Acute Lower Gastrointestinal Bleeding in an Emergency Department and Performance of the SHA2PE Score: A Retrospective Observational Study

Lower gastrointestinal bleeding (LGIB) is a frequent cause of emergency department (ED) consultation, leading to investigations but rarely to urgent therapeutic interventions. The SHA2PE score aims to predict the risk of hospital-based intervention, but has never been externally validated. The aim of our single-center retrospective study was to describe patients consulting our ED for LGIB and to test the validity of the SHA2PE score. We included 251 adult patients who consulted in 2017 for hematochezia of <24 h duration; 53% were male, and the median age was 54 years. The most frequent cause of LGIB was unknown (38%), followed by diverticular disease and hemorrhoids (14%); 20% had an intervention. Compared with the no-intervention group, the intervention group was 26.5 years older, had more frequent bleeding in the ED (47% vs. 8%) and more frequent hypotension (8.2% vs. 1.1%), more often received antiplatelet drugs (43% vs. 18%) and anticoagulation therapy (28% vs. 9.5%), more often had a hemoglobin level of <10.5 g/dl (49% vs. 6.2%) on admission, and had greater in-hospital mortality (8.2% vs. 0.5%) (all p < 0.05). The interventions included transfusion (65%), endoscopic hemostasis (47%), embolization (8.2%), and surgery (4%). The SHA2PE score predicted an intervention with sensitivity of 71% (95% confidence interval: 66–83%), specificity of 81% (74–86%), and positive and negative predictive values of 53% (40–65%) and 90% (84–95%), respectively. SHA2PE performance was inferior to that in the original study, with a 1 in 10 chance of erroneously discharging a patient for outpatient intervention. Larger prospective validation studies are needed before the SHA2PE score can be recommended to guide LGIB patient management in the ED.

Pharmacist-Driven Culture and Sexually Transmitted Infection Testing Follow-Up Program in the Emergency Department

Expanding pharmacist-driven antimicrobial stewardship efforts in the emergency department (ED) can improve antibiotic management for both admitted and discharged patients. We piloted a pharmacist-driven culture and rapid diagnostic technology (RDT) follow-up program in patients discharged from the ED. This was a single-center, pre- and post-implementation, cohort study examining the impact of a pharmacist-driven culture/RDT follow-up program in the ED. Adult patients discharged from the ED with subsequent positive cultures and/or RDT during the pre- (21 August 2018–18 November 2018) and post-implementation (19 November 2018–15 February 2019) periods were screened for inclusion. The primary endpoints were time from ED discharge to culture/RDT review and completion of follow-up. Secondary endpoints included antimicrobial agent prescribed during outpatient follow-up, repeat ED encounters within 30 days, and hospital admissions within 30 days. Baseline characteristics were analyzed using descriptive statistics. Time-to-event data were analyzed using the Wilcoxon signed-rank test. One-hundred-and-twenty-seven patients were included, 64 in the pre-implementation group and 63 in the post-implementation group. There was a 36.3% reduction in the meantime to culture/RDT data review in the post-implementation group (75.2 h vs. 47.9 h, p < 0.001). There was a significant reduction in fluoroquinolone prescribing in the post-implementation group (18.1% vs. 5.4%, p = 0.036). The proportion of patients who had a repeat ED encounter or hospital admission within 30 days was not significantly different between the pre- and post-implementation groups (15.6 vs. 19.1%, p = 0.78 and 9.4% vs. 7.9%, p = 1.0, respectively). Introduction of a pharmacist culture and RDT follow-up program in the ED reduced time to data review, time to outpatient intervention and outpatient follow-up of fluoroquinolone prescribing.

Manualised Cognitive Behaviour Therapy for Anorexia Nervosa: Use of Treatment Modules in the ANTOP Study

Standardised treatment manuals facilitate therapy planning and enhance comparability for research purposes. Within the Anorexia Nervosa Treatment of Out Patients (ANTOP) study, the largest multisite outpatient intervention trial in anorexia nervosa (AN) to date, manualised enhanced cognitive-behavioural therapy (CBT-E) was offered as one treatment modality. The manual consisted of 9 modules, of which Motivation, Nutrition, Formulation and Relapse Prevention were compulsory. Homework worksheets were provided, to ensure the transfer of therapeutic improvements to daily life. This study investigated the use of modules and worksheets in order to explore practice styles of trained therapists in the treatment of AN. This secondary analysis was based on log-sheets (n = 2604) CBT-E therapists completed after each session. Frequencies of modules and worksheets used across all sessions were calculated. Relationships, such as that between use of module and duration of illness, were examined. The most commonly used module was Motivation. In patients with longer illness duration, the module Self Esteem seemed to be particularly important. The worksheet Scales, balancing the pros and cons of AN, was prioritised by therapists. The results underline the importance of motivational work in the treatment of AN, including validating the ambivalence experienced by most AN patients. With increasing duration of illness, resource-oriented elements, such as self esteem stabilisation, should be of focus.