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Introduction: Tension pyopneumothorax is a rare, life-threatening condition that occurs as a complication of intrathoracic infection or bronchopleural fistula. In the few cases reported in the literature, the patients typically have multiple comorbidities, underlying lung disease, and/or an immunocompromised state., Case Report: This case describes tension pyopneumothorax in a previously healthy adolescent male with no existing risk factors for this disease. After emergent stabilization and admission, surgical exploration of the chest revealed no fistulas or pleural defects. Extensive workup did not show any underlying risk factors for development of this condition., Conclusion: This case of pyopneumothorax with progression to tension physiology is exceedingly rare. Uniquely, the patient had no underlying medical or anatomical predisposition to developing this condition. The case also emphasizes pediatric patients' capacity to compensate in the setting of critical illness., Competing Interests: Conflicts of Interest: By the CPC-EM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none.

Introduction: The perforation of a cecal diverticulum is a rare and challenging condition for the emergency physician., Case Report: A 47-year-old man with a past surgical history of bilateral inguinal hernia repair presented to the emergency department (ED) with acute abdominal pain of three days' duration. Pain was localized to the right lower quadrant (RLQ), with anorexia as the only associated symptom. Upon arrival to the ED, his exam demonstrated focal RLQ tenderness to palpation, rebound tenderness, and guarding. Labs did not show any elevation in inflammatory markers, liver enzymes, or lipase. Computed tomography showed no evidence of acute appendicitis, colitis, or hernia recurrence. After morphine and reassessment, the patient still had a focal peritoneal exam in the RLQ. Surgical consultation was obtained and recommended additional non-opioid analgesia as well as serial abdominal exams. After several repeat abdominal exams, there was no change in the focality of the patient's pain. Surgery was reconsulted and opted to take the patient to the operating room for exploratory laparoscopy with "appendicitis" as the presumptive diagnosis. Pathology report revealed a perforated cecal diverticulum that was adherent to the abdominal wall. The patient did well and was discharged on his third postoperative day., Conclusion: This case further underlines that even in the era of sensitive imaging tools, the diagnostic value of a targeted physical exam with clinical re-evaluation can never be overestimated.

Background: There is a growing movement to increase palliative care consults from the emergency department (ED) to reduce healthcare costs and improve quality of life. The surprise question is a screening tool that emergency medicine physicians may be able to use towards achieving this goal., Objective: The objectives of this study were to increase awareness of hospice and palliative care medicine (HPM) among emergency medicine (EM) providers and to evaluate whether this heightened awareness increased palliative care consults among participating emergency medicine providers., Methods: We conducted an anonymous convenience sample survey and two educational interventions about HPM including the surprise question among emergency medicine resident and attending physicians at a large urban public academic quaternary care center from July to November 2018. A report of palliative care consults ordered between August 1, 2017 and January 1, 2019 was generated from the electronic health records used by the hospital. The number of palliative care consults made before and after the educational intervention was compared., Results: After the first educational intervention centered on the surprise question, palliative care consults from the ED increased from an average of 2.25 per month (range 0 to 8, SD: 2.38) to 12.67 per month (range 9 to 19, SD: 4.01, p < .001)., Conclusion: Educating EM physicians about the surprise question can increase the number of palliative care consults from the ED, thereby potentially improving patient care and decreasing costs by avoiding unwanted healthcare interventions.

Emergency department presentations of syncope can vary from benign to life-threatening etiologies. Older patients are at increased risk of cardiac causes of syncope. Ventricular standstill is a rare phenomenon that can manifest as syncope and must be correctly identified and promptly treated to prevent sudden cardiac arrest. We report the case of a 70-year old man with dizziness and convulsive syncope whose initial ECG showed a right bundle branch block, but then developed ventricular standstill and intermittent high-grade AV block while still in the ED. He was transferred to the ICU and underwent pacemaker implantation. A high index of suspicion for dysrhythmias should be maintained for any patient presenting to the ED with high-risk syncope., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Thoracolumbar (TL) injury is a common finding in the severely injured multi-trauma patient. However, the incidence and pattern of TL injury in patients with milder trauma is unclear., Objective: The aim of this study was to collect and analyze evidence for the development of a clinical decision rule (CDR) to evaluate the TL spine in patients with non-severe blunt trauma and avoid dedicated imaging in low-risk cases., Methods: Adult patients with blunt trauma who presented to a major academic center (May 2016 to October 2017) and received dedicated imaging of the TL spine were included. Exclusion criteria consisted of any coexisting condition preventing the acquisition of history or examination. The primary endpoint is TL spine injury requiring orthopedic evaluation, bracing/orthosis, or surgery. Preliminary CDR derivation was performed with recursive partitioning., Results: Of 4612 patients screened, 1049 (22.7%) met inclusion criteria. Thirty-six (3.4%) patients were found to have TL spine injury, of which 88.9% received spinal bracing, orthosis, or surgery. Absence of midline tenderness conveyed the highest negative predictive value, followed by a non-severe mechanism of injury, lack of neurologic examination findings, and age < 65 years. No patients in this cohort with these four findings had a TL spine injury., Conclusions: In certain lower-risk blunt trauma patients < 65 years of age, focused examination combined with mechanism of injury may be highly sensitive (100%) to rule out TL injury without the need for dedicated imaging. However, validation is necessary, given multiple study limitations. Potential instrument to screen for TL injury in minor trauma: TL injury is unlikely if all four of the following are present: 1) no midline back tenderness or deformity, 2) no focal neurologic signs or symptoms or altered mentation, 3) age < 65 years; and 4) lack of severe mechanism of injury, for example, fall greater than standing, motor-vehicle collision with rollover/ejection/pedestrian or unenclosed vehicle, and assault with a weapon., (Copyright © 2019 Elsevier Inc. All rights reserved.)

