, Abstract-Background: Emergency physicians regularly encounter agitated patients. In extremely agitated and violent patients, the onset of many traditional medications is relatively slow and often requires additional medication. Ketamine is frequently used in emergency departments (EDs) for procedural sedation and intubation, but has recently been suggested as a treatment for acute agitation. Objectives: We sought to examine the use of ketamine in the treatment of acute agitation in an ED setting, including vital sign changes as a result of this medication. Methods: This is a structured review of an historical cohort of patients over 7 years at two university EDs. Patients were included if they received ketamine as treatment for acute agitation. Abstracted data included age, vital signs including hypoxia, any additional medications for agitation, and alcohol/drug intoxication. Results: Ketamine was administered for agitation on 32 visits involving 27 patients. Preadministration systolic blood pressure was 131 ± 20 mm Hg, with an average postadministration increase of 17 ± 25 mm Hg. The average baseline heart rate was 98 ± 23 beats/min, with an average increase of 8 ± 17 beats/min. No patients became hypoxic; 62.5% of patients required additional calming medication. Alcohol or drug intoxication was present in 40.6% of patients. Conclusions: We found ketamine was used rarely, but had few major adverse effects on vital signs even in a population with 21.9% alcohol intoxication. However, a high proportion (62.5%) of patients required additional pharmacologic treatment for agitation, implying that administering ketamine is useful only for initial control of severe agitation. Ó 2015 Elsevier Inc.

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, Abstract-Background: Although first-generation antipsychotics (FGAs) have long been used in the emergency department (ED) to treat acute agitation, little is known about how these medications are used in modern clinical practice. In particular, little work has been published about whether ED clinicians administer FGAs with adjunctive medications in accordance with expert guidelines or the prescribing practices of FGAs over time. Objectives: 1) To provide a comparison of the frequency with which FGAs are administered with adjunctive benzodiazepines or anticholinergic medications. 2) To analyze the prescribing trends for FGAs over time, particularly in the years after the U.S. Food and Drug Administration (FDA) black-box warning for droperidol. Methods: This is a structured review of a retrospective cohort of patients receiving haloperidol or droperidol in two EDs over a 7-year period. Results: Haloperidol or droperidol was administered on 2833 patient visits during the study period, with haloperidol being administered most often. Adjunctive medications are administered less than half of the time. The use of droperidol has remained relatively static, whereas the use of haloperidol has increased. Conclusions: First-generation antipsychotics are still widely utilized in the ED. When administered, these medications are used with adjunctive medications that may decrease side effects less than half of the time. Droperidol use has remained unchanged in the years after the FDA black-box warning, whereas use of haloperidol has continued to rise. Ó 2015 Elsevier Inc.

Dear Editor:The goal of advance care planning (ACP) is for patients to communicate their end-of-life (EoL) treatment preferences to a selected proxy. However, it is not clear what information must be shared to adequately inform a proxy. Given the practical challenges of measuring ACP conversations, previous studies have focused on measuring ACP surrogates such as code status documentation or completion of advance directives (ADs) and/ or physician orders for life-sustaining treatment (POLSTs). 1,2 However, it has been demonstrated that AD completion alone does not necessarily promote high-quality EoL communication or understanding between patients and proxies. 3 The aim of this pilot study was to determine the feasibility of completing a focused ACP conversation identifying an informed proxy in a single clinic visit. This study was completed in adult cancer patients with a prognosis of less than one year. A clinical social worker led the ACP intervention between study patients and proxies focusing on three EoL preferences: (1) the patient's personal definition of quality of life, (2) his or her specific plan if he or she cannot achieve this quality of life, and (3) desired location of death. The proxy was deemed ''informed'' if he or she understood these three EoL preferences. Patients were encouraged but not required to complete an AD/POLST and followed until death.Thirty-five patients were screened and 34 patients were available for the analytic sample (Table 1). Eighty-two percent (n = 28) of proxies were ''informed'' following the intervention, and 65% (n = 22) completed the intervention in a single visit. Following the intervention, 54% completed a new AD (n = 15) and 9% (n = 3) completed a POLST. There was a statistically significant increase in AD/POLST completion ( p < 0.001). For those patients that died (n = 31), there was 81% (n = 25) and 61% (n = 19) concordance of desired and actual code status and location of death, respectively. Neither concordance was significantly different based on the completion of an AD/POLST ( p = 0.34 and p = 0.27). These rates are higher than those demonstrated in prior studies, 1 including our institutional historical rate. 4

67 Background: Cancer cachexia is defined by skeletal muscle loss, with or without fat loss (Fearon et al 2011); however, inclusion criteria for cachexia clinical trials requires a defined weight loss over time rather than muscle loss. We hypothesized that cross sectional imaging may reveal the presence of cachexia otherwise obscured by fat mass changes. Methods: A retrospective analysis of longitudinal CT scans was performed in metastatic colorectal cancer (mCRC) patients screened for a cancer cachexia trial, which required ≥5% weight loss in the prior 6 mos. De-identified CT images were analyzed for total muscle, subcutaneous, and visceral fat cross-sectional areas (cm2) at the 3rd lumbar vertebra at baseline and up to 12 mos prior (Lieffers et al 2009). Logistic regression was used to test differences between patients with <5% vs ≥5% weight loss. Random intercept regression was used to evaluate significant trends in CT measures over time. Results: 42 mCRC patients were screened and 3(7%) enrolled. Patients were excluded for comorbidity/contraindication 14 (33%), excessive [>20%] weight loss 4 (9.5%), and insufficient [<5%] weight loss 19 (45%). For the <5% weight loss subset, there was a mean of 6.7 CT scans (SD=2.67) and of 9% (SD=5.4, min=0%, 25th percentile=4.9%) mean max muscle loss. Notably this group was simultaneously losing muscle (p=0.002) and gaining visceral adipose (p=0.007). For the ≥5% weight loss subset, there was a mean of 7.5 CT scans (SD=4.5) and 20% (SD=10.0, min=5.2%, 25th percentile =10.6) mean max muscle loss. Greater max muscle loss increased the odds of being in the ≥5% weight loss subset (OR=1.19, 95% CI: 1.06,1.33). This group also had a significant decrease in visceral adipose over time (p<0.001). Redefined inclusion criteria of ≥5% muscle loss would have included 14 of the 19 patients excluded because of <5% weight loss. Conclusions: Defining cancer cachexia as weight loss over time may be limited as it does not capture body composition changes and hinders trial accrual. Cross-sectional CT body composition analysis may improve early detection of muscle loss and improve trial accrual.