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Objectives Patients with chronic diseases are often forced to seek emergency care for exacerbations. In the face of large predicted increases in the prevalence of chronic diseases, there is increased pressure to avoid hospitalizing these patients at the end of the ED visit, if they can obtain the care they need in the outpatient setting. We performed this scoping study to provide a broad overview of the published literature on the transition of care between ED and primary care following ED discharge. Methods We performed a MEDLINE search of English-language articles published between 1990 and March 2015. We created a data-charting form a priori of the search. Papers were organized into themes, with new themes created when none of the existing themes matched the paper. Papers with multiple themes were assigned preferentially to the theme that was consistent with their primary objectives. We created a descriptive numerical summary of the included studies. Results Of 1,138 titles, there were 252 potentially relevant abstracts, and among those 122 met criteria for full paper review. An additional 11 papers were acquired from reference review. From the 133 papers, 85 were included in the study. The papers were categorized into seven themes. These included Follow-up compliance and its predictors (38 studies), Telephone calls to discharged ED patients (15 studies), ED navigators (14 studies), The current system (nine studies), Ways to alert primary care providers ( PCPs) of the ED visit (seven studies), and Patient views and PCP information requirements (one each). In the Follow-up compliance and predictors theme, the two most frequently identified significant predictors for increasing the frequency of follow-up care were the provision of a follow-up appointment time prior to ED departure and the presence of health insurance. Follow-up telephone calls to patients resulted in better follow-up rates, but increased ED return visits in some studies. In the current system patients themselves are the conduit, and the barriers to follow-up care can be high. E-mail and/or electronic medical record alerts to the PCP are relatively new, and no studies limited the alerts to patients who had a defined need for follow-up care. Conclusions A plethora of work has been published on the transition of care from ED to primary care. To decrease hospitalizations among the upcoming wave of patients with chronic diseases, it appears that the two most efficient areas to target are a primary care follow-up appointment system and health insurance. Further research is needed in particular to identify the patients who actually need follow-up care and to develop information technology solutions that can be effectively implemented within the current emergency healthcare system. [ABSTRACT FROM AUTHOR]

Background: Critically ill children may require airway management to optimize delivery of oxygen and ventilation during resuscitation. We performed a systematic review of studies comparing the use of bag‐valve‐mask ventilation (BVM), supraglottic airway devices (SGA), and endotracheal intubation (ETI) in pediatric patients requiring prehospital airway management. Methods: We searched Ovid MEDLINE, EMBASE, and Cochrane databases for papers that compared SGA or ETI to BVM use in children, including studies that reported survival outcomes. We followed the Preferred Reporting Items in Systematic Reviews and Meta‐Analyses (PRISMA) guidelines and assessed study quality using the Newcastle‐Ottawa Scale. We compared key characteristics of the candidate papers, including inclusion criteria, definitions of airway interventions, and association with outcomes. Results: Of 773 studies, eight met criteria for inclusion. Only one study was a randomized controlled trial; the other seven studies were observational. Four studies compared ETI to BVM, two studies compared SGA to BVM, one study compared ETI to SGA, and two studies compared advanced airway management (AAM) to BVM. Primary outcomes varied, ranging from overall mortality and 24‐h mortality to 1‐month survival, hospital survival, and neurologically favorable survival. Four of the studies found no difference in survival with the use of ETI, and four found increased mortality with the use of ETI. Associations with outcomes could not be assessed by meta‐analysis due to limited number of studies and the wide variation in the design, population, interventions, and outcome measures of the included studies. Conclusions: In this systematic review, studies of prehospital pediatric airway management varied in scope, design, and conclusions. There was insufficient evidence to evaluate efficacy of pediatric prehospital airway management; however, the current research suggests that there are equal or worse outcomes with the use of ETI compared to other airway techniques. Additional clinical trials are needed to assess the merits of this practice. [ABSTRACT FROM AUTHOR]

Abstract: Background: This systematic review addresses the controversy over the decision to anticoagulate patients with subsegmental pulmonary embolism (SSPE). Methods: We searched Ovid MEDLINE, PubMed, Embase, the Cochrane Library, Scopus, Web of Science, ClinicalTrials.gov, Google Scholar, and bibliographies in March 2017. Two authors reviewed and retained papers with symptomatic patients who underwent computerized tomographic pulmonary angiography and had sufficient information to determine SSPE; decision to treat (or not) with systemic anticoagulation; and outcomes of bleeding, venous thromboembolism (VTE) recurrence, and death. Papers were assessed for selection and publication bias and heterogeneity, with Eggers and the inconsistency indexes (I2). Results: From 1,512 papers screened, we included 14 studies comprising 15,563 patients for full‐length review and analysis. Pooled data demonstrated I2 = 99% with an Eggers p < 0.001, suggesting significant publication bias. The pooled prevalence of SSPE was 4.6% (95% confidence interval [CI] = 1.8%–8.5%). The frequency of bleeding in SSPE patients treated with anticoagulation (n = 589) was 8.1% (95% CI = 2.8%–15.8%), with no available bleeding data in untreated patients (n = 126). The frequency of VTE recurrence within 90 days was 5.3% (95% CI = 1.6%–10.9%) for treated versus 3.9% (95% CI = 4.8%–13.4%) for untreated, while the frequency of death was 2.1% (95% CI = 3.4%–5.2%) for treated versus 3.0% (95% CI = 2.8%–8.6%) for untreated. Conclusion: This systematic review highlights the lack of any clinical trial to make a clear inference about harm or benefit of anticoagulation for SSPE. Comparison of pooled data from uncontrolled outcome studies shows no increase in VTE recurrence or death rates for patients who were not anticoagulated. These data suggest clinical equipoise for decision to anticoagulate or not anticoagulate patients with SSPE. However, this inference is limited by small numbers, imprecision, and the lack of a controlled clinical trial. [ABSTRACT FROM AUTHOR]

Objectives: Survivors of acute cardiovascular disease (CVD) events, such as acute coronary syndrome (ACS) and stroke, may experience significant psychological distress during and following the acute event. Long‐term adverse effects may follow, including the development of posttraumatic stress disorder (PTSD), increased overall all‐cause mortality, and recurrent cardiac events. The goal of this concepts paper is to describe and summarize the rates of adverse psychological outcomes, such as PTSD, following cardiovascular emergencies, to review how these psychological factors are associated with increased risk of future events and long‐term health and to provide a theoretical framework for future work. Methods: A panel of two board‐certified emergency physicians, one with a doctorate in experimental psychology, along with one PhD clinical psychologist with expertise in psychoneuroendocrinology were co‐authors involved in the paper. Each author used various search strategies (e.g., PubMed, Psycinfo, Cochrane, and Google Scholar) for primary research and reviewed articles related to their section. The references were reviewed and evaluated for relevancy and included based on review by the lead authors Results: A meta‐analysis of 24 studies (N > 2,300) found the prevalence of ACS‐induced PTSD at nearly 12%, while a meta‐analysis of nine studies (N = 1,138) found that 25% of survivors of transient ischemic attack and stroke report PTSD symptoms. The presence of PTSD doubles 3‐year risk of CVD/mortality risk in ACS survivors. Cardiac patients treated during periods of ED overcrowding, hallway care, and perceived poor clinician–patient communication appear at greater risk for subsequent PTSD. Conclusions: Psychological stress is often present in patients undergoing evaluation for acute CVD events. Understanding such associations provides a foundation to appreciate the potential contribution of psychological variables on acute and long‐term cardiovascular recovery, while also stimulating future areas of research and discovery. [ABSTRACT FROM AUTHOR]

Background: Due to the acuity and time‐sensitive needs of their clinical condition, patients presenting with certain emergent pathologies may lack capacity to provide meaningful prospective informed consent to participate in clinical research. For these reasons, these populations have often been excluded from research investigations. To mitigate this, regulations allowing exception from informed consent (EFIC; 21 CFR 50.24) or waiver of informed consent (WIC; 45 CFR 46.101) were developed in 1996. The purpose of this study was to identify trends in the utilization of EFIC and WIC in emergency research. We also sought to describe the disclosure of necessary prestudy regulatory requirements and justification for the use of EFIC/WIC as reported in completed EFIC/WIC clinical trials. Methods: This study is a review of 20 years of published trials using EFIC or WIC as the primary method of patient consent. Studies were identified using a MEDLINE search; ClinicalTrials.gov; queries to emergency and resuscitation researchers, research directors, department chairs, and principal investigators of acute care research networks; clinical review papers; and a query of the Federal Drug Administration (FDA) docket. All eligible studies were reviewed by three investigators and study data of interest were abstracted. Data are presented descriptively. Results: We identified 45 potentially eligible studies; 11 were ongoing (with no data yet available), four were completed (with no publications or data available), and two did not use EFIC or WIC. Of the remaining 28 studies, 24 (86%) used EFIC and four used WIC. The most common pathologies under study were cardiac arrest (10), hemorrhagic shock (six), and traumatic brain injury (five). Completion of the prestudy regulatory requirements was reported as follows: FDA investigational new drug/investigational device exemption application (for FDA regulated studies; 14, 50%), community consultation (13, 46%), public disclosure (10, 36%), and opt‐out procedures if requested by the institutional review board (seven, 25%). The justification of the need for the use of EFIC or WIC in the reported clinical trial, as defined as mention of at least one of the eight established criteria, was described in the text of 13 (46%) publications. Conclusions: Since their implementation in 1996, the EFIC/WIC regulations have allowed progress in research aimed at determining optimal care for devastating life‐threatening conditions. However, consistent and rigorous report of regulatory prestudy requirements and justification of the use of EFIC/WIC is lacking in clinical trial publications or on websites such as ClinicalTrials.gov. Since research without consent is an ethically sensitive issue and not widely understood, better justification of its needs within the presentation of the research itself may educate the general medical community and also reduce concerns about whether or not the regulations are being properly applied. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: Point‐of‐care ultrasound (POCUS) has been suggested as an initial investigation in the management of renal colic. Our objectives were: 1) to determine the accuracy of POCUS for the diagnosis of nephrolithiasis and 2) to assess its prognostic value in the management of renal colic. Methods: The review protocol was registered to the PROSPERO database (CRD42016035331). An electronic database search of MEDLINE, Embase, and PubMed was conducted utilizing subject headings, keywords, and synonyms that address our research question. Bibliographies of included studies and narrative reviews were manually examined. Studies of adult emergency department patients with renal colic symptoms were included. Any degree of hydronephrosis was considered a positive POCUS finding. Accepted criterion standards were computed tomography evidence of renal stone or hydronephrosis, direct stone visualization, or surgical findings. Screening of abstracts, quality assessment with the QUADAS‐2 instrument, and data extraction were performed by two reviewers, with discrepancies resolved by consensus with a third reviewer. Test performance was assessed by pooled sensitivity and specificity, calculated likelihood ratios, and a summary receiver operator curve (SROC). The secondary objective of prognostic value was reported as a narrative summary. Results: The electronic search yielded 627 unique titles. After relevance screening, 26 papers underwent full‐text review, and nine articles met all inclusion criteria. Of these, five high‐quality studies (N = 1,773) were included in the meta‐analysis for diagnostic accuracy and the remaining yielded data on prognostic value. The pooled results for sensitivity and specificity were 70.2% (95% confidence interval [CI] = 67.1%–73.2%) and 75.4% (95% CI = 72.5%–78.2%), respectively. The calculated positive and negative likelihood ratios were 2.85 and 0.39. The SROC generated did not show evidence of a threshold effect. Two of the studies in the meta‐analysis found that the finding of moderate or greater hydronephrosis yielded a specificity of 94.4% (95% CI = 92.7%–95.8%). Four studies examining prognostic value noted a higher likelihood of a large stone when positive POCUS findings were present. The largest randomized trial showed lower cumulative radiation exposure and no increase in adverse events in those who received POCUS investigation as the initial renal colic investigation. Conclusion: Point‐of‐care ultrasound has modest diagnostic accuracy for diagnosing nephrolithiasis. The finding of moderate or severe hydronephrosis is highly specific for the presence of any stone, and the presence of any hydronephrosis is suggestive of a larger (>5 mm) stone in those presenting with renal colic. [ABSTRACT FROM AUTHOR]

