Jonathan Edlow - Academia.edu (original) (raw)

Papers by Jonathan Edlow

Research paper thumbnail of TiTrATE

Neurologic Clinics, 2015

Diagnosing dizziness can be challenging, and the consequences of missing dangerous causes, such a... more Diagnosing dizziness can be challenging, and the consequences of missing dangerous causes, such as stroke, can be substantial. Most physicians use a diagnostic paradigm developed more than 40 years ago that focuses on the type of dizziness, but this approach is flawed. This article proposes a new paradigm based on symptom timing, triggers, and targeted bedside eye examinations (TiTrATE). Patients fall into 1 of 4 major syndrome categories, each with its own differential diagnosis and set of targeted examination techniques that help make a specific diagnosis. Following an evidence-based approach could help reduce the frequency of misdiagnosis of serious causes of dizziness. In the spirit of the flipped classroom, the editors of this Neurologic Clinics issue on emergency neuro-otology have assembled a collection of unknown cases to be accessed electronically in multimedia format. By design, cases are not linked with specific articles, to avoid untoward cueing effects for the learner. The cases are real and are meant to demonstrate and reinforce lessons provided in this and subsequent articles. In addition to pertinent elements of medical history, cases include videos of key examination findings.

Research paper thumbnail of Value of abdominal CT in the emergency department for patients with abdominal pain

European radiology, 2003

The purpose of our study is to demonstrate the value of CT in the emergency department (ED) for p... more The purpose of our study is to demonstrate the value of CT in the emergency department (ED) for patients with non-traumatic abdominal pain. Between August 1998 and April 1999, 536 consecutive patients with non-traumatic abdominal pain were entered into our study. Using a computer order entry system, physicians were asked to identify: (a) their most likely diagnosis; (b) their level of certainty in their diagnosis; (c) if they thought CT would be normal or abnormal; (d) their treatment plan (prior to knowledge of the CT results); and (e) their role in deciding to order CT. This information was correlated with each patient's post-CT diagnosis and subsequent management. Pre- and post-CT diagnoses were concordant in 200 of 536 (37%) patients. The physicians' certainty in the accuracy of their pre-CT diagnosis was less than high in 88% of patients. Prior to CT, the management plan included hospital admission for 402 patients. Following CT, only 312 patients were actually admitted...

Research paper thumbnail of Spectrum of Dizziness Visits to US Emergency Departments: Cross-Sectional Analysis From a Nationally Representative Sample

Mayo Clinic Proceedings, 2008

To describe the spectrum of visits to US emergency departments (EDs) for acute dizziness and dete... more To describe the spectrum of visits to US emergency departments (EDs) for acute dizziness and determine whether ED patients with dizziness are diagnosed as having a range of benign and dangerous medical disorders, rather than predominantly vestibular ones. A cross-sectional study of ED visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS) used a weighted sample of US ED visits (1993-2005) to measure patient and hospital demographics, ED diagnoses, and resource use in cases vs controls without dizziness. Dizziness in patients 16 years or older was defined as an NHAMCS reason-for-visit code of dizziness/vertigo (1225.0) or a final International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis of dizziness/vertigo (780.4) or of a vestibular disorder (386.x). A total of 9472 dizziness cases (3.3% of visits) were sampled over 13 years (weighted 33.6 million). Top diagnostic groups were otologic/vestibular (32.9%), cardiovascular (21.1%), respiratory (11.5%), neurologic (11.2%, including 4% cerebrovascular), metabolic (11.0%), injury/poisoning (10.6%), psychiatric (7.2%), digestive (7.0%), genitourinary (5.1%), and infectious (2.9%). Nearly half of the cases (49.2%) were given a medical diagnosis, and 22.1% were given only a symptom diagnosis. Predefined dangerous disorders were diagnosed in 15%, especially among those older than 50 years (20.9% vs 9.3%; P<.001). Dizziness cases were evaluated longer (mean 4.0 vs 3.4 hours), imaged disproportionately (18.0% vs 6.9% undergoing computed tomography or magnetic resonance imaging), and admitted more often (18.8% vs 14.8%) (all P<.001). Dizziness is not attributed to a vestibular disorder in most ED cases and often is associated with cardiovascular or other medical causes, including dangerous ones. Resource use is substantial, yet many patients remain undiagnosed.

