Emergency Medicine Research Associates

Active Studies

Developing a Decision Instrument to Guide Selective Abdominal/Pelvic Imaging of Blunt Trauma Patients

(IRB#15-001602)

Background

Unrecognized abdominal and pelvic injuries can result in catastrophic disability and death. Sporadic reports of “occult” injuries have generated concern, and physicians, fearing that they may miss such an injury, have adopted the practice of obtaining computed tomography on virtually all patients with significant blunt trauma. This practice exposes large numbers patients to dangerous radiation at considerable expense, while detecting injuries in a small minority of cases. Existing data suggest that a limited number of criteria can reliably identify blunt injury victims who have “no risk” of abdominal or pelvic injuries, and hence no need for computed tomography (CT), without misidentifying any injured patient. It is estimated that nationwide implementation of such criteria could result in an annual reduction in radiographic charges of $75 million, and a significant decrease in radiation exposure and radiation induced malignancies.

Objective

This study seeks to determine whether “low risk” criteria can reliably identify patients who have sustained significant abdominal or pelvic injuries and safely decrease CT imaging of blunt trauma patients.

Our Role

All blunt trauma victims undergoing computed tomography (CT) of the abdomen/pelvis in the emergency department (ED) will undergo routine clinical evaluations prior to radiographic imaging. Our volunteers will observe and record vitals for each trauma patient. We are also responsible for assuring that ED physicians record the presence or absence of specific clinical findings as well as the presence or absence of abdominal or pelvic injuries.

 

 

Crystalloid Liberal Or Vasopressors Early Resuscitation in Sepsis (CLOVERS)

(IRB#18-000466)

Background

Sepsis is defined as “a life-threatening organ dysfunction caused by a dysregulated host response to infection” (Sepsis-3 Consensus). It is the leading cause of death in U.S. hospitals and has been identified as a condition requiring early and aggressive intervention. As the condition progresses, it may lead to the state of septic shock in which there is a profound and complex derangement of the inflammatory response and cellular metabolism with vasodilation and circulatory collapse. This condition carries a much higher mortality rate. A landmark study led by Dr. Rivers in 2001 showed that Early Goal Directed Therapy (EGDT), which included the use of intravenous fluids and vasopressors to maintain minimum values of specific vital signs related to perfusion (CVP, SvO2, and MAP) led to a significant decrease in mortality. Large amounts of early intravenous (IV) fluid administration (along with early recognition and administration of antibiotics) has continued to be a mainstay in sepsis treatment. Recent trials (ProCESS, ARISE, and ProMISe) have demonstrated that that targeting of similar physiologic endpoints (CVP, SvO2, and MAP) using fluid resuscitation did not lead to a decrease in mortality. It was interesting to note that overall mortality in all arms was lower than in the 2001 study, presumably due to advances in the overall standard of care (including early recognition and aggressive treatment) of sepsis. Additionally, the FEAST trial, limited to pediatric patients, found that children in septic shock who received early IV fluids had a higher 48-hour mortality. Also, the small CLASSIC trial showed that a more conservative fluid approach led to decreased incidence of kidney injury, though mortality remained similar. This has brought into question the benefits of the widespread practice of aggressive fluid in order to maintain the previously studied hemodynamic endpoints.

Specific Aims

This study aims to determine the impact of a restrictive fluids strategy (vasopressors first followed by rescue fluids) as compared to a liberal fluid strategy (fluids first followed by rescue vasopressors) on 90-day in-hospital mortality in 2,320 patients with sepsis-induced hypotension.

Our Role

Patient screening; assist study team with enrollment and study start up procedures.

 

Diverticulitis Evaluation of Patient Burden, Utilization, and Trajectory

(IRB#16-000599)

Background

Diverticulitis is diagnosed when the small pouches that line the digestive system (called “diverticula”) become inflamed or infected. Symptoms of diverticulitis include moderate to severe abdominal pain, nausea, fever, or chills. When a patient has an episode of diverticulitis, they may be prescribed antibiotics to treat it. Patients who have had several episodes of diverticulitis may consider surgical treatment to remove the affected part of the colon. The perceived burden of diverticulitis on the lives of those who do and do not undergo elective resection and characteristics of those who may report greater impact (e.g., age less than 50) have not been systematically assessed. Addressing these evidence gaps is essential to evaluating the effectiveness of modern diverticulitis care and informing future practice guidelines aimed at more patient-centered care for millions of Americans. The study is important for the development of comparative evaluations of operative and non-operative approaches to diverticulitis and novel non-surgical treatments.