Objective: Many patients are initially diagnosed with a new suspected cancer through the emergency department (ED). The objective of this systematic review was to compare stage of cancer and survival of patients diagnosed with cancer through the ED to patients diagnosed elsewhere. Methods: Electronic searches of Medline and EMBASE were conducted and reference lists were hand‐searched. Studies comparing adult patients diagnosed with any type of cancer through the ED (ED diagnosis) to patients diagnosed elsewhere (non‐ED diagnosis) were included. Two reviewers independently screened titles and abstracts, assessed quality of the studies, and extracted data. The risk of bias of included studies was assessed using the Newcastle‐Ottawa Scale. Data pertaining to patient outcomes were summarized and pooled using random‐effects models and reported as risk ratios (RRs) with 95% confidence intervals (CIs), where applicable. Results: Fourteen studies were included. There was an increased risk of more advanced/later stage cancer (Stage III/IV or late‐stage vs. earlier stage) among patients with an ED diagnosis of cancer compared to a non‐ED diagnosis of cancer (RR 1.30, 95% CI 1.39–1.58). Survival was lower for patients with an ED diagnosis of cancer compared to those diagnosed elsewhere (RR 0.61, 95% CI 0.49–0.75). Conclusions: Patients with an ED diagnosis of cancer had more advanced/late stage of cancer at diagnosis and worse survival compared to patients diagnosed elsewhere. Future research examining patients diagnosed with cancer through the ED is required. [ABSTRACT FROM AUTHOR]

Background: Distinguishing peritonsillar abscess (PTA) from peritonsillar cellulitis using clinical assessment is challenging as many features overlap for both conditions, and physical examination is only about 75% sensitive and 50% specific for diagnosing PTA. The primary objective of this systematic review was to determine the test characteristics of ultrasound for diagnosing PTA when compared to a reference standard of computed tomography or acquisition of pus via needle aspiration or incision and drainage. Methods: This systematic review was performed in accordance with the Preferred Reporting Items for a Systematic Review and Meta‐analysis of Diagnostic Test Accuracy (PRISMA‐DTA) guidelines. We searched seven databases from 1960 to November 2022. Two independent reviewers completed study selection, data extraction, and QUADAS‐2 risk‐of‐bias assessment. We used a bivariate random‐effects model to calculate pooled sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR–). We also conducted subgroup analyses on radiology ultrasound compared to point‐of‐care ultrasound (POCUS) and intraoral compared to transcervical scanning techniques. Results: From 339 citations, we identified 18 studies for inclusion. Because one study only reported positive cases of PTA (thereby preventing the calculation of specificity), it was excluded from the analysis, so the analysis included a total of 17 studies with 812 patients, of whom 541 had PTA. Pooled bivariate sensitivity was 86% (95% confidence interval [CI] 78%–91%), specificity 76% (95% CI 67%–82%), LR+ 3.51 (95% CI 2.59–4.89), and LR– 0.19 (95% CI 0.12–0.30). On subgroup analysis, radiology‐performed ultrasound had a sensitivity and specificity of 89% and 71%, compared to POCUS, which had a sensitivity and specificity of 74% and 79%. Comparing the two different techniques, intraoral had a sensitivity and specificity of 91% and 75% while transcervical had a sensitivity and specificity of 80% and 81%. Conclusions: Ultrasound demonstrates high sensitivity for ruling out PTA, but it only has moderate specificity for ruling in the diagnosis. [ABSTRACT FROM AUTHOR]

Objectives: The objective was to conduct a systematic review and qualitative evidence synthesis (QES) to identify best practices, benefits, harms, facilitators, and barriers to the routine collection of sociodemographic variables in emergency departments (EDs). Methods: This work is a systematic review and QES. We conducted a comprehensive search of Medline (Ovid), CINAHL (Ebsco), Cochrane Central (OVID), EMBASE (Ovid), and the multidisciplinary Web of Science Core database using peer‐reviewed search strategies, complemented by a gray literature search. We included citations containing perspectives on routine sociodemographic variable collection in EDs and recommendations on definitions or processes of collection or benefits, harms, facilitators, or barriers related to the routine collection of sociodemographic variables in EDs. We conducted this systematic review and QES adhering to the Joanna Briggs Institute guidelines. Two reviewers independently selected included studies and extracted data. We conducted a best‐fit framework synthesis and paired inductive thematic analysis of the included studies. We generated recommendations based on the QES. Results: We included 21 unique reports that enrolled 10,454 patients or respondents in our systematic review and QES. Publication dates of included studies ranged from 2011 to 2021. Included citations were published in Australia, Canada, and the United States. We synthesized 11 benefits, 14 potential harms, 15 barriers, and 19 facilitators and identified 14 best practice recommendations from included citations. Conclusions: Health systems should routinely collect sociodemographic variables in EDs guided by recommendations that minimize harms and maximize benefits and consider relevant barriers and facilitators. Our recommendations can serve as a guide for the equity‐focused reformation of emergency medicine health information systems. [ABSTRACT FROM AUTHOR]

Background: Canalith repositioning maneuvers (such as the Epley maneuver) are recommended by specialty guidelines for management of benign paroxysmal positional vertigo (BPPV) yet are frequently underutilized in the emergency department (ED). Methods: We conducted a systematic review (SR) of SRs to summarize the evidence of Epley maneuver for the treatment of posterior canal (pc) BPPV in any setting. We included SRs of randomized controlled trials (RCTs) that compared Epley to control in adult patients with pc‐BPPV. Titles, abstracts, and full texts were screened in duplicate. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) assessment was used to rate certainty of evidence. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported. Meta‐analysis of individual studies was conducted with random and fixed effects. Results: From 2228 titles, seven SRs were selected for quality assessment. One review was of higher methodological quality, included only RCTs, and was the most current and comprehensive. Five of the 11 RCTs of the review, including 312 patients with pc‐BPPV diagnosed by Dix–Hallpike, were relevant to our question. Meta‐analysis of four RCTs (251 patients) showed the use of Epley (compared to control) was associated with higher complete resolution of vertigo at 1 week (OR 7.19, 95% CI 1.52–33.98, moderate certainty). Meta‐analysis of three RCTs (195 patients) showed the use of Epley was associated with higher conversion to negative Dix–Hallpike at 1 week (OR 6.67, 95% CI 1.52–33.98, moderate certainty). The number‐needed‐to‐treat was three. Meta‐analysis of the outcomes at 1 month, and when observational studies were included, showed similar results. No serious adverse effects were reported. Conclusions: Symptoms of pc‐BPPV improve with the Epley maneuver. Emergency clinicians should become familiar with performing the Epley for BPPV. Further studies on ED implementation and clinician education of Epley are needed. [ABSTRACT FROM AUTHOR]

Objectives: Rising demand for emergency and urgent care services is well documented, as are the consequences, for example, emergency department (ED) crowding, increased costs, pressure on services, and waiting times. Multiple factors have been suggested to explain why demand is increasing, including an aging population, rising number of people with multiple chronic conditions, and behavioral changes relating to how people choose to access health services. The aim of this systematic mapping review was to bring together published research from urgent and emergency care settings to identify drivers that underpin patient decisions to access urgent and emergency care. Methods: Systematic searches were conducted across Medline (via Ovid SP), EMBASE (via Ovid), The Cochrane Library (via Wiley Online Library), Web of Science (via the Web of Knowledge), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; via EBSCOhost). Peer-reviewed studies written in English that reported reasons for accessing or choosing emergency or urgent care services and were published between 1995 and 2016 were included. Data were extracted and reasons for choosing emergency and urgent care were identified and mapped. Thematic analysis was used to identify themes and findings were reported qualitatively using framework-based narrative synthesis. Results: Thirty-eight studies were identified that met the inclusion criteria. Most studies were set in the United Kingdom (39.4%) or the United States (34.2%) and reported results relating to ED (68.4%). Thirty-nine percent of studies utilized qualitative or mixed research designs. Our thematic analysis identified six broad themes that summarized reasons why patients chose to access ED or urgent care. These were access to and confidence in primary care; perceived urgency, anxiety, and the value of reassurance from emergency-based services; views of family, friends, or healthcare professionals; convenience (location, not having to make appointment, and opening hours); individual patient factors (e.g., cost); and perceived need for emergency medical services or hospital care, treatment, or investigations. Conclusions: We identified six distinct reasons explaining why patients choose to access emergency and urgent care services: limited access to or confidence in primary care; patient perceived urgency; convenience; views of family, friends, or other health professionals; and a belief that their condition required the resources and facilities offered by a particular healthcare provider. There is a need to examine demand from a whole system perspective to gain better understanding of demand for different parts of the emergency and urgent care system and the characteristics of patients within each sector. [ABSTRACT FROM AUTHOR]