Research paper thumbnail of Thunderclap Headache With Normal CT and Lumbar Puncture: Further Investigations Are Unnecessary: For

Research paper thumbnail of Overreliance on Symptom Quality in Diagnosing Dizziness: Results of a Multicenter Survey of Emergency Physicians

Mayo Clinic Proceedings, 2007

Research paper thumbnail of Abdominal pain radiating to the back

The Journal of Emergency Medicine, 2003

Research paper thumbnail of Does the presence of crystal arthritis rule out septic arthritis?

The Journal of Emergency Medicine, 2007

The objective of this study was to determine the incidence of septic arthritis in the presence of... more The objective of this study was to determine the incidence of septic arthritis in the presence of joint crystals. A retrospective study was conducted at a university tertiary care referral center. The study population included all patients with synovial fluid crystals in the joint aspirate sent to the laboratory during the 7-year study period. Septic arthritis was defined as a positive synovial culture. Of the 265 joint aspirates containing crystals, 183 (69.0%) contained gout crystals, 81 (30.6%) contained pseudogout crystals, and 1 (0.4%) contained both. Four (1.5%) of the aspirates had positive cultures. The mean synovial WBC of the 4 samples with concomitant crystals and septic arthritis was 113,000 (95% confidence interval [CI] 72,700-153,200), which was significantly higher than the entire population at 23,200 (95% CI 19,400-27,000; p < 0.01). Of note, all 4 patients with concomitant disease had significant co-morbidities and synovial WBC counts greater than 50,000. Septic arthritis and acute crystal-induced arthritis can occur simultaneously; there were 4 cases (1.5%) of concomitant disease in our study population. The presence of crystals cannot exclude septic arthritis with certainty.

Research paper thumbnail of Should calcium and magnesium levels be checked in patients with a prolonged QTc?

Annals of Emergency Medicine, 2004

Research paper thumbnail of 379: Antiplatelet Administration Following Transient Ischemic Attack and Subsequent Stroke Risk: An International Systematic Review

Annals of Emergency Medicine, 2010

Research paper thumbnail of Clinical policy

Annals of Emergency Medicine, 2004

Research paper thumbnail of Clinical Policy: Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department

Annals of Emergency Medicine, 2006

Research paper thumbnail of Value of abdominal CT in the emergency department for patients with abdominal pain

European …, 2003

The purpose of our study is to demonstrate the value of CT in the emergency department (ED) for p... more The purpose of our study is to demonstrate the value of CT in the emergency department (ED) for patients with non-traumatic abdomi-nal pain. Between August 1998 and April 1999, 536 consecutive patients with non-traumatic abdominal pain were entered into our study. ...

Research paper thumbnail of Disconnect Between Charted Vestibular Diagnoses and Emergency Department Management Decisions: A Cross-sectional Analysis From a Nationally Representative Sample

Academic Emergency Medicine, 2009

Research paper thumbnail of National Study on Emergency Department Visits for Transient Ischemic Attack, 1992-2001

Academic Emergency Medicine, 2006

To describe the epidemiology of U.S. emergency department (ED) visits for transient ischemic atta... more To describe the epidemiology of U.S. emergency department (ED) visits for transient ischemic attack (TIA) and to measure rates of antiplatelet medication use, neuroimaging, and hospitalization during a ten-year time period. The authors obtained data from the 1992-2001 National Hospital Ambulatory Medical Care Survey. TIA cases were identified by having ICD-9 code 435. From 1992 to 2001, there were 769 cases, representing 2,969,000 ED visits for TIA. The population rate of 1.1 ED visits per 1,000 U.S. population (95% CI = 0.92 to 1.30) was stable over time. TIA was diagnosed in 0.3% of all ED visits. Physicians administered aspirin and other antiplatelet agents to a small percentage of patients, and 42% of TIA patients (95% CI = 29% to 55%) received no medications at all in the ED. Too few data points existed to measure a statistically valid trend over time. Physicians performed computed tomography scanning in 56% (95% CI = 45% to 66%) of cases and performed magnetic resonance imaging (MRI) in < 5% of cases, and there was a trend toward increased imaging over time. Admission rates did not increase during the ten-year period, with 54% (95% CI = 42% to 67%) admitted. Regional differences were noted, however, with the highest admission rate found in the Northeast (68%). Between 1992 and 2001, the population rate of ED visits for TIA was stable, as were admission rates (54%). Antiplatelet medications appear to be underutilized and to be discordant with published guidelines. Neuroimaging increased significantly. These findings may reflect the limited evidence base for the guidelines, educational deficits, or other barriers to guideline implementation.

