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Introduction: Claims data raises the possibility that on demand telemedicine programs might increase new utilization, offsetting the cost benefits described in some retrospective analyses. We prospectively evaluated the cost of a synchronous audio-video on-demand telemedicine taking into account both what patients would have done instead of the telemedicine visit as well as the care patients received after the visit., Materials and Methods: We conducted a prospective observational study of patients who received care from an on-demand telemedicine program. At the time of the visit, we surveyed patients about the alternative care that would have been requested, if they had not done the telemedicine visit. We also obtained information following the visit about what further care was received. Using cost data derived from the literature we performed a sensitivity analysis to determine the cost impact of the on-demand telemedicine visit., Results: There were 650 patients enrolled with a mean age of 37 who were 68% female; 74% had their care concerns resolved on the telemedicine visit; only 16% would have "done nothing" if they had not done the telemedicine visit, representing possible new utilization. Net cost savings per telemedicine visit was calculated to range from $19-$121 per visit., Conclusions: In our on-demand telemedicine program, we found the majority of health concerns could be resolved in a single consultation and new utilization was infrequent. Synchronous audio-video telemedicine consults resulted in short-term cost savings by diverting patients from more expensive care settings., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Previous studies have demonstrated lower mortality among patients transported to single urban trauma centers by private vehicle (PV) compared with Emergency Medical Services (EMS). We sought to describe the characteristics and outcomes of injured patients transported by PV in a state trauma system compared to patients transported by EMS., Methods: We performed a retrospective cohort study of state trauma registry data for patients admitted to all Pennsylvania trauma centers over 5 years (1/2003 to 12/2007). Our primary exposure of interest was prehospital mode of transport and our primary outcome of interest was in-hospital mortality. Unadjusted analyses were performed as were adjusted analyses controlling for injury severity. Data are presented as percents, odds ratios (ORs), and 95% confidence intervals., Results: Of the 91132 patients analyzed, 9.6% were transported to the emergency department by PV and 90.4% by EMS. Overall Injury Severity Score (ISS) was 13.3 ± 11.0 (ISS for EMS 13.7 ± 11.3, PV 9.2 ± 7.1, P < .001), and 6.6% of patients died (EMS 7.1%, PV 1.5%, P < .001). After adjusting for injury severity, patients transported by EMS were more likely to die than PV patients (OR 1.9 [95% CI 1.5-2.4]). This effect persisted in blunt, penetrating, advanced life support, and basic life support subgroups, but not in the severely injured (ISS >15, ISS >25) subgroups., Conclusions: Nearly 10% of injured patients arrive at trauma centers by private vehicle. Transport of injured patients by EMS was associated with higher mortality than PV transport. This may reflect the effects of prehospital time, prehospital interventions, or other confounders., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Dignitary Protection Medicine (DPM) is a new area of medical expertise that incorporates elements of virtually all medical and surgical specialties, drawing heavily from travel, tactical and expedition medicine. The fundamentals of DPM stem from the experiences of White House, State Department and other physicians who have traveled extensively with dignitaries. Furthermore, increased international travel of business executives and political dignitaries has mandated a need for proficiency in this realm. We sought to define the requisite knowledge base and skill sets that form the foundation of this new area of specialization., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Study Objective: Despite creatinine clearance (CrCl) being a better estimate of renal function, serum creatinine (Cr) is more commonly used to screen for renal insufficiency in patients scheduled for an enhanced abdominal computed tomography (CT) in an attempt to reduce the likelihood of contrast-induced nephropathy (CIN). Our objective was to determine the incidence of renal insufficiency (a CrCl <60 mL/min) among patients who have serum Cr below 1.5 mg/dL (the most commonly accepted Cr cutoff for the administration of intravenous contrast). This study was conducted in a population of emergency department patients with acute abdominal pain being considered for CT scan., Methods: We performed post hoc analysis of a prospective cross-sectional study that enrolled nongravid adults with acute nontraumatic abdominal pain. Patients on dialysis were excluded. The data that we collected included demographics, history, duration/description of pain, patient reported weight, laboratory data, imaging studies, and final diagnosis. Creatinine clearance values (< or >60 mL/min) were compared to Cr values of 1.0, 1.2, 1.5, and 1.8 mg/dL to determine the percentage of patients at risk for nephropathy after contrast injection at each Cr cutoff. Descriptive statistics were used with 95% confidence intervals (CIs)., Results: Seven hundred sixty-five patients were enrolled; 59% (451/765) had an abdominal CT scan. Of 108 patients with CrCl less than 60 mL/min, 59 patients had a Cr less than 1.8 mg/dL (55%; 95% CI, 45%-64%); 43 had a Cr less than 1.5 mg/dL, the most commonly accepted Cr cutoff for contrast administration (40%; 95% CI, 31%-50%); 21 patients had a Cr less than 1.2 mg/dL (19%; 95% CI, 12%-28%); and 10 had a Cr less than 1.0 mg/dL (9%; 95% CI, 5%-16%)., Conclusion: The most commonly used Cr cutoff (1.5 mg/dL) for contrast administration fails to identify 40% of the patients at risk for CIN. Future studies should address whether using CrCl rather than serum Cr decreases the incidence of contrast-induced nephropathy.