Objective: The objective was to evaluate the comparative effectiveness and safety of pharmacological and nonpharmacological management options for atrial fibrillation/atrial flutter with rapid ventricular response (AFRVR) in patients with acute decompensated heart failure (ADHF) in the acute care setting. Methods: This study was a systematic review of observational studies or randomized clinical trials (RCT) of adult patients with AFRVR and concomitant ADHF in the emergency department (ED), intensive care unit, or step‐down unit. The primary effectiveness outcome was successful rate or rhythm control. Safety outcomes were adverse events, such as symptomatic hypotension and venous thromboembolism. Results: A total of 6577 unique articles were identified. Five studies met inclusion criteria: one RCT in the inpatient setting and four retrospective studies, two in the ED and the other three in the inpatient setting. In the RCT of diltiazem versus placebo, 22 patients (100%) in the treatment group had a therapeutic response compared to 0/15 (0%) in the placebo group, with no significant safety differences between the two groups. For three of the observational studies, data were limited. One observation study showed no difference between metoprolol and diltiazem for successful rate control, but worsening heart failure symptoms occurred more frequently in those receiving diltiazem compared to metoprolol (19 patients [33%] vs. 10 patients [15%], p = 0.019). A single study included electrical cardioversion (one patient exposed with failure to convert to sinus rhythm) as nonpharmacological management. The overall risk of bias for included studies ranged from serious to critical. Missing data and heterogeneity of definitions for effectiveness and safety outcomes precluded the combination of results for quantitative meta‐analysis. Conclusions: High‐level evidence to inform clinical decision making regarding effective and safe management of AFRVR in patients with ADHF in the acute care setting is lacking. [ABSTRACT FROM AUTHOR]

Objectives: Adjunct therapy with anticholinergic agents has been proposed to reduce the incidence of extrapyramidal side effects such as akathisia following treatment with neuroleptics or metoclopramide. This systematic review assessed the effectiveness of anticholinergic agents to prevent neuroleptic or metoclopramide‐induced akathisia in patients presenting to the emergency department (ED) with benign headache. Methods: Eight electronic databases and the gray literature were searched to identify randomized controlled trials involving adult patients presenting to the ED with primary headache treated with neuroleptic or metoclopramide. Study selection, data extraction, and quality assessment were completed by two independent reviewers. Individual or pooled meta‐analysis of dichotomous outcomes were calculated as relative risks (RRs) with 95% confidence intervals (CIs) using a random‐effects model. Heterogeneity was assessed using the I2 statistic. Results: A total of 1032 studies were screened, of which two studies were included in the review. Both studies provided patients with diphenhydramine following treatment with neuroleptics or metoclopramide. Treatment with diphenhydramine did not reduce the incidence of akathisia compared to treatment with placebo (RR 0.83, 95% CI 0.43–1.61, I2 = 0%). The impact of diphenhydramine on pain relief, need for rescue medications, and relief of other extrapyramidal side effects was reported in one of the two studies, with no significant differences noted in any outcomes compared to patients treated with placebo. Conclusion: This review found insufficient evidence to recommend the use of diphenhydramine as an adjunct therapy to prevent akathisia in ED patients treated with neuroleptics or metoclopramide for primary headache. This finding relies on the results of two small randomized controlled trials with incomplete outcome reporting. Additional high‐quality studies are needed to better understand the clinical efficacy of agents with anticholinergic properties in the ED management of patients with primary headaches. [ABSTRACT FROM AUTHOR]

Objectives: The objective was to conduct a scoping review of the literature and develop consensus‐derived research priorities for future research inquiry in an effort to (1) identify and summarize existing research related to race, racism, and antiracism in emergency medicine (EM) and adjacent fields and (2) set the agenda for EM research in these topic areas. Methods: A scoping review of the literature using PubMed and EMBASE databases, as well as review of citations from included articles, formed the basis for discussions with community stakeholders, who in turn helped to inform and shape the discussion and recommendations of participants in the Society for Academic Emergency Medicine (SAEM) consensus conference. Through electronic surveys and two virtual meetings held in April 2021, consensus was reached on terminology, language, and priority research questions, which were rated on importance or impact (highest, medium, lower) and feasibility or ease of answering (easiest, moderate, difficult). Results: A total of 344 articles were identified through the literature search, of which 187 met inclusion criteria; an additional 34 were identified through citation review. Findings of racial inequities in EM and related fields were grouped in 28 topic areas, from which emerged 44 key research questions. A dearth of evidence for interventions to address manifestations of racism in EM was noted throughout. Conclusions: Evidence of racism in EM emerged in nearly every facet of our literature. Key research priorities identified through consensus processes provide a roadmap for addressing and eliminating racism and other systems of oppression in EM. [ABSTRACT FROM AUTHOR]

Background: Existing evidence suggest the emergence of palliative care (PC) services in the emergency department (ED). To gain insight into the nature of these services and provide direction to future actions, there is a need for a comprehensive review that ascertains the components of these services, integration models, and outcomes. Methods: A scoping review design was employed and reported according to the PRISMA extension guidelines for scoping reviews. Extensive searches in peer‐reviewed databases (CINAHL, EMBASE, PubMed, Cochrane Library, and Medline) and gray literature sources (Trove, MedNar, OpenGrey, and the Agency for Healthcare Research and Quality) were undertaken and supplemented with hand searching. Titles, abstracts, and full text were reviewed in duplicate. Studies were eligible for inclusion if they reported on a PC intervention implemented in the ED for adults. Codes were formulated across the included studies, which facilitated the conduct of a narrative synthesis. Results: Twenty‐three studies were retained with the majority (n = 15) emerging from the United States. The components of PC interventions in the ED were categorized as: (1) screening, (2) goals of care discussion and communication, (3) managing pain and other distressing symptoms in the ED, (4) transitions across care settings, (5) end‐of‐life (EoL) care, (6) family/caregiver support, and (7) ED staff education. Traditional PC consultations and integrated ED–PC services were the main modes of delivery. PC in the ED can potentially improve patient symptoms, facilitate access to relevant services, reduce length of stay, improve care at the EoL, facilitate bereavement and postbereavement support for family members, and improve ED staff confidence in delivering PC. Conclusions: PC implementation in the ED may potentially improve patient and family outcomes. More studies are needed, however, to standardize trigger or screening tools. More prospective studies are also needed to test PC interventions in the ED. [ABSTRACT FROM AUTHOR]

Objective: The objective was to identify the most important and impactful peer‐reviewed global emergency medicine (GEM) articles published in 2021. The top articles are summarized in brief narratives and accompanied by a comprehensive list of all identified articles that address the topic during the year to serve as a reference for clinicians, researchers, and policy makers. Methods: A systematic PubMed search was carried out to identify all GEM articles published in 2021. Title and abstract screening was performed by trained reviewers and editors to identify articles in one of three categories based on predefined criteria: disaster and humanitarian response (DHR), emergency care in resource‐limited settings (ECRLS), and emergency medicine development (EMD). Included articles were each scored by two reviewers using established rubrics for original (OR) and review (RE) articles. The top 5% of articles overall and the top 5% of articles from each category (DHR, ECRLS, EMD, OR, and RE) were included for narrative summary. Results: The 2021 search identified 44,839 articles, of which 444 articles screened in for scoring, 25% and 22% increases from 2020, respectively. After removal of duplicates, 23 articles were included for narrative summary. ECRLS constituted the largest category (n = 16, 70%), followed by EMD (n = 4, 17%) and DHR (n = 3, 13%). The majority of top articles were OR (n = 14, 61%) compared to RE (n = 9, 39%). Conclusions: The GEM peer‐reviewed literature continued to grow at a fast rate in 2021, reflecting the continued expansion and maturation of this subspecialty of emergency medicine. Few high‐quality articles focused on DHR and EMD, suggesting a need for further efforts in those fields. Future efforts should focus on improving the diversity of GEM research and equitable representation. [ABSTRACT FROM AUTHOR]

Background: Shoulder dislocations are a common injury prompting presentation to the emergency department. Point‐of‐care ultrasound (POCUS) is a diagnostic tool for shoulder dislocations, which has the potential to reduce time to diagnosis and reduction, radiation exposure, and health care costs. This systematic review sought to evaluate the diagnostic accuracy of POCUS for diagnosing shoulder dislocations. Methods: We searched PubMed, Scopus, CINAHL, LILACS, the Cochrane databases, Google Scholar, and bibliographies of selected articles for all prospective and randomized controlled trials evaluating the diagnostic accuracy of POCUS for identifying shoulder dislocations. We dual‐extracted data into a predefined worksheet and performed quality analysis using the QUADAS‐2 tool. We performed a meta‐analysis with subgroup analyses by technique and transducer type. As a secondary outcome, we assessed the diagnostic accuracy of identifying associated fractures. Results: Ten studies met our inclusion criteria, comprising 1,836 assessments with 636 dislocations (34.6%). Overall, POCUS was 100% (95% confidence interval [CI], 85.6%–100%) sensitive and 100% (95% CI, 79.4%–100%) specific for the diagnosis of shoulder dislocation with a LR+ of 11,254.8 (95% CI, 3.9–3.3e7) and a LR− of <0.1 (95% CI, < 0.1–0.2). When compared with the anterior/lateral technique, the posterior technique had greater sensitivity but no difference in specificity. There was no difference between transducer types. POCUS was also 96.8% (95% CI, 92.6%–98.7%) sensitive and 99.7% (95% CI, 92.5%–100%) specific for the diagnosis of associated fractures. Conclusions: POCUS is a sensitive and specific tool for the rapid identification of shoulder dislocations and reductions, as well as for the detection of associated fractures. POCUS should be considered as an alternate diagnostic tool for the diagnosis and management of shoulder dislocations. [ABSTRACT FROM AUTHOR]