Research paper thumbnail of ED patients with vertigo: can we identify clinical factors associated with acute stroke?

The American Journal of Emergency Medicine, 2012

Research paper thumbnail of Predicting difficult and traumatic lumbar punctures

The American Journal of Emergency Medicine, 2007

The objective of this study is to determine if visual and tactile inspection of the spine is usef... more The objective of this study is to determine if visual and tactile inspection of the spine is useful in the prediction of a difficult or traumatic lumbar puncture (LP). This was a prospective, observational, cohort study conducted in the emergency department (ED) on patients who were undergoing an LP. Physicians prospectively completed a structured data form that included information about the patient, number of prior LPs performed, their assessment of the LP difficulty, and the number of needlesticks required. A "difficult" LP and a "traumatic" tap were defined a priori. Chi2, t tests, and regression were used as appropriate; an independent statistician performed the statistical analysis. The study was conducted at an urban university teaching hospital with an annual ED census of approximately 48,000 patients between November 1, 2002, and June 1, 2003. The study population included a convenience sample of patients undergoing LP in the ED. Of the 148 patients enrolled, LP was difficult in 47 (32%) patients and traumatic in 23 (16%) patients. The percentage of patients that did not have a visible spine was significantly higher in the difficult and traumatic groups (P < .05). Among patients where the physician was unable to visualize the spine, there were significantly more difficult LPs (P < .05). It may be possible to predict which patients will have difficult or traumatic LPs before performing the procedure. Simple bedside assessments of spine visibility and palpability may assist in planning the approach to an LP in patients.

Research paper thumbnail of How sensitive is the synovial fluid white blood cell count in diagnosing septic arthritis?

The American Journal of Emergency Medicine, 2007

This study was conducted to determine the sensitivity of the current standard for synovial fluid ... more This study was conducted to determine the sensitivity of the current standard for synovial fluid leukocytosis analysis in diagnosing infectious arthritis or a septic joint. How accurate is the standard synovial fluid white blood cell (WBC) cutoff of 50,000 WBC/mm3 to rule out septic arthritis? We conducted a retrospective study at an urban tertiary care medical center with 50,000 adult emergency department visits per year. The study population consisted of patients with infectious arthritis confirmed by synovial fluid culture growth of a pathogenic organism. The study period lasted from January 1996 to December 2002. Extracted data included synovial fluid leukocyte count, Gram's stain, culture, past medical history, and discharge diagnosis. Fisher exact test was used to compare proportions. Sensitivity and means were calculated with 95% confidence intervals (CI). There were 49 culture-positive synovial fluid aspirates in the 6-year study period. Nineteen (39%) of 49 patients (95% CI, 25%-52%) had a synovial WBC of less than 50,000/mm3 and 30 (61%) of 49 patients (95% CI, 48%-75%) had a synovial WBC of more than 50,000/mm3. The sensitivity of the 50,000 synovial WBC/mm3 cutoff was 61% (95% CI, 48%-75%). Twenty-seven (55%) of 49 patients had a negative Gram's stain (95% CI, 41%-69%) and 15 (56%) of 27 patients (95% CI, 37%-74%) with negative Gram's stain had a synovial WBC of less than 50,000/mm3. A synovial fluid WBC cutoff of 50,000/mm3 lacks the sensitivity required to be clinically useful in ruling out infectious arthritis.

