under the receiver operating characteristic curve were lower for clinician estimate compared with the computerized method for acute coronary syndrome: 0.64 (95% confidence interval [CI] 0.51 to 0.77) for clinician gestalt versus 0.78 (95% CI 0.71 to 0.85) for attribute matching. For pulmonary embolism, these values were 0.81 (95% CI 0.79 to 0.92) for clinician gestalt and 0.84 (95% CI 0.76 to 0.93) for attribute matching. Conclusion: Compared with a validated machine-based method, clinicians consistently overestimated pretest probability but on receiver operating curve analysis were as accurate for pulmonary embolism but not acute coronary syndrome.
MeSH term(s)	Acute Coronary Syndrome/complications ; Acute Coronary Syndrome/diagnosis ; Chest Pain/etiology ; Dyspnea/etiology ; Electrocardiography ; Gestalt Theory ; Humans ; Practice Patterns, Physicians' ; Probability ; Prospective Studies ; Pulmonary Embolism/complications ; Pulmonary Embolism/diagnosis ; ROC Curve ; Visual Analog Scale
Language	English
Publishing date	2014-03
Publishing country	United States
Document type	Clinical Trial ; Journal Article ; Multicenter Study
ZDB-ID	603080-4
ISSN	1097-6760 ; 0196-0644
ISSN (online)	1097-6760
ISSN	0196-0644
DOI	10.1016/j.annemergmed.2013.08.023
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Zs.A 1344: Show issues

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Article ; Online: Frequency of cardiotoxicity following intramuscular administration of epinephrine in emergency department patients with anaphylaxis.

Pauw, Emily K / Stubblefield, William B / Wrenn, Jesse O / Brown, Sarah K / Cosse, Millie S / Curry, Zoe S / Darcy, Terence P / James, Tia'Asia E / Koetter, Paige E / Nicholson, Caitlin E / Parisi, Frank N / Shepherd, Laura G / Soppet, Savannah L / Stocker, Michael D / Walston, Bernard M / Self, Wesley H / Han, Jin H / Ward, Michael J

Journal of the American College of Emergency Physicians open

2024 Volume 5, Issue 1, Page(s) e13095

Abstract: Objectives: Epinephrine can be a life-saving treatment for patients with anaphylaxis. Potential cardiovascular side effects of epinephrine may contribute to clinician hesitancy to use it. However, the frequency of cardiotoxicity resulting from ... ...

Abstract	Objectives: Epinephrine can be a life-saving treatment for patients with anaphylaxis. Potential cardiovascular side effects of epinephrine may contribute to clinician hesitancy to use it. However, the frequency of cardiotoxicity resulting from epinephrine treatment for anaphylaxis is not well described. We sought to describe the frequency of cardiotoxicity following intramuscular (IM) administration of epinephrine in adult emergency department (ED) patients with anaphylaxis. Methods: We conducted a retrospective observational study at a single, quaternary care academic ED in Tennessee. We identified consecutive ED visits with the diagnosis of anaphylaxis from 2017 to 2021 who received at least one intramuscular (IM) dose of epinephrine in the ED. Analysis was primarily descriptive. The primary outcome was cardiotoxicity, the occurrence of any of the following after epinephrine administration: ischemic electrocardiogram changes, systolic blood pressure >200 mmHg, or cardiac arrest ≤4 h; elevated troponin ≤12 h; or percutaneous coronary intervention or depressed ejection fraction ≤72 h. Results: Among 338 included patients, 16 (4.7%; 95%CI: 2.8-7.6%) experienced cardiotoxicity. Cardiotoxic events included eight (2.4%) ischemic electrocardiogram changes, six (1.8%) episodes of elevated troponin, five (1.5%) atrial arrhythmias, one (0.3%) ventricular arrythmia, and one (0.3%) depressed ejection fraction. Patients with cardiotoxicity were significantly older, had more comorbidities, and were more likely to have received multiple doses of epinephrine or an epinephrine infusion compared with a single IM dose of epinephrine. Conclusions: Among 338 consecutive adult ED patients who received IM epinephrine for anaphylaxis during a recent 4-year period, cardiotoxic side effects were observed in approximately 5% of patients.
Language	English
Publishing date	2024-01-06
Publishing country	United States
Document type	Journal Article
ISSN	2688-1152
ISSN (online)	2688-1152
DOI	10.1002/emp2.13095
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Article ; Online: Change in Antibodies to SARS-CoV-2 Over 60 Days Among Health Care Personnel in Nashville, Tennessee.