Objectives: Knowledge of patient's health literacy (HL) in the emergency department (ED) can facilitate care delivery and reduce poor health outcomes. This systematic review investigates HL measurement instruments used in the ED and their psychometric properties, accuracy in detecting limited HL, and feasibility. Methods: We searched in five biomedical databases for studies published between 1990 and January 2021, evaluating HL measurement instruments tested in the ED on internal consistency, criterion validity, diagnostic accuracy, or feasibility. Reviewers screened studies for relevance and assessed methodologic quality with published criteria. Data were synthesized around study and instrument characteristics and outcomes of interest. Results: Of the 2,376 references screened, seven met our inclusion criteria. Studied instruments varied in objective (n = 5) and subjective (n = 6) measurement of HL skills, and in HL constructs measured. The Brief Health Literacy Screen (BHLS) and the Subjective Numeracy Scale demonstrate acceptable and good internal consistency across studies. None of the instruments perform consistently well on criterion validity. The Rapid Estimate of Adult Literacy in Medicine–Revised and the Newest Vital Sign, both objective tests with short administration times, demonstrate good accuracy in one study with high risk of bias. The BHLS, a short subjective measure, shows moderate accuracy across studies including one with low risk of bias. Conclusions: Several short instruments seem valid in measuring HL and accurate in detecting limited HL among ED patients, each with its practical advantages and disadvantages and specific measurement of HL. Additional research is necessary to develop a robust evidence base supporting these instruments. [ABSTRACT FROM AUTHOR]

Background: Recurrent abdominal pain in the emergency department (ED) might represent an opportunity for screening of depression and/or anxiety. Methods: We systematically searched five databases for studies evaluating the effect of screening for depression and/or anxiety in ED patients with recurrent and undifferentiated abdominal pain. Given paucity of direct evidence, we also searched for indirect evidence including studies that assessed prevalence of depression and/or anxiety in EDs (not necessarily recurrent abdominal pain), diagnostic accuracy of screening tools, effectiveness of screening in other settings, and outcomes such as repeat ED visits of patients with abdominal pain who were screened in the ED. Two methodologists evaluated certainty in the evidence using the GRADE approach. Results: A total of 4,337 citations were reviewed, and zero studies were found on the effect of screening in patients with recurrent and undifferentiated abdominal pain in the ED. A total of 35 studies were included as relevant indirect evidence. In studies of ED patients with abdominal pain, depression ranged from 10% to 29%, while anxiety ranged from 18% to 50%. False positives appear to be an issue given relatively low specificity of screening tools. One randomized trial including ED patients with vague symptoms evaluated the effect of depression screening on a composite outcome of depression recognition, psychiatric consultation, or referral by the emergency physician (risk ratio = 1.49, 95% confidence interval [CI] = 0.49 to 4.53, very low certainty). One study reported that patients with undifferentiated abdominal pain who screened positive for depression have had increased ED recidivism (odds ratio = 3.17, 95% CI = 1.14 to 8.85, very low certainty). Conclusions: We were unable to identify any evidence that confirms that depression or anxiety screening in ED patients with recurrent and undifferentiated abdominal pain improves outcomes or changes management downstream. [ABSTRACT FROM AUTHOR]

Background: There is a lack of consensus regarding the role of investigations among patients presenting to the emergency department (ED) with recurrent seizures. The aim of this systematic review was to determine the frequency and utility of commonly requested investigations for nontrauma patients presenting to the ED with recurrent seizures. Methods: The MEDLINE, EMBASE, and Cochrane Library databases were searched (March 2021) for articles on this topic using search terms related to recurrent seizures, investigations, and the ED. The inclusion criteria required that articles include adult nontrauma patients presenting to the ED. Studies exclusively investigating first‐episode seizures, trauma patients, and status epilepticus were excluded. Eligible studies were assessed for bias using the Newcastle‐Ottawa scale. Results of studies were presented using proportions. Results: There were six cohort studies included that contributed data from 36,595 patients. All six studies assessed at least one of our primary outcomes for computed tomography (CT) brain scans. The proportion of patients who underwent a head CT ranged from 13% to 42%. The rates of abnormal head CT findings ranged from 8% to 21%. One study reported on magnetic resonance imaging (MRI) and found it used infrequently in 0.79% of cases. The proportion and yield of nonneuroimaging investigations were not well evaluated in this patient population. Only one study reported on the utility of sodium levels or blood glucose results for this population and reported abnormalities in sodium levels for 19% of patients and abnormalities in glucose levels in 50% of patients. Conclusions: In this population, CT brain scans appeared to be performed uncommonly but with moderate rates of abnormal findings. In the absence of prolonged alteration of consciousness, a history of brain tumor, or positive neurologic findings, however, neuroimaging was of low yield. Given the heterogeneity and potential limitations of these studies, further research on this topic is required. [ABSTRACT FROM AUTHOR]

Background: The objective was to systematically evaluate the sensitivity of diffusion‐weighted magnetic resonance imaging (DW‐MRI) for transient global amnesia (TGA) across various time frames compared to the reference‐standard clinical criteria. Methods: All indexed publications related to TGA and MRI through June 2020 were retrieved by a medical librarian. Two independent reviewers identified original research studies of adults with a clinical diagnosis of TGA using Caplan and Hodges and Warlow criteria (reference standard) who were evaluated with DW‐MRI. Pooled estimates and its 95% confidence intervals (CI) for the proportion of acute TGA patients with positive DW‐MRI (i.e., sensitivity) were obtained using random‐effects meta‐analysis for various time frames. Quality assessment was performed using the revised Quality of Assessment of Diagnostic Accuracy Studies (QUADAS‐2) tool. Results: After screening 665 reports, we identified 81 potentially relevant studies. Twenty‐three studies representing 1688 patients met eligibility criteria, but not all studies had data available for meta‐analysis. The pooled sensitivity (also described as positivity rate) of DW‐MRI was 15.6% (95% CI = 2.6%–35.0%) between 0 and 12 h from symptom onset, 23.1% (95% CI = 6.1%–45.7%) at 0–24 h, 72.8% (95% CI = 40.8%–96.3) at 12–24 h, 68.8% (95% CI = 44.8%–88.8%) at 24–36 h, 72.4% (95% CI = 59.8%–83.5%) at 36–48 h, 82.8% (95% CI = 54.7%–99.6%) at 48–60 h, 66.9% (95% CI = 47.5%–83.9%) at 60–72 h, and 72.0% (95% CI = 30.1%–100.0%) at 72–96 h. There was significant concern for risk of bias in the QUADAS‐2 domains of patient selection and index test, yielding a low level of certainty in the pooled estimates. Conclusion: DW‐MRI lesions are uncommon in patients with TGA early after symptom onset, but the sensitivity (i.e., positivity rate) of DW‐MRI increases with time. Despite the limited quality of existing evidence, obtaining an early DW‐MRI in patients with clinical diagnosis of TGA in the acute setting is likely a low‐yield test. [ABSTRACT FROM AUTHOR]

Objectives: The objective was to assess the prognostic value of hypertension detected in the emergency department (ED). Methods: The ED presents a unique opportunity to predict long‐term cardiovascular disease (CVD) outcomes with its potential for high‐footfall, and large‐scale routine data collection applied to underserved patient populations. A systematic review and meta‐analyses were conducted to assess the prognostic performance and feasibility of ED‐measured hypertension as a risk factor for long‐term CVD outcomes. We searched MEDLINE and Embase databases and gray literature sources. The target populations were undifferentiated ED patients. The prognostic factor of interest was hypertension. Feasibility outcomes included prevalence, reliability, and follow‐up attendance. Meta‐analyses were performed for feasibility using a random effect and exact likelihood. Results: The searches identified 1072 studies after title and abstract review, 53 studies had their full text assessed for eligibility, and 26 studies were included. Significant heterogeneity was identified, likely due to the international populations and differing study design. The meta‐analyses estimate of prevalence for ED‐measured hypertension was 0.31 (95% confidence interval 0.25–0.37). ED hypertension was persistent outside the ED (FE estimate of 0.50). The proportion of patients attending follow‐up was low with an exact likelihood estimate of 0.41. Three studies examined the prognostic performance of hypertension and demonstrated an increased risk of long‐term CVD outcomes. Conclusion: Hypertension can be measured feasibly in the ED and consequently used in a long‐term cardiovascular risk prediction model. There is an opportunity to intervene in targeted individuals, using routinely collected data. [ABSTRACT FROM AUTHOR]

Objectives: Individual‐level social needs have been shown to substantially impact emergency department (ED) care transitions of older adults. The Geriatric Emergency care Applied Research (GEAR) Network aimed to identify care transition interventions, particularly addressing social needs, and prioritize future research questions. Methods: GEAR engaged 49 interdisciplinary stakeholders, derived clinical questions, and conducted searches of electronic databases to identify ED discharge care transition interventions in older adult populations. Informed by the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) framework, data extraction and synthesis of included studies included the degree that intervention components addressed social needs and their association with patient outcomes. GEAR convened a consensus conference to identify topics of highest priority for future care transitions research. Results: Our search identified 248 unique articles addressing care transition interventions in older adult populations. Of these, 17 individual care transition intervention studies were included in the current literature synthesis. Overall, common care transition interventions included coordination efforts, comprehensive geriatric assessments, discharge planning, and telephone or in‐person follow‐up. Fourteen of the 17 care transition intervention studies in older adults specifically addressed at least one social need within the PRAPARE framework, most commonly related to access to food, medicine, or health care. No care transition intervention addressing social needs in older adult populations consistently reduced subsequent health care utilization or other patient‐centered outcomes. GEAR stakeholders identified that determining optimal outcome measures for ED–home transition interventions was the highest priority area for future care transitions research. Conclusions: ED care transition intervention studies in older adults frequently address at least one social need component and exhibit variation in the degree of success on a wide array of health care utilization outcomes. [ABSTRACT FROM AUTHOR]

Objectives: The objective of this study was to conduct an umbrella review of therapeutic studies relevant to emergency medicine, analyzing patterns in effect size, power, and signals of potential bias across an entire field of clinical research. Methods: We combined topic‐ and journal‐driven searches of PubMed and Google Scholar for published articles of systematic reviews and meta‐analyses (SRMA) relevant to emergency medicine (last search in November 2020). Data were screened and extracted by six investigators. Redundant meta‐analyses were removed. Whenever possible for each comparison we extracted one meta‐analysis on mortality with the most events and one meta‐analysis on a nonmortality outcome with the most studies. From each meta‐analysis we extracted all individual study effects; outcomes were converted to odds ratios (ORs) and placed on a common scale where an OR < 1.0 represents a reduction in a harmful outcome with an experimental treatment versus control. Outcomes were analyzed at the level of individual studies and at the level of summary effects across meta‐analyses. Results: A total of 332 articles contained 431 eligible meta‐analyses with a total of 3,129 individual study outcomes; of these, 2,593 (83%) were from randomized controlled trials. The median OR across all studies was 0.70. Within each meta‐analysis, the earliest study effect on average demonstrated larger benefit compared to the overall summary effect. Only 57 of 431 meta‐analyses (13%) both favored the experimental intervention and did not show any signal of small study effects or excess significance, and of those only 12 had at least one study with 80% or higher power to detect an OR of 0.70. Of these, no interventions significantly decreased mortality in well‐powered trials. Although the power of studies increased somewhat over time, the majority of studies were underpowered. Conclusions: Few interventions studied within SRMAs relevant to emergency medicine seem to have strong and unbiased evidence for improving outcomes. The field would benefit from more optimally powered trials. [ABSTRACT FROM AUTHOR]