Research paper thumbnail of Assessing the rates of error and adverse events in the ED.

Research paper thumbnail of TiTrATE

Neurologic Clinics, 2015

Diagnosing dizziness can be challenging, and the consequences of missing dangerous causes, such a... more Diagnosing dizziness can be challenging, and the consequences of missing dangerous causes, such as stroke, can be substantial. Most physicians use a diagnostic paradigm developed more than 40 years ago that focuses on the type of dizziness, but this approach is flawed. This article proposes a new paradigm based on symptom timing, triggers, and targeted bedside eye examinations (TiTrATE). Patients fall into 1 of 4 major syndrome categories, each with its own differential diagnosis and set of targeted examination techniques that help make a specific diagnosis. Following an evidence-based approach could help reduce the frequency of misdiagnosis of serious causes of dizziness. In the spirit of the flipped classroom, the editors of this Neurologic Clinics issue on emergency neuro-otology have assembled a collection of unknown cases to be accessed electronically in multimedia format. By design, cases are not linked with specific articles, to avoid untoward cueing effects for the learner. The cases are real and are meant to demonstrate and reinforce lessons provided in this and subsequent articles. In addition to pertinent elements of medical history, cases include videos of key examination findings.

Research paper thumbnail of Value of abdominal CT in the emergency department for patients with abdominal pain

European radiology, 2003

The purpose of our study is to demonstrate the value of CT in the emergency department (ED) for p... more The purpose of our study is to demonstrate the value of CT in the emergency department (ED) for patients with non-traumatic abdominal pain. Between August 1998 and April 1999, 536 consecutive patients with non-traumatic abdominal pain were entered into our study. Using a computer order entry system, physicians were asked to identify: (a) their most likely diagnosis; (b) their level of certainty in their diagnosis; (c) if they thought CT would be normal or abnormal; (d) their treatment plan (prior to knowledge of the CT results); and (e) their role in deciding to order CT. This information was correlated with each patient's post-CT diagnosis and subsequent management. Pre- and post-CT diagnoses were concordant in 200 of 536 (37%) patients. The physicians' certainty in the accuracy of their pre-CT diagnosis was less than high in 88% of patients. Prior to CT, the management plan included hospital admission for 402 patients. Following CT, only 312 patients were actually admitted...

Research paper thumbnail of Spectrum of Dizziness Visits to US Emergency Departments: Cross-Sectional Analysis From a Nationally Representative Sample

Mayo Clinic Proceedings, 2008

To describe the spectrum of visits to US emergency departments (EDs) for acute dizziness and dete... more To describe the spectrum of visits to US emergency departments (EDs) for acute dizziness and determine whether ED patients with dizziness are diagnosed as having a range of benign and dangerous medical disorders, rather than predominantly vestibular ones. A cross-sectional study of ED visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS) used a weighted sample of US ED visits (1993-2005) to measure patient and hospital demographics, ED diagnoses, and resource use in cases vs controls without dizziness. Dizziness in patients 16 years or older was defined as an NHAMCS reason-for-visit code of dizziness/vertigo (1225.0) or a final International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis of dizziness/vertigo (780.4) or of a vestibular disorder (386.x). A total of 9472 dizziness cases (3.3% of visits) were sampled over 13 years (weighted 33.6 million). Top diagnostic groups were otologic/vestibular (32.9%), cardiovascular (21.1%), respiratory (11.5%), neurologic (11.2%, including 4% cerebrovascular), metabolic (11.0%), injury/poisoning (10.6%), psychiatric (7.2%), digestive (7.0%), genitourinary (5.1%), and infectious (2.9%). Nearly half of the cases (49.2%) were given a medical diagnosis, and 22.1% were given only a symptom diagnosis. Predefined dangerous disorders were diagnosed in 15%, especially among those older than 50 years (20.9% vs 9.3%; P<.001). Dizziness cases were evaluated longer (mean 4.0 vs 3.4 hours), imaged disproportionately (18.0% vs 6.9% undergoing computed tomography or magnetic resonance imaging), and admitted more often (18.8% vs 14.8%) (all P<.001). Dizziness is not attributed to a vestibular disorder in most ED cases and often is associated with cardiovascular or other medical causes, including dangerous ones. Resource use is substantial, yet many patients remain undiagnosed.