Patel, Manish M / Thornburg, Natalie J / Stubblefield, William B / Talbot, H Keipp / Coughlin, Melissa M / Feldstein, Leora R / Self, Wesley H

JAMA

2020 Volume 324, Issue 17, Page(s) 1781–1782

MeSH term(s)	Antibodies, Viral/blood ; COVID-19/epidemiology ; COVID-19/immunology ; COVID-19/therapy ; Health Personnel ; Immunization, Passive ; SARS-CoV-2/immunology ; Seroepidemiologic Studies ; Tennessee
Chemical Substances	Antibodies, Viral
Keywords	covid19
Language	English
Publishing date	2020-09-17
Publishing country	United States
Document type	Journal Article ; Research Support, U.S. Gov't, P.H.S.
ZDB-ID	2958-0
ISSN	1538-3598 ; 0254-9077 ; 0002-9955 ; 0098-7484
ISSN (online)	1538-3598
ISSN	0254-9077 ; 0002-9955 ; 0098-7484
DOI	10.1001/jama.2020.18796
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Article ; Online: Serial Thromboelastography and the Development of Venous Thromboembolism in Critically Ill Patients With COVID-19.

Marvi, Tanya K / Stubblefield, William B / Tillman, Benjamin F / Tenforde, Mark W / Patel, Manish M / Lindsell, Christopher J / Self, Wesley H / Grijalva, Carlos G / Rice, Todd W

Critical care explorations

2022 Volume 4, Issue 1, Page(s) e0618

Abstract: To test the hypothesis that relatively lower clot strength on thromboelastography maximum amplitude (MA) is associated with development of venous thromboembolism (VTE) in critically ill patients with COVID-19.: Design: Prospective, observational ... ...

Abstract	To test the hypothesis that relatively lower clot strength on thromboelastography maximum amplitude (MA) is associated with development of venous thromboembolism (VTE) in critically ill patients with COVID-19. Design: Prospective, observational cohort study. Setting: Tertiary care, academic medical center in Nashville, TN. Patients: Patients with acute respiratory failure from COVID-19 pneumonia admitted to the adult medical ICU without known VTE at enrollment. Interventions: None. Measurements and main results: Ninety-eight consecutive critically ill adults with laboratory-confirmed COVID-19 were enrolled. Thromboelastography parameters and conventional coagulation parameters were measured on days 0 (within 48 hr of ICU admission), 3, 5, and 7 after enrollment. The primary outcome was diagnosis of VTE with confirmed deep venous thrombosis and/or pulmonary embolism by clinical imaging or autopsy. Twenty-six patients developed a VTE. Multivariable regression controlling for antiplatelet exposure and anticoagulation dose with death as a competing risk found that lower MA was associated with increased risk of VTE. Each 1 mm increase in enrollment and peak MA was associated with an 8% and 14% decrease in the risk of VTE, respectively (enrollment MA: subdistribution hazard ratio [SHR], 0.92; 95% CI, 0.87-0.97; Conclusions: When controlling for the competing risk of death, lower enrollment and peak MA were associated with increased risk of VTE. Lower platelet counts and fibrinogen levels at enrollment were associated with increased risk of VTE. The association of diminished MA, platelet counts, and fibrinogen with VTE may suggest a relative consumptive coagulopathy in critically ill patients with COVID-19.
Language	English
Publishing date	2022-01-18
Publishing country	United States
Document type	Journal Article
ISSN	2639-8028
ISSN (online)	2639-8028
DOI	10.1097/CCE.0000000000000618
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