Objective: The objective was to identify, screen, highlight, review, and summarize some of the most rigorously conducted and impactful original research (OR) and review articles (RE) in global emergency medicine (EM) published in 2020 in the peer‐reviewed and gray literature. Methods: A broad systematic search of peer‐reviewed publications related to global EM indexed on PubMed and in the gray literature was conducted. The titles and abstracts of the articles on this list were screened by members of the Global Emergency Medicine Literature Review (GEMLR) Group to identify those that met our criteria of OR or RE in the domains of disaster and humanitarian response (DHR), emergency care in resource‐limited settings (ECRLS), and EM development. Those articles that met these screening criteria were then scored using one of three scoring templates appropriate to the article type. Those articles that scored in the top 5% then underwent in‐depth narrative summarization. Results: The 2020 GEMLR search initially identified 35,970 articles, more than 50% more than last year's search. From these, 364 were scored based on their full text. Nearly three‐fourths of the scored articles constituted OR, of which nearly three‐fourths employed quantitative research methods. Nearly 10% of the articles identified this year were directly related to COVID‐19. Research involving ECRLS again constituted most of the articles in this year's review, accounting for more than 60% of the literature scored. A total of 20 articles underwent in‐depth narrative critiques. Conclusions: The number of studies relevant to global EM identified by our search was very similar to that of last year. Revisions to our methodology to identify a broader range of research were successful in identifying more qualitative research and studies related to DHR. The number of COVID‐19–related articles is likely to continue to increase in subsequent years. [ABSTRACT FROM AUTHOR]

Objectives: Management of hemodynamically stable patients with penetrating neck trauma (PNT) has evolved in recent years with improvements in imaging technology. Computed tomography angiography (CTA) encompassing all zones of the neck has become part of the standard diagnostic algorithm for PNT patients who do not require immediate surgical intervention for vascular or aerodigestive injuries (ADI). Several studies have demonstrated favorable operating characteristics for CTA at excluding arterial injuries; however, consensus as to CTA's ability to detect ADI is lacking. We conducted a systematic review (PROSPERO registration number CRD42019133509) to answer the question Is CTA sufficient to rule out ADI in hemodynamically stable PNT patients without hard signs? Methods: Investigators independently searched PubMed, EMBASE, and Web of Science from their inception to August 2020 for the search terms "penetrating neck injuries" and "CT scan." To be included, studies required sufficient data to construct a 2×2 table of CTA for ADI. The operating characteristics of CTA for detecting ADIs are reported as sensitivity, specificity, and likelihood ratios (LRs), with 95% confidence intervals (95% CIs). Bias in our studies was quantified by QUADAS‐2. Results: Our search identified 1,242 citations with seven studies with moderate to high risk of bias meeting our inclusion/exclusion criteria and encompassing 877 subjects with an ADI prevalence of 13.4%. CTA for ADI had sensitivity of 92% (95% CI = 85% to 97%), specificity of 88% (95% CI = 85% to 90%), positive likelihood ratio of 12.2 (95% CI = 4.6 to 32), and negative LR of 0.14 (95% CI = 0.05 to 0.37). Of the 26 identified esophageal injuries across our studies that were diagnosed by either swallow studies or surgical exploration, five (19%, 95% CI = 8.1% to 38.3%) were initially missed by CTA. Conclusion: CTA alone is not sufficient to exclude esophageal injuries in PNT. Because delayed diagnosis is associated with increased morbidity, additional diagnostic interventions should be undertaken if there is remaining concern for esophageal injury. [ABSTRACT FROM AUTHOR]

Background: Exception from informed consent (EFIC) regulations for research in emergency settings contain unique requirements for community consultation and public disclosure. These requirements address ethical challenges intrinsic to this research context. Multiple approaches have evolved to accomplish these activities that may reflect and advance different aims. This scoping review was designed to identify areas of consensus and lingering uncertainty in the literature. Methods: Scoping review methodology was used. Conceptual and empirical literature related to community consultation and public disclosure for EFIC research was included and identified through a structured search using Embase, HEIN Online, PubMed, and Web of Science. Data were extracted using a standardized tool with domains for major literature categories. Results: Among 84 manuscripts, major domains included conceptual or policy issues, reports of community consultation processes and results, and reports of public disclosure processes and results. Areas of consensus related to community consultation included the need for a two‐way exchange of information and use of multiple methods. Public acceptance of personal EFIC enrollment is commonly 64% to 85%. There is less consensus regarding how to assess attitudes, what "communities" to prioritize, and how to determine adequacy for individual projects. Core goals of public disclosure are less well developed; no metrics exist for assessing adequacy. Conclusions: Multiple methods are used to meet community consultation and public disclosure requirements. There remain no settled norms for assessing adequacy of public disclosure, and there is lingering debate about needed breadth and depth of community consultation. [ABSTRACT FROM AUTHOR]

Objectives: Corneal abrasions are common ophthalmic presentations to emergency departments. Among emergency physicians and ophthalmologists, there are highly variable practice patterns with regard to management of resultant pain and discomfort. The goal of this study was to review and analyze the efficacy and safety of topical pain therapies for corneal abrasions, including topical anesthetics, nonsteroidal anti‐inflammatory drugs (NSAIDs), cycloplegics, steroids, pressure patching, and the use of a bandage contact lens (BCL). Methods: The review followed the Preferred Reporting Items for Systematic Review and Meta‐analysis (PRISMA) guidelines. The protocol was established a priori and published on PROSPERO (CRD42020201288). MEDLINE, EMBASE, CENTRAL, and Web of Science were searched until December 31, 2020. Primary studies comparing topical pain therapies to another therapy or control were included. Primary outcomes included percentage of corneal abrasions healed at 24, 48, and 72 hours, as well as pain control at 24 and 48 hours. Secondary outcomes included use of oral analgesia and incidence of complications. Risk of bias was assessed using validated tools. Quality of evidence was assessed using the GRADE methodology. Results: Overall, 33 studies (31 randomized controlled trials [RCTs], two cohort studies) comprising 4,167 patients with corneal abrasions were analyzed. Only the data for topical NSAIDs were of adequate evidence from which to draw conclusions; topical NSAIDs demonstrated significantly reduced pain scores at 24 hours (standardized mean differences [SMD] –0.69, 95% CI = –0.98 to –0.41) and 48 hours (SMD = –0.56, 95% CI = –1.02 to –0.10) as well as 53% (95% CI = 34% to 67%) lower oral analgesia use compared to control. Based on available data, topical anesthetics, cycloplegics, patching, and the use of a BCL did not result in any significant difference in pain scores or use of oral analgesia, while no studies examined topical steroids. No interventions resulted in healing delays or significantly higher rates of complications compared to controls. Conclusions: There was strong evidence to support that topical NSAIDs reduce pain associated with corneal abrasions in the first 48 hours and the need for oral analgesia. The existing evidence was insufficient to support or refute the use of topical anesthetics, cycloplegics, steroids, or BCL for pain control in corneal abrasions. Pressure patching was ineffective at pain reduction and may increase the risk of complications. Delays in healing or other complications were not significantly different between any intervention or control for simple, uncomplicated corneal abrasions; however, larger RCTs are required to identify any differences in rare complications. [ABSTRACT FROM AUTHOR]

Background: The prehospital phase is critical in ensuring that stroke treatment is delivered quickly and is a major source of time delay. This study sought to identify and examine prehospital stroke workflow optimizations (PSWOs) and their impact on improving health systems, reperfusion rates, treatment delays, and clinical outcomes. Methods: The authors conducted a systematic literature review and meta‐analysis by extracting data from several research databases (PubMed, Cochrane, Medline, and Embase) published since 2005. We used appropriate key search terms to identify clinical studies concerning prehospital workflow optimization, following Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines. Results: The authors identified 27 articles that looked at the impact of prehospital workflow optimizations on time and treatment parameters; 26 were included in the meta‐analysis. The PSWO were subgrouped into three categories: improved intravenous thrombolysis (IVT) triage, large‐vessel occlusion (LVO) bypass, and mobile stroke unit (MSU). The salient findings are as follows: improved IVT triage led to significantly improved rates of IVT (relative risk [RR] = 1.80, 95% confidence interval [CI] = 1.18 to 2.75); however, MSU did not (RR = 1.22, 95% CI = 0.98 to 1.52). Improved IVT triage (standard mean difference [SMD] = –0.82, 95% CI = –1.32 to –0.32), LVO bypass (SMD = –0.80, 95% CI = –1.13 to –0.47), and MSU (SMD = –0.87, 95% CI = –1.57 to –0.17) were found to significantly reduce door‐to‐needle time for IVT. MSU was found to significantly reduce call‐to‐needle (SMD = –1.41, 95% CI = –1.94 to –0.88) and onset‐to‐needle (SMD = –1.15, 95% CI = –1.74 to –0.56) times for IVT. MSU additionally demonstrated significant reduction in door‐to‐perfusion (SMD = –0.72, 95% CI = –1.32 to –0.12) as well as call‐to‐perfusion (SMD = –0.73, 95% CI = –1.08 to –0.38) times for EVT. Finally, PSWO did not demonstrate significant improvements in rates of good functional outcome (RR = 1.04, 95% CI = 0.97 to 1.12) or mortality at 90 days (RR = 1.00, 95% CI = 0.76 to 1.31). Conclusions: This systematic review and meta‐analysis found that PSWO significantly improves several time metrics related to stroke treatment leading to improvement in IVT reperfusion rates. Thus, the implementation of these measures in stroke networks is a promising avenue to improve an often‐neglected aspect of the stroke response. However, the limited available data suggest functional outcomes and mortality are not significantly improved by PSWO; hence, further studies and improvement strategies vis‐à‐vis PSWOs are warranted. [ABSTRACT FROM AUTHOR]