Objective

To better understand the care given to patients who have diverticulitis and their outcomes (whether they have surgery or medical therapy).

Our Role

In this study, our volunteers’ roles span from screening and consenting patients to interviewing patients and completing case report forms.

 

Outpatient Venous Thromboemboelism Management (Outpatient VTE)

(IRB#16-001624)

Background

Venous Thromboembolism (VTE) occurs when a blood clot in a deep vein in the periphery, such as in the leg, groin or arm, also known as deep venous thrombosis (DVT), travels in the circulation and lodges in a pulmonary vessel, known as pulmonary embolism (PE). Until recently, the most common treatment for VTE was the administration of injectable low molecular weight heparin (LMWH) and vitamin K antagonists. However, since the development of oral anticoagulants, such as Apixaban and Rivaroxaban, patients have shown a preference towards this more convenient treatment rather than their injectable counterpart. Regardless of this, physicians are often apprehensive about discharging low-risk patients with VTE, who could be plausibly treated at home with oral anticoagulants, largely due to the lack of a well-founded and standardized system to guarantee their follow up care as well as their full compliance with the treatment plan. As a result, these low-risk patients get unnecessarily admitted and undergo traditional LMWH treatment.

Specific Aims

This work seeks to standardize a protocol which will ameliorate the transition of care of low-risk patients with VTE (including both, PE and DVT) from the emergency department to their homes. The efficacy of this protocol will be assessed by measuring 30-day re-hospitalization rates for patients with VTE receiving outpatient treatment under either one of the following three treatment arms: LMWH, Apixaban, or Rivaroxaban.

Our Role

Patient screening; assist study team with enrollment.

 

Evaluation of the High Sensitivity Troponin Test on Alinity

(IRB#19-000182)

Background

Heart attacks are a type of coronary thrombosis, in which buildup of plaque, fat, and cholesterol can form blockages in the coronary arteries leading to the heart. The resulting myocardial ischemia and myocardial necrosis, characteristic of a typical myocardial infarction (MI), yields a release of cardiac troponin (cTnI) in the blood stream. Due to the specificity and sensitivity of cTnI, the troponin lab is used widely across hospitals in order to detect MI in patients. Current machines that run the troponin lab utilize a multi-use cartridge technology that is subject to degradation over time. However, the newly developed Alinity i STAT High Sensitive Troponin-I assay and analyzer utilizes a single-use cartridge technology that is not subject to this kind of degradation. This study aims to see the effectiveness and efficiency of this new machine relative to current industry standards.

Objective

The primary objective of this study is to evaluate the performance of the investigational Alinity i STAT High Sensitive Troponin-I assay (STAT hsTnI) for both males and females presenting to the ED with chest discomfort or equivalent ischemic symptoms suggestive of ACS.

Our Role

Patient screening; assist study team with enrollment; communicate patient enrollments with Emergency Department Laboratory who will run the Troponin Assay

Pediatric Pulse Oximetry Variation Between Respiratory Diseases

(IRB#18-002048)

Background

Overall, there are about 30 million pediatric patients that present to the emergency departments across the United States and about 2/3 of these patients are under 10 years old. Out of these pediatric patients, about 40% have respiratory illnesses. Due to the rise of the automation industry, respiratory illnesses have become the leading cause of child hospitalization, especially in developing countries. Children are extremely susceptible to air issues as they are still developing their respiratory system, inhale a greater volume of air in proportion to their body weight, and often use rapid and deep mouth breath.

Once a pediatric patient is triaged in the emergency department, vital signs are taken to help detect and monitor medical problems. However, while other vital signs such as heart rate, blood pressure, respiratory rate, etc. give medical professionals information due to previously established quantifications of what is normal, there is little information for interpreting normal initial oxygen saturations in pediatric patients, especially under the age of 2. To this date, there have been very few studies and literature that address what are normal and abnormal initial oxygen saturation values among kids with respiratory illnesses and kids without respiratory illnesses[1].

Objective

The specific aims of this study are to create a predictive model to understand what is a normal and abnormal initial oxygen saturation value for pediatric patients under the age of 11 that present to the emergency department and evaluate whether these values vary if the patient has a respiratory illness. In addition, by comparing initial and final vitals, we can determine if the treatment given to the patient is effective in increasing their oxygen saturation.