Research paper thumbnail of Thunderclap Headache With Normal CT and Lumbar Puncture: Further Investigations Are Unnecessary: For

Research paper thumbnail of Overreliance on Symptom Quality in Diagnosing Dizziness: Results of a Multicenter Survey of Emergency Physicians

Mayo Clinic Proceedings, 2007

Research paper thumbnail of Abdominal pain radiating to the back

The Journal of Emergency Medicine, 2003

Research paper thumbnail of Does the presence of crystal arthritis rule out septic arthritis?

The Journal of Emergency Medicine, 2007

The objective of this study was to determine the incidence of septic arthritis in the presence of... more The objective of this study was to determine the incidence of septic arthritis in the presence of joint crystals. A retrospective study was conducted at a university tertiary care referral center. The study population included all patients with synovial fluid crystals in the joint aspirate sent to the laboratory during the 7-year study period. Septic arthritis was defined as a positive synovial culture. Of the 265 joint aspirates containing crystals, 183 (69.0%) contained gout crystals, 81 (30.6%) contained pseudogout crystals, and 1 (0.4%) contained both. Four (1.5%) of the aspirates had positive cultures. The mean synovial WBC of the 4 samples with concomitant crystals and septic arthritis was 113,000 (95% confidence interval [CI] 72,700-153,200), which was significantly higher than the entire population at 23,200 (95% CI 19,400-27,000; p < 0.01). Of note, all 4 patients with concomitant disease had significant co-morbidities and synovial WBC counts greater than 50,000. Septic arthritis and acute crystal-induced arthritis can occur simultaneously; there were 4 cases (1.5%) of concomitant disease in our study population. The presence of crystals cannot exclude septic arthritis with certainty.

Research paper thumbnail of Should calcium and magnesium levels be checked in patients with a prolonged QTc?

Annals of Emergency Medicine, 2004

Research paper thumbnail of 379: Antiplatelet Administration Following Transient Ischemic Attack and Subsequent Stroke Risk: An International Systematic Review

Annals of Emergency Medicine, 2010

Research paper thumbnail of Clinical policy

Annals of Emergency Medicine, 2004

Research paper thumbnail of Clinical Policy: Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department

Annals of Emergency Medicine, 2006

Research paper thumbnail of Value of abdominal CT in the emergency department for patients with abdominal pain

European …, 2003

The purpose of our study is to demonstrate the value of CT in the emergency department (ED) for p... more The purpose of our study is to demonstrate the value of CT in the emergency department (ED) for patients with non-traumatic abdomi-nal pain. Between August 1998 and April 1999, 536 consecutive patients with non-traumatic abdominal pain were entered into our study. ...

Research paper thumbnail of Disconnect Between Charted Vestibular Diagnoses and Emergency Department Management Decisions: A Cross-sectional Analysis From a Nationally Representative Sample

Academic Emergency Medicine, 2009

Research paper thumbnail of National Study on Emergency Department Visits for Transient Ischemic Attack, 1992-2001

Academic Emergency Medicine, 2006

To describe the epidemiology of U.S. emergency department (ED) visits for transient ischemic atta... more To describe the epidemiology of U.S. emergency department (ED) visits for transient ischemic attack (TIA) and to measure rates of antiplatelet medication use, neuroimaging, and hospitalization during a ten-year time period. The authors obtained data from the 1992-2001 National Hospital Ambulatory Medical Care Survey. TIA cases were identified by having ICD-9 code 435. From 1992 to 2001, there were 769 cases, representing 2,969,000 ED visits for TIA. The population rate of 1.1 ED visits per 1,000 U.S. population (95% CI = 0.92 to 1.30) was stable over time. TIA was diagnosed in 0.3% of all ED visits. Physicians administered aspirin and other antiplatelet agents to a small percentage of patients, and 42% of TIA patients (95% CI = 29% to 55%) received no medications at all in the ED. Too few data points existed to measure a statistically valid trend over time. Physicians performed computed tomography scanning in 56% (95% CI = 45% to 66%) of cases and performed magnetic resonance imaging (MRI) in < 5% of cases, and there was a trend toward increased imaging over time. Admission rates did not increase during the ten-year period, with 54% (95% CI = 42% to 67%) admitted. Regional differences were noted, however, with the highest admission rate found in the Northeast (68%). Between 1992 and 2001, the population rate of ED visits for TIA was stable, as were admission rates (54%). Antiplatelet medications appear to be underutilized and to be discordant with published guidelines. Neuroimaging increased significantly. These findings may reflect the limited evidence base for the guidelines, educational deficits, or other barriers to guideline implementation.

