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Background: Studies of IV magnesium sulfate as a treatment for acute asthma have had mixed results, with some data suggesting a benefit for acute severe asthma, but not for mild-to-moderate asthma. In a multicenter cohort, this study tests the hypothesis that administration of magnesium sulfate improves pulmonary function in patients with acute severe asthma.Design: Placebo-controlled, double-blind, randomized clinical trial.Setting: Emergency departments (EDs) of eight hospitals.Patients: Patients aged 18 to 60 years presenting with acute asthma and FEV1 < or = 30% predicted on arrival to the ED.Intervention: All patients received nebulized albuterol at regular intervals and IV methylprednisolone. Two grams of IV magnesium sulfate or placebo were administered 30 min after ED arrival. The primary efficacy end point was FEV1 at 240 min, and the data analysis was intent to treat.Results: Two hundred forty-eight patients were included, and the mean FEV1 on ED arrival was 22.9% predicted. At 240 min, patients receiving magnesium had a mean FEV1 of 48.2% predicted, compared to 43.5% predicted in the placebo-treated group (mean difference, 4.7%; 95% confidence interval [CI], 0.29 to 9.3%; p = 0.045). A regression model confirmed the effect of magnesium compared to placebo was greater in patients with a lower initial FEV1 (p < 0.05). If the initial FEV1 was < 25% predicted, the final FEV1 was 45.3% predicted in the magnesium-treated group and 35.6% predicted in the placebo-treated group (mean difference, 9.7%; 95% CI, 4.0 to 15.3%; p = 0.001). If the initial FEV was > or = 25% predicted, magnesium administration was not beneficial; the final FEV1 was 51.1% predicted in the magnesium-treated group and 53.9% predicted in the placebo-treated group (mean difference, - 2.9%, 95% CI, - 9.4 to 3.7; p = not significant). Overall, the use of magnesium sulfate did not improve hospital admission rates.Conclusion: Administration of 2 g of IV magnesium sulfate improves pulmonary function when used as an adjunct to standard therapy in patients with very severe, acute asthma. [ABSTRACT FROM AUTHOR]

Background: Patients with dementia, an underrecognized terminal illness, frequently visit the emergency department (ED). These patients may benefit from ED-initiated palliative care (PC) consultation., Objective: The study's objective was to track the rate of ED-initiated PC consultation for patients with advanced dementia (AD) after an educational intervention, and to categorize decision making for physicians who chose not to initiate consultation., Methods: As part of a quality improvement project at a suburban, tertiary care, university-affiliated medical center, emergency physicians (EPs) were taught to identify AD patients and initiate PC consultation. A convenience sample of patients over age 70 was screened for AD by research staff from July 1, 2012 to August 1, 2012 using the Functional Assessment Staging (FAST) criteria. A questionnaire was then administered to patients' physicians to inquire about barriers to initiating consultation. Questionnaires and medical records of those who met AD criteria were reviewed to examine patient characteristics, disposition information, and consultation initiation barriers., Results: Patients (N=548) over 70 who visited the ED were approached and 304 completed the screening. Fifty-one of the 304 met criteria for AD. Their average age was 86; 33% were male. Eighteen of the 51 (35%) patients received a PC consultation sometime during their ED or hospital stay. Four of the 18 (22%) consultations were ED initiated. In 23 of 51 (45%) unique cases, physicians responded to the questionnaire. The majority felt that a PC consult was not appropriate for patients based on their knowledge, attitudes, or beliefs., Conclusion: Preexisting physician attitudes, knowledge, and beliefs prevent emergency physicians from addressing PC needs for AD patients.

Objective: To prospectively evaluate psychological stress reactions among residents in an emergency medicine (EM) rotation during a 4-week period., Methods: Pre- and postrotation psychological distress levels were assessed over a 4-week EM rotation. Subjects were evaluated by several psychometric measures. These included the assessment of anxiety, depressive, and other psychological symptoms by the Brief Symptom Inventory (BSI), and the occurrence of traumatic anxiety via the Dissociative Experience Scale (DES). Also assessed were the Impact of Events Scale and the Holmes Social Readjustment Ratings Scale (Holmes), a baseline life-change measure. Demographic data were obtained. The study occurred in a university-affiliated teaching hospital ED. The 45 EM residents and 27 non-EM residents were analyzed as a group, followed by subgroup analysis comparing EM vs non-EM residents., Results: An increase in psychological distress over the 4-week rotation was found in the non-EM group, but not in the EM group. For the non-EM residents, all 10 BSI scales worsened and 3 of 4 DES scales worsened (p = 0.002), indicative of increased psychological distress. In contrast, analysis of the 45 EM residents showed improvement in 8 of 10 BSI scales and 3 of 4 DES scales (p = 0.057)., Conclusion: A significant increase in psychologic distress was found among the non-EM residents during an EM rotation. The EM residents showed a trend for a decrease in psychological distress over the same 4-week period.

Study Objective: This study was conducted to determine whether intravenous magnesium sulfate (MgSO4), when used as part of a standardized treatment protocol, can improve pulmonary function and decrease admission rate in patients presenting to the emergency department with exacerbations of asthma., Design: In this randomized double-blind placebo-controlled study, patients with acute asthma were treated with inhaled beta-agonists at regular intervals and intravenous (IV) steroids. At 30 min after entry, patients received either 2 g IV MgSO4 or IV placebo. Patients were monitored for up to 4 h with regular measurements of pulmonary function. Patients who were discharged from the emergency department were contacted at 1 day and 7 days for follow-up., Setting: Emergency departments of a university-affiliated, voluntary hospital and municipal hospital., Participants: Asthmatics aged 18 to 65 years during acute exacerbation with FEV1 less than 75% predicted both before and after a single albuterol treatment., Interventions: Patients were given 2 g of MgSO4 or placebo as an adjunct to standardized emergency department procedure for acute asthma., Measurements and Results: One hundred thirty-five patients were studied. Hospital admission rates were 35.3% for placebo-treated group and 25.4% for the magnesium-treated group (p = 0.21). FEV1 measured at 120 min was 56% predicted for the placebo-treated group and 55% predicted for the magnesium-treated group. (p = 0.92) For subgroup analysis, patients were divided into "severe" (baseline FEV1 < 25% predicted on presentation) or "moderate" (baseline FEV1, 25 to 75% predicted on presentation). For the severe group, admission rates were 78.6% (11/14) for the placebo-treated group and 33.3% (7/21) for the magnesium-treated group (p = 0.009). For the moderate patients, admission rates were 22.4% (11/49) for the placebo-treated group and 22.2% (10/25) for the magnesium-treated group (p = 0.98). There was no significant improvement in FEV1 in the moderate group for magnesium-treated patients. However, in the severe group, there was a significant improvement in FEV1 at 120 min and 240 min (p = 0.014 and 0.026, respectively)., Conclusion: Intravenous MgSO4 decreased admission rate and improved FEV1 in patients with acute severe asthma but did not cause significant improvement in patients with moderate asthma.