Our Role

Our role is to identify any pediatric patients under the age 11 and collect data from the routine examination and evaluation for these patients.

Netrin-1 Myocardial Infarction (MI) Biomarker

(IRB#16-002018)

Background

Approximately 700,000 patients each year are discharged from hospitals throughout the United States with an acute coronary syndrome, including ST-elevation myocardial infarction (STEMI). Among patients with acute coronary syndromes, 25% to 40% present with STEMI. Currently, there are no clinically approved treatments for the prevention of cardiac ischemia/reperfusion (I/R) injury or to limit the extent of cell death following MI. Netrins are a family of laminin-like proteins, which were initially identified for their role in embryonic axonal guidance. The role of netrin-1 in cardiovascular disease is an emerging area of research. The Cai Lab at the UCLA Geffen School of Medicine (DGSOM) previously identified netrin-1 as a biomarker of interest. In addition to functioning as a potent angiogenic factor through nitric oxide production, studies have demonstrated that netrin-1 potentially reduces ischemia-reperfusion induced infarct size by more than 50% while significantly improving cardiac functions, both ex vivo and in vivo. The implicated role of netrin-1 signaling in pre-clinical studies shows promise for the development of a robust therapeutic strategy for acute MI.

Objective

This study aims to assess correlations between netrin-1 signaling and characteristics of myocardial infraction (MI) in patients (including infract size, cardiac functions, and all clinical information pertaining to cardiovascular risk factors). Blood samples will be drawn from qualified candidates that meet the inclusion and exclusion criteria. The collected study data and samples will be held at the UCLA Department of Medicine for future research use. Analyses of patient samples will be conducted to better characterize associations between netrin-1 signaling and characteristics of MI in patients. The findings from this study could in turn be used to evaluate the potential clinical benefits of netrin-1 as a biomarker in cardiovascular illness and the development of novel therapeutic targets for MI.

Our Role

EMRA’s role is to monitor for STEMI patients, obtain initial blood samples drawn by hospital personnel, transport and hand-off samples to laboratory personnel.

Emergency Medicine Palliative Care Access (EMPallA)

(IRB#19-001378)

Background

According to the World Health Organization, palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual. Palliative care can include hospice care, but is distinct from hospice in that it may be delivered throughout the time course of serious, life-limiting illness alongside life-prolonging, disease-model treatment. Emergency department (ED)-initiated palliative care has been shown to improve patient-centered outcomes in older adults with serious, life-limiting illnesses. However, the optimal modality for providing such interventions is unknown.

Objective

The aims of this study are to compare nurse-led telephonic case management to facilitated, outpatient specialty palliative care for older adults with serious, life-limiting illness on: (1) quality of life in patients; (2) healthcare utilisation (eg, ED revisits, hospital admissions, hospice use) (3) loneliness and symptom burden; and (4) caregiver strain,caregiver quality of life, and bereavement.

Our Role

EMRA’s will screen the ED trackboard to identify patients with potential CHF, COPD, or cancer and notify the study team if the patient meets full screening tool criteria.

 

Derivation and Validation of Two Decision Instruments for Selective Chest CT in Blunt Trauma: A Multicenter Prospective Observational Study (NEXUS Chest CT) 10/2015 PLOS
NEXUS Chest Validation of a Decision Instrument for Selective Chest Imaging in Blunt Trauma 10/2013 JAMA Network
External Validation of the San Francisco Syncope Rule 11/2006 Research Gate
Defining “therapeutically inconsequential” head computed tomographic findings in patients with blunt head trauma 07/2014 Annals of Emergency Medicine
Developing a Decision Instrument to Guide Computed Tomographic Imaging of Blunt Head Injury Patients 10/2005 The Journal of Trauma
Using Serial Hemoglobin Levels to Detect Occult Blood Loss in the Early Evaluation of Blunt Trauma Patients 9/2017 The Journal of Emergency Medicine
Emergency medicine and psychiatry agreement on diagnosis and disposition of emergency department patients with behavioral emergencies. 04/2011 Link: Pubmed
Early Neuromuscular Blockade in the Acute Respiratory Distress Syndrome. 05/2019 Link: New England Journal of Medicine