Research paper thumbnail of ED patients with vertigo: can we identify clinical factors associated with acute stroke?

The American Journal of Emergency Medicine, 2012

Research paper thumbnail of Predicting difficult and traumatic lumbar punctures

The American Journal of Emergency Medicine, 2007

The objective of this study is to determine if visual and tactile inspection of the spine is usef... more The objective of this study is to determine if visual and tactile inspection of the spine is useful in the prediction of a difficult or traumatic lumbar puncture (LP). This was a prospective, observational, cohort study conducted in the emergency department (ED) on patients who were undergoing an LP. Physicians prospectively completed a structured data form that included information about the patient, number of prior LPs performed, their assessment of the LP difficulty, and the number of needlesticks required. A "difficult" LP and a "traumatic" tap were defined a priori. Chi2, t tests, and regression were used as appropriate; an independent statistician performed the statistical analysis. The study was conducted at an urban university teaching hospital with an annual ED census of approximately 48,000 patients between November 1, 2002, and June 1, 2003. The study population included a convenience sample of patients undergoing LP in the ED. Of the 148 patients enrolled, LP was difficult in 47 (32%) patients and traumatic in 23 (16%) patients. The percentage of patients that did not have a visible spine was significantly higher in the difficult and traumatic groups (P < .05). Among patients where the physician was unable to visualize the spine, there were significantly more difficult LPs (P < .05). It may be possible to predict which patients will have difficult or traumatic LPs before performing the procedure. Simple bedside assessments of spine visibility and palpability may assist in planning the approach to an LP in patients.

Research paper thumbnail of How sensitive is the synovial fluid white blood cell count in diagnosing septic arthritis?

The American Journal of Emergency Medicine, 2007

This study was conducted to determine the sensitivity of the current standard for synovial fluid ... more This study was conducted to determine the sensitivity of the current standard for synovial fluid leukocytosis analysis in diagnosing infectious arthritis or a septic joint. How accurate is the standard synovial fluid white blood cell (WBC) cutoff of 50,000 WBC/mm3 to rule out septic arthritis? We conducted a retrospective study at an urban tertiary care medical center with 50,000 adult emergency department visits per year. The study population consisted of patients with infectious arthritis confirmed by synovial fluid culture growth of a pathogenic organism. The study period lasted from January 1996 to December 2002. Extracted data included synovial fluid leukocyte count, Gram's stain, culture, past medical history, and discharge diagnosis. Fisher exact test was used to compare proportions. Sensitivity and means were calculated with 95% confidence intervals (CI). There were 49 culture-positive synovial fluid aspirates in the 6-year study period. Nineteen (39%) of 49 patients (95% CI, 25%-52%) had a synovial WBC of less than 50,000/mm3 and 30 (61%) of 49 patients (95% CI, 48%-75%) had a synovial WBC of more than 50,000/mm3. The sensitivity of the 50,000 synovial WBC/mm3 cutoff was 61% (95% CI, 48%-75%). Twenty-seven (55%) of 49 patients had a negative Gram's stain (95% CI, 41%-69%) and 15 (56%) of 27 patients (95% CI, 37%-74%) with negative Gram's stain had a synovial WBC of less than 50,000/mm3. A synovial fluid WBC cutoff of 50,000/mm3 lacks the sensitivity required to be clinically useful in ruling out infectious arthritis.

Research paper thumbnail of Assessing the rates of error and adverse events in the ED.