En: Although infection rates and the impact of infection on hospital emergency departments (EDs) are known or can be reliably estimated, the incidence and prevalence of sepsis vary in relation to which definitions or registers used. Sepsis is also well known to be under-diagnosed by physicians in general and by ED physicians in particular. Over half of sepsis cases are community-acquired, and 50% to 60% of patients in intensive care units (ICUs) with sepsis or septic shock are admitted directly from the ED. Pneumonia and urinary tract infections are the most common points of focus in sepsis, septic shock, bacteremia, and ED admissions to the ICU for infectious processes. For this article a multinational group of experts representing Latin American emergency medicine associations reviewed and analyzed similarities and differences in the epidemiology of sepsis in different geographic locations. We consider key aspects and geographic similarities and differences in the early identification of patients with severe sepsis; criteria that define the diagnosis; appropriate early antibiotic and fluid therapy; the roles of triage systems and multidisciplinary sepsis code units; and the use of biological markers in this time-dependent disease. We also discuss key points and strategies for improving the diagnosis, prognosis, and care of sepsis patients in the ED.

Objective: To calculate the emergency department (ED)-level Escherichia coli percentage of isolates susceptible to commonly used antibiotics and to determine the risk factors associated with inadequate empiric antibiotic therapy among patients treated for urinary tract infections (UTIs) in our ED., Methods: Retrospective cohort study conducted at a large tertiary teaching hospital. Participants included patients older than 18years of age who had a urine culture with growth of >100,000 colonies of E. coli. Demographic and therapeutic choices associated with inadequate empiric antibiotic therapy were explored. Antimicrobial susceptibility pattern of E. coli isolates recovered from ED patients were calculated, and stratified by gender and age., Results: A total of 300 unique patients had E. coli bacteriuria during the study period. Among patients who received at least one dose of antibiotic in the ED, variables independently associated with an increased risk of inadequate empiric therapy were age (relative risk [RR] 1.016; 95% confidence interval [CI] 1.001-1.031; P=0.032), male gender (RR 2.507; 95% CI 1.470-4.486; P=0.001), and use of fluoroquinolones (RR 2.128; 95% CI 1.249-3.624 P=0.005). Sub-group analysis of patients discharged from the ED showed that definitive therapy with nitrofurantoin decreased the risk of inadequate empiric antibiotic therapy by 80% (RR 0.202; CI 0.065-0.638; P=0.006). ED-level antibiograms showed differences in antimicrobial susceptibility of E. coli by age and gender., Conclusions: Development of ED-level antimicrobial susceptibility data and consideration of patients' clinical characteristics can help better guide selection of empiric antibiotic therapy for the treatment of UTIs., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Organisms resistant to antimicrobials continue to emerge and spread. This study was performed to measure the medical and societal cost attributable to antimicrobial-resistant infection (ARI)., Methods: A sample of high-risk hospitalized adult patients was selected. Measurements included ARI, total cost, duration of stay, comorbidities, acute pathophysiology, Acute Physiology and Chronic Health Evaluation III score, intensive care unit stay, surgery, health care-acquired infection, and mortality. Hospital services used and outcomes were abstracted from electronic and written medical records. Medical costs were measured from the hospital perspective. A sensitivity analysis including 3 study designs was conducted. Regression was used to adjust for potential confounding in the random sample and in the sample expanded with additional patients with ARI. Propensity scores were used to select matched control subjects for each patient with ARI for a comparison of mean cost for patients with and without ARI., Results: In a sample of 1391 patients, 188 (13.5%) had ARI. The medical costs attributable to ARI ranged from $18,588 to $29,069 per patient in the sensitivity analysis. Excess duration of hospital stay was 6.4-12.7 days, and attributable mortality was 6.5%. The societal costs were $10.7-$15.0 million. Using the lowest estimates from the sensitivity analysis resulted in a total cost of $13.35 million in 2008 dollars in this patient cohort., Conclusions: The attributable medical and societal costs of ARI are considerable. Data from this analysis could form the basis for a more comprehensive evaluation of the cost of resistance and the potential economic benefits of prevention programs.

Urothelial plaques consist of four major uroplakins (Ia, Ib, II, and III) that form two-dimensional crystals covering the apical surface of urothelium, and provide unique opportunities for studying membrane protein assembly. Here, we describe a novel 35-kD urothelial plaque-associated glycoprotein that is closely related to uroplakin III: they have a similar overall type 1 transmembrane topology; their amino acid sequences are 34% identical; they share an extracellular juxtamembrane stretch of 19 amino acids; their exit from the ER requires their forming a heterodimer with uroplakin Ib, but not with any other uroplakins; and UPIII-knockout leads to p35 up-regulation, possibly as a compensatory mechanism. Interestingly, p35 contains a stretch of 80 amino acid residues homologous to a hypothetical human DNA mismatch repair enzyme-related protein. Human p35 gene is mapped to chromosome 7q11.23 near the telomeric duplicated region of Williams-Beuren syndrome, a developmental disorder affecting multiple organs including the urinary tract. These results indicate that p35 (uroplakin IIIb) is a urothelial differentiation product structurally and functionally related to uroplakin III, and that p35-UPIb interaction in the ER is an important early step in urothelial plaque assembly.