Background: Social determinants of health (SDoH) have significant implications for health outcomes in the United States. Emergency departments (EDs) function as the safety nets of the American health care system, caring for many vulnerable populations. ED‐based interventions to assess social risk and mitigate social needs have been reported in the literature. However, the breadth and scope of these interventions have not been evaluated. As the field of social emergency medicine (SEM) expands, a mapping and categorization of previous interventions may help shape future research. We sought to identify, summarize, and characterize ED‐based interventions aimed at mitigating negative SDoH. Methods: We conducted a scoping review to identify and characterize peer‐reviewed research articles that report ED‐based interventions to address or impact SDoH in the United States. We designed and conducted a search in Medline, CINAHL, and Cochrane CENTRAL databases. Abstracts and, subsequently, full articles were reviewed independently by two reviewers to identify potentially relevant articles. Included articles were categorized by type of intervention and primary SDoH domain. Reported outcomes were also categorized by type and efficacy. Results: A total of 10,856 abstracts were identified and reviewed, and 596 potentially relevant studies were identified. Full article review identified 135 articles for inclusion. These articles were further subdivided into three intervention types: a) provider educational intervention (18%), b) disease modification with SDoH focus (26%), and c) direct SDoH intervention (60%), with 4% including two "types." Articles were subsequently further grouped into seven SDoH domains: 1) access to care (33%), 2) discrimination/group disparities (7%), 3) exposure to violence/crime (34%), 4) food insecurity (2%), 5) housing issues/homelessness (3%), 6) language/literacy/health literacy (12%), 7) socioeconomic disparities/poverty (10%). The majority of articles reported that the intervention studied was effective for the primary outcome identified (78%). Conclusion: Emergency department–based interventions that address seven different SDoH domains have been reported in the peer‐reviewed literature over the past 30 years, utilizing a variety of approaches including provider education and direct and indirect focus on social risk and need. Characterization and understanding of previous interventions may help identify opportunities for future interventions as well as guide a SEM research agenda. [ABSTRACT FROM AUTHOR]

Objectives: Emergency department (ED) patients with unexplained syncope are at risk of experiencing an adverse event within 30 days. Our objective was to systematically review the accuracy of multivariate risk stratification scores for identifying adult syncope patients at high and low risk of an adverse event over the next 30 days. Methods: We conducted a systematic review of electronic databases (MEDLINE, Cochrane, Embase, and CINAHL) from database creation until May 2020. We sought studies evaluating prediction scores of adults presenting to an ED with syncope. We included studies that followed patients for up to 30 days to identify adverse events such as death, myocardial infarction, stroke, or cardiac surgery. We only included studies with a blinded comparison between baseline clinical features and adverse events. We calculated likelihood ratios and confidence intervals (CIs). Results: We screened 13,788 abstracts. We included 17 studies evaluating nine risk stratification scores on 24,234 patient visits, where 7.5% (95% CI = 5.3% to 10%) experienced an adverse event. A Canadian Syncope Risk Score (CSRS) of 4 or more was associated with a high likelihood of an adverse event (LRscore≥4 = 11, 95% CI = 8.9 to 14). A CSRS of 0 or less (LRscore≤0 = 0.10, 95% CI = 0.07 to 0.20) was associated with a low likelihood of an adverse event. Other risk scores were not validated on an independent sample, had low positive likelihood ratios for identifying patients at high risk, or had high negative likelihood ratios for identifying patients at low risk. Conclusion: Many risk stratification scores are not validated or not sufficiently accurate for clinical use. The CSRS is an accurate validated prediction score for ED patients with unexplained syncope. Its impact on clinical decision making, admission rates, cost, or outcomes of care is not known. [ABSTRACT FROM AUTHOR]

Objective: There has been increased interest in the use of low‐dose ketamine (LDK) as an alternative analgesic for the management of acute pain in the emergency department (ED). The objective of this systematic review was to compare the analgesic effectiveness and safety profile of LDK and morphine for acute pain management in the ED. Methods: Electronic searches of Medline and EMBASE were conducted and reference lists were hand‐searched. Randomized controlled trials (RCTs) comparing LDK to morphine for acute pain control in the ED were included. Two reviewers independently screened abstracts, assessed quality of the studies, and extracted data. Data were pooled using random‐effects models and reported as mean differences and risk ratios (RRs) with 95% confidence intervals (CIs). We used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty of the evidence. Results: Eight RCTs were included with a total of 1,191 patients (LDK = 598, morphine = 593). There was no significant difference in reported mean pain scores between LDK and morphine within the first 60 minutes after analgesia administration and a slight difference in pain scores favoring morphine at 60 to 120 minutes. The need for rescue medication was also similar between groups (RR = 1.26, 95% CI = 0.50 to 3.16), as was the proportion of patients who experienced nausea (RR = 0.97, 95% CI = 0.63 to 1.49) and hypoxia (RR = 0.38, 95% CI = 0.10 to 1.41). All outcomes were judged to have low certainty in the evidence. Conclusion: Low‐dose ketamine and morphine had similar analgesic effectiveness within 60 minutes of administration with comparable safety profiles, suggesting that LDK is an effective alternative analgesic for acute pain control in the ED. [ABSTRACT FROM AUTHOR]

Background: Cutaneous abscesses are common presentations to the emergency department. While the primary treatment for most abscesses is conventional incision and drainage (CID), this is painful and can lead to multiple return visits. The loop drainage technique (LDT) has been proposed as an alternate, less‐invasive approach to abscess management. The primary outcome of this study was to compare LDT with CID for skin and soft tissue abscesses. Methods: PubMed, Scopus, CINAHL, LILACS, Google Scholar, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and bibliographies of selected articles were assessed for all retrospective, prospective observational, and randomized controlled trials comparing treatment failures between LDT and CID among patients with skin and soft tissue abscesses. Data were dual extracted into a predefined worksheet and quality analysis was performed using the Cochrane Risk of Bias tool or the Newcastle‐Ottawa scale. Data were summarized and presented as odds ratios (ORs) with 95% confidence intervals (CIs). Subgroup analyses were performed for adult and pediatric patients. Results: A total of 1,374 studies were identified with eight studies (n = 910 patients) selected for inclusion. Overall, CID failed in 69 of 487 patients (14.17%), while LDT failed in 35 of 423 patients (8.27%). There was an OR of 2.02 (95% CI = 1.29 to 3.18) in favor of higher failures in the CID group. This finding remained consistent with only randomized controlled trials (OR = 1.75, 95% CI = 1.07 to 2.86), but no difference was identified in the adult or pediatric subgroups. Conclusion: The LDT was associated with reduced treatment failures when compared with CID. Future studies should further assess the impact on pain, cosmetic outcomes, and health care costs. [ABSTRACT FROM AUTHOR]

Objective: Having shown promise in other medical fields, we sought to determine whether machine learning (ML) models perform better than usual care in diagnostic and prognostic prediction for emergency department (ED) patients. Methods: In this systematic review, we searched MEDLINE, Embase, Central, and CINAHL from inception to October 17, 2019. We included studies comparing diagnostic and prognostic prediction of ED patients by ML models to usual care methods (triage‐based scores, clinical prediction tools, clinician judgment) using predictor variables readily available to ED clinicians. We extracted commonly reported performance metrics of model discrimination and classification. We used the PROBAST tool for risk of bias assessment (PROSPERO registration: CRD42020158129). Results: The search yielded 1,656 unique records, of which 23 studies involving 16,274,647 patients were included. In all seven diagnostic studies, ML models outperformed usual care in all performance metrics. In six studies assessing in‐hospital mortality, the best‐performing ML models had better discrimination (area under the receiver operating characteristic curve [AUROC] =0.74–0.94) than any clinical decision tool (AUROC =0.68–0.81). In four studies assessing hospitalization, ML models had better discrimination (AUROC =0.80–0.83) than triage‐based scores (AUROC =0.68–0.82). Clinical heterogeneity precluded meta‐analysis. Most studies had high risk of bias due to lack of external validation, low event rates, and insufficient reporting of calibration. Conclusions: Our review suggests that ML may have better prediction performance than usual care for ED patients with a variety of clinical presentations and outcomes. However, prediction model reporting guidelines should be followed to provide clinically applicable data. Interventional trials are needed to assess the impact of ML models on patient‐centered outcomes. [ABSTRACT FROM AUTHOR]

Background: Clinical guidelines have supported outpatient treatment of low‐risk pulmonary embolism (PE) since 2014, but adoption of this practice has been slow. Direct oral anticoagulant (DOAC) therapy for venous thromboembolism (VTE) is now as common as vitamin K antagonist treatment, but data are sparse regarding outcomes for patients with low‐risk PE treated with DOACs as outpatients. We conducted a systematic review of literature on outcomes of outpatient management for PE, including comparisons to inpatient treatment and differences by anticoagulant class. Methods: We searched Medline, Embase, PubMed, CENTRAL, clinicaltrials.gov, and ICTRN for studies published from January 1980 through February 2019 using a predefined strategy developed with a medical librarian. We included English‐language randomized controlled trials (RCTs) and prospective nonrandomized trials (NRTs) of adult patients diagnosed with acute, symptomatic PE, and discharged from the emergency department or within 48 hours. Our primary outcome included four major adverse outcomes (all‐cause mortality, PE‐related mortality, recurrent VTE, and major bleeding) within 30 and 90 days. A preplanned subanalysis of high‐quality studies assessed outcomes associated with different anticoagulation treatment classes. Results: Our initial search identified 6,818 records, of which 12 studies (four RCT, eight NRT) with a total of 3,191 patients were included in the review. All RCTs and six NRTs were determined to have low to moderate risk of bias and were classified as high quality. Outpatients in these studies (n = 1,814) had rates of 90‐day major adverse outcomes below 1%, including all‐cause mortality (0.7%, 95% confidence interval [CI] = 0.4% to 1.2%), PE‐related mortality (0.06%, 95% CI = 0.01% to 0.3%), recurrent VTE (0.8%, 95% CI = 0.5% to 1.4%), and major bleeding (0.8%, 95% CI = 0.5% to 1.4%). Exploratory analysis revealed no association between anticoagulant treatment class and rates of major adverse outcomes. Conclusion: Among patients with low‐risk PE treated as outpatients, few patients experienced major adverse outcomes such as mortality, recurrent VTE, or major bleeding within 90 days. [ABSTRACT FROM AUTHOR]

Background: Older adult delirium is often unrecognized in the emergency department (ED), yet the most compelling research questions to overcome knowledge‐to‐practice deficits remain undefined. The Geriatric Emergency care Applied Research (GEAR) Network was organized to identify and prioritize delirium clinical questions. Methods: GEAR identified and engaged 49 transdisciplinary stakeholders including emergency physicians, geriatricians, nurses, social workers, pharmacists, and patient advocates. Adhering to Preferred Reporting Items for Systematic Reviews and Meta‐Analyses for Scoping Reviews, clinical questions were derived, medical librarian electronic searches were conducted, and applicable research evidence was synthesized for ED delirium detection, prevention, and management. The scoping review served as the foundation for a consensus conference to identify the highest priority research foci. Results: In the scoping review, 27 delirium detection "instruments" were described in 48 ED studies and used variable criterion standards with the result of delirium prevalence ranging from 6% to 38%. Clinician gestalt was the most common "instrument" evaluated with sensitivity ranging from 0% to 81% and specificity from 65% to 100%. For delirium management, 15 relevant studies were identified, including one randomized controlled trial. Some intervention studies targeted clinicians via education and others used clinical pathways. Three medications were evaluated to reduce or prevent ED delirium. No intervention consistently prevented or treated delirium. After reviewing the scoping review results, the GEAR stakeholders identified ED delirium prevention interventions not reliant on additional nurse or physician effort as the highest priority research. Conclusions: Transdisciplinary stakeholders prioritize ED delirium prevention studies that are not reliant on health care worker tasks instead of alternative research directions such as defining etiologic delirium phenotypes to target prevention or intervention strategies. [ABSTRACT FROM AUTHOR]

Objectives: Child abuse is a significant cause of morbidity and mortality in preverbal children who cannot explain their injuries. Fractures are among the most common injuries associated with abuse but of themselves fractures may not be recognized as abusive until a comprehensive child abuse evaluation is completed, often prompted by other signs or subjective features. We sought to determine which children presenting with rib or long‐bone fractures should undergo a routine abuse evaluation based on age. Methods: A systematic review searching Ovid, PubMed/Medline, Scopus, and CINAHL from 1980 to 2020 was performed. An evidence‐based framework was generated by a consensus panel and applied to the results of the systematic review to form recommendations. Fifteen articles were suitable for final analysis. Results: Studies with comparable age ranges of subjects and sufficient evidence to meet the determination of abuse standard for pediatric patients with rib, humeral, and femoral fractures were identified. Seventy‐seven percent of children presenting with rib fractures aged less than 3 years were abused; when those involved in motor vehicle collisions were excluded, 96% were abused. Abuse was identified in 48% of children less than 18 months with humeral fractures. Among those with femoral fractures, abuse was diagnosed in 34% and 25% of children aged less than 12 and 18 months, respectively. Conclusion: Among children who were not in an independently verified incident, the authors strongly recommend routine evaluation for child abuse, including specialty child abuse consultation, for: 1) children aged less than 3 years old presenting with rib fractures and 2) children aged less than 18 months presenting with humeral or femoral fractures (Level of Evidence: III Review). [ABSTRACT FROM AUTHOR]

Objective: The annual systematic search of the peer‐reviewed and gray literature relevant to global emergency medicine (EM) was conducted by the Global Emergency Medicine Literature Review (GEMLR) to screen, evaluate, and review the most rigorously conducted and relevant research in global EM published in 2019. Methods: After a broad search of PubMed and websites of organizations publishing relevant gray literature, all articles that were deemed relevant to the fields of disaster and humanitarian response, emergency care in resource‐limited settings, and EM development by at least one reviewer, an editor, and the managing editors were then scored by two different reviewers using a 20‐point scoring template relevant to either original research (OR) or review (RE) articles. This scoring system rates articles on their clarity, research design, ethics, importance to global EM, and breadth of impact. Articles that then scored in the top 5% were then critiqued in depth. Results: A total of 23,321 article titles and abstracts were screened by 22 reviewers with a wide swath of clinical and research experience in global EM. From these, a total of 356 articles underwent full‐text review and scoring on the 20‐point scale; 26% were categorized as disaster and humanitarian response, 58% as emergency care in resource‐limited settings, and 15% as EM development. Of these 356 articles, 276 (77.5%) were OR articles and 80 (22.5%) were RE articles. The 16 articles that scored in the top 5% (>17.5 of 20 points) received full in‐depth narrative summaries. Conclusions: In 2019, the overall number of studies relevant to global EM that were identified by our search decreased from the prior year, but more high‐scoring articles related to the development of EM clinical practice and as a specialty in resource‐constrained settings were identified. [ABSTRACT FROM AUTHOR]

Objective: The objective was to systematically identify and summarize out‐of‐hospital measures of circulatory compromise as diagnostic predictors of serious injury, focusing on measures usable by emergency medical services to inform field triage decisions. Methods: We searched Ovid MEDLINE, CINAHL, and the Cochrane databases from 1996 through August 2017 for published literature on individual circulatory measures in trauma. We reviewed reference lists of included articles for additional relevant citations. Measures of diagnostic accuracy included sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC). Indicators of serious injury included resource need, serious anatomic injury, and mortality. We pooled estimates when data permitted. Results: We identified 114 articles, reporting results of 111 studies. Measures included systolic blood pressure (sBP), heart rate (HR), shock index (SI), lactate, base deficit, and HR variability. Pooled out‐of‐hospital sensitivity estimates were sBP < 90 mm Hg = 19% (95% confidence interval [CI] = 12% to 29%), HR ≥ 110 beats/min = 28% (95% CI = 20% to 37%), SI > 0.9 = 37% (95% CI = 22% to 56%), and lactate > 2.0 mmol/L = 74% (95% CI = 48% to 90%). Pooled specificity estimates were sBP < 90 mm Hg = 95% (95% CI = 91% to 97%), HR ≥ 110 beats/min = 85% (95% CI = 74% to 91%), SI > 0.9 = 85% (95% CI = 72% to 92%), and lactate > 2.0 mmol/L = 62% (95% CI = 51% to 72%). Pooled AUROCs included sBP = 0.67 (95% CI = 0.58 to 0.75), HR = 0.67 (95% CI = 0.56 to 0.79), SI = 0.72 (95% CI = 0.66 to 0.77), and lactate = 0.77 (95% CI = 0.67 to 0.82). Strength of evidence was low to moderate. Conclusions: Out‐of‐hospital circulatory measures are associated with poor to fair discrimination for identifying trauma patients with serious injuries. Many seriously injured patients have normal circulatory measures (low sensitivity), but when present, the measures are highly specific for identifying patients with serious injuries. [ABSTRACT FROM AUTHOR]

Objectives: The objective was to systematically review the published literature on the diagnostic accuracy of out‐of‐hospital respiratory measures for identifying patients with serious injury, focusing on measures feasible for field triage by emergency medical services personnel. Methods: We searched Ovid MEDLINE, CINAHL, and the Cochrane databases from January 1, 1996, through August 31, 2017. We included studies on the diagnostic accuracy (sensitivity, specificity, and area under the receiver operating characteristic curve [AUROC]) for all respiratory measures used to identify patients with serious injury (resource use, serious anatomic injury, and mortality). We assessed studies for risk of bias and strength of evidence (SOE). We performed meta‐analysis for measures with sufficient data. Results: We identified 46 articles reporting results of 44 studies. Out‐of‐hospital respiratory measures included respiratory rate, pulse oximetry, and airway support. Meta‐analysis was only possible for respiratory rate, which demonstrated a pooled sensitivity for serious injury of 13% (95% confidence interval [CI] = 5 to 29, I2 = 97.8%), specificity of 96% (95% CI = 83 to 99, I2 = 99.6%), and AUROC of 0.70 (95% CI = 0.66 to 0.79, I2 = 16.6%). For oxygen saturation, sensitivity ranged from 13% to 63%; specificity, 85% to 99%; and AUROC, 0.53 to 0.76. Need for airway support had a sensitivity of 8% to 53% and specificity of 61% to 100%; studies did not report AUROC. Across respiratory measures, the SOE was low. Other respiratory measures (pH, end‐tidal carbon dioxide [CO2], and sublingual partial pressure of CO2) were reported only in emergency department studies. Conclusions: Data on the accuracy of out‐of‐hospital respiratory measures for field triage are limited and of low quality. Based on available research, respiratory rate, oxygen saturation, and need for airway intervention all have low sensitivity, high specificity, and poor to fair discrimination for identifying seriously injured patients. [ABSTRACT FROM AUTHOR]

Objectives: The opioid crisis has risen dramatically in North America in the new millennium, due to both illegal and prescription opioid use. While emergency departments (EDs) represent a potentially strategic setting for interventions to reduce harm from opioid use disorder (OUD), the absence of a recent synthesis of literature limits implementation and scalability. To fill this gap, we conducted a systematic review of the literature on interventions targeting OUDs initiated in EDs. Methods: Using an explicit search strategy (PROSPERO), the MEDLINE, CINAHL Complete, EMBASE, and EBM reviews databases were searched from 1980 to October 4, 2019. The gray literature was explored using Google Scholar. Study characteristics were abstracted independently. The methodologic quality and risk of bias were assessed. Results: Twelve of 2,270 studies met the inclusion criteria (two of high quality). In addition to the heterogeneity of the outcome measures used (retention in treatment, opioid consumption, and overdose), brief intervention and buprenorphine initiation (six of 12 studies) were the most documented with mixed effects for the former and positive short‐term and confined to single ED sites effects for the latter. Conclusion: Emergency departments can be an appropriate setting for initiating opioid agonist treatment, but to be sustained, it likely needs to be coupled with community‐based follow‐up and support to ensure longer‐term retention. The scarcity of high‐quality evidence on OUD interventions initiated in emergency settings highlights the need for future research. [ABSTRACT FROM AUTHOR]

Objectives: In patients at low clinical probability of acute aortic syndromes (AASs), decision on advanced aortic imaging is cumbersome. Integration of the aortic dissection detection risk score (ADD‐RS) with D‐dimer (DD) provides a potential pipeline for standardized diagnostic rule‐out. We systematically reviewed and summarized supporting data. Methods: Cross‐sectional studies assessing integration of ADD‐RS with DD for diagnosis of AASs were identified on MEDLINE, EMBASE and Web Of Science databases. Two reviewers independently screened articles, assessed quality, and extracted data. The quality of design and reporting was evaluated with the QUADAS‐2 and STARD tools. Individual patient data were obtained, to allow analysis of both conventional (500 ng/mL) and age‐adjusted (DDage‐adj) DD cutoffs. Data were summarized for four diagnostic strategies combining ADD‐RS = 0 or ≤ 1, with DD < 500 ng/mL or < DDage‐adj. The statistical heterogeneity of the diagnostic variables was estimated with Higgins' I2. Pooled values were calculated for variables showing nonsignificant heterogeneity. Results: After screening of 680 studies, four articles (including a total of 3,804 patients) met inclusion criteria. One prospective study provided a low risk of bias/applicability concerns, while methodologic limitations were found in the other three retrospective studies. Statistical heterogeneity was negligible for sensitivity and negative likelihood ratio (LR) values and significant for specificity and positive LR values of all diagnostic strategies. Pooled sensitivity was 99.9% (95% confidence interval [CI] = 99.3% to 100%, I2 = 0) for ADD‐RS = 0 and DD < 500 ng/mL or < DDage‐adj, 98.9% (95% CI = 97.9% to 99.9%, I2 = 0) for ADD‐RS ≤ 1 and DD < 500 ng/mL, and 97.6% (95% CI = 96.3% to 98.9%, I2 = 0) for ADD‐RS ≤ 1 and DD < DDage‐adj. Conclusions: Despite methodologic limitations, integration of ADD‐RS = 0 or ≤ 1 with DD < 500 ng/mL shows negligible heterogeneity and consistently high sensitivity across studies, thus supporting reliability for diagnostic rule‐out of AASs. Data supporting ADD‐RS = 0 plus DDage‐adj appear preliminary and require further scrutiny. [ABSTRACT FROM AUTHOR]

Introduction: Dizziness is a common complaint presented in the emergency department (ED). A subset of these patients will present with acute vestibular syndrome (AVS). AVS is a clinical syndrome defined by the presence of vertigo, nystagmus, head motion intolerance, ataxia, and nausea/vomiting. These symptoms are most often due to benign vestibular neuritis; however, they can be a sign of a dangerous central cause, i.e., vertebrobasilar stroke. The Head Impulse test, Nystagmus, Test of Skew (HINTS) examination has been proposed as a bedside test for frontline clinicians to rule out stroke in those presenting with AVS. Our objective was to assess the diagnostic accuracy of the HINTS examination to rule out a central cause of vertigo in an adult population presenting to the ED with AVS. Our aim was to assess the diagnostic accuracy when performed by emergency physicians versus neurologists. Methods: We searched PubMed, Medline, Embase, the Cochrane database, and relevant conference abstracts from 2009 to September 2019 and performed hand searches. No restrictions for language or study type were imposed. Prospective studies with patients presenting with AVS using criterion standard of computed tomography and/or magnetic resonance imaging were selected for review. Two independent reviewers extracted data from relevant studies. Studies were combined if low clinical and statistical heterogeneity was present. Study quality was assessed using the QUADAS‐2 tool. Random effects meta‐analysis was performed using RevMan 5 and SAS 9.3. Results: A total of five studies with 617 participants met the inclusion criteria. The mean (±SD) study length was 5.3 (±3.3) years. Prevalence of vertebrobasilar stroke ranged 9.3% to 44% (mean ± SD = 39.1% ± 17.1%). The most common diagnoses were vertebrobasilar stroke (mean ± SD = 34.8% ± 17.1%), peripheral cause (mean ± SD = 30.9% ± 16%), and intracerebral hemorrhage (mean ± SD = 2.2% ± 0.5%). The HINTS examination, when performed by neurologists, had a sensitivity of 96.7% (95% CI = 93.1% to 98.5%, I2 = 0%) and specificity of 94.8% (95% CI = 91% to 97.1%, I2 = 0%). When performed by a cohort of physicians including both emergency physicians (board certified) and neurologists (fellowship trained in neurootology or vascular neurology) the sensitivity was 83% (95% CI = 63% to 95%) and specificity was 44% (95% CI = 36% to 51%). Conclusions: The HINTS examination, when used in isolation by emergency physicians, has not been shown to be sufficiently accurate to rule out a stroke in those presenting with AVS. [ABSTRACT FROM AUTHOR]

Objective: Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) emerged as a global pandemic in early 2020 with rapidly evolving approaches to diagnosing the clinical illness called coronavirus disease (COVID‐19). The primary objective of this scoping review is to synthesize current research of the diagnostic accuracy of history, physical examination, routine laboratory tests, real‐time reverse transcription–polymerase chain reaction (rRT‐PCR), immunology tests, and computed tomography (CT) for the emergency department (ED) diagnosis of COVID‐19. Secondary objectives included a synopsis of diagnostic biases likely with current COVID‐19 research as well as corresponding implications of false‐negative and false‐positive results for clinicians and investigators. Methods: A Preferred Reporting Items for Systematic Reviews and Meta‐Analyses–Scoping Review (PRISMA‐ScR)–adherent synthesis of COVID‐19 diagnostic accuracy through May 5, 2020, was conducted. The search strategy was designed by a medical librarian and included studies indexed by PubMed and Embase since January 2020. Results: A total of 1,907 citations were screened for relevance. Patients without COVID‐19 are rarely reported, so specificity and likelihood ratios were generally unavailable. Fever is the most common finding, while hyposmia and hypogeusia appear useful to rule in COVID‐19. Cough is not consistently present. Lymphopenia is the mostly commonly reported laboratory abnormality and occurs in over 50% of COVID‐19 patients. rRT‐PCR is currently considered the COVID‐19 criterion standard for most diagnostic studies, but a single test sensitivity ranges from 60% to 78%. Multiple reasons for false‐negatives rRT‐PCR exist, including sample site tested and disease stage during which sample was obtained. CT may increase COVID‐19 sensitivity in conjunction with rRT‐PCR, but guidelines for imaging patients most likely to benefit are emerging. IgM and IgG serology levels are undetectable in the first week of COVID‐19, but sensitivity (range = 82% to 100%) and specificity (range = 87% to 100%) are promising. Whether detectable COVID‐19 antibodies correspond to immunity remains unanswered. Current studies do not adhere to accepted diagnostic accuracy reporting standards and likely report significantly biased results if the same tests were to be applied to general ED populations with suspected COVID‐19. Conclusions: With the exception of fever and disorders of smell/taste, history and physical examination findings are unhelpful to distinguish COVID‐19 from other infectious conditions that mimic SARS‐CoV‐2 like influenza. Routine laboratory tests are also nondiagnostic, although lymphopenia is a common finding and other abnormalities may predict severe disease. Although rRT‐PCR is the current criterion standard, more inclusive consensus‐based criteria will likely emerge because of the high false‐negative rate of PCR tests. The role of serology and CT in ED assessments remains undefined. [ABSTRACT FROM AUTHOR]

Background: Patients with chronic noncancer pain (CNCP) present unique challenges to emergency department (ED) care providers and administrators. Their conditions lead to frequent ED visits for pain relief and symptom management and are often poorly addressed with costly, low‐yield care. A systematic review has not been performed to inform the management of frequent ED utilizing patients with CNCP. Therefore, we synthesized the available evidence on interventional strategies to improve care‐associated outcomes for this patient group. Methods: We searched Medline, EMBASE, CINAHL, CENTRAL, SCOPUS, and Web of Science from database inception to June 2018 for eligible interventional studies aimed at reducing frequent ED utilization among adult patients with CNCP. Articles were assessed in duplicate in accordance with methodologic recommendations from the Cochrane Handbook for Systematic Reviews of Interventions. Outcomes of interest were the frequency of subsequent ED visits, type and amount of opioids administered in the ED and prescribed at discharge, and costs. Methodologic quality was assessed using the Cochrane Risk of Bias in Non‐Randomized Studies of Interventions and Risk of Bias tools for nonrandomized and randomized studies, respectively. Results: Thirteen studies including 1,679 patients met the inclusion criteria. Identified interventions implemented pain policies (n = 4), individualized care plans (n = 5), ED care coordination (n = 2), chronic pain management pathways (n = 1), and behavioral health interventions (n = 1). All of the studies reported a decrease in ED visit frequency following their respective interventions. These reductions were especially pronounced in studies whose interventions were focused around individualized care plans and primary care involvement. Interventions implementing opioid restriction and pain management policies were largely successful in reducing the amounts of opioid medications administered and prescribed in the ED. Conclusions: Multifaceted interventions, especially those employing individualized care plans, can successfully reduce subsequent ED visits, ED opioid administration and prescription, and care‐associated costs for frequent ED utilizing patients with CNCP. [ABSTRACT FROM AUTHOR]

Background: Community‐acquired pneumonia (CAP) is an important source of morbidity and mortality. However, overtreatment of acute cough illness with antibiotics is an important problem, so improved diagnosis of CAP could help reduce inappropriate antibiotic use. Methods: This was a meta‐analysis of prospective cohort studies of patients with clinically suspected pneumonia or acute cough that used imaging as the reference standard. All studies were reviewed in parallel by two researchers and quality was assessed using the QUADAS‐2 criteria. Summary measures of accuracy included sensitivity, specificity, likelihood ratios, the diagnostic odds ratio, and the area under the receiver operating characteristic curve (AUROCC) and were calculated using bivariate meta‐analysis. Results: We identified 17 studies, of which 12 were judged to be at low risk of bias and the remainder at moderate risk of bias. The prevalence of CAP was 10% in nine primary care studies and was 20% in seven emergency department studies. The probability of CAP is increased most by an abnormal overall clinical impression suggesting CAP (positive likelihood ratio [LR+] = 6.32, 95% CI = 3.58 to 10.5), egophony (LR+ = 6.17, 95% CI = 1.34 to 18.0), dullness to percussion (LR+ = 2.62, 95% CI = 1.14 to 5.30), and measured temperature (LR+ = 2.52, 95% CI = 2.02 to 3.20), while it is decreased most by the absence of abnormal vital signs (LR− = 0.25, 95% CI = 0.11 to 0.48). The overall clinical impression also had the highest AUROCC at 0.741. Conclusions: While most individual signs and symptoms were unhelpful, selected signs and symptoms are of value for diagnosing CAP. Teaching and performing these high value elements of the physical examination should be prioritized, with the goal of better targeting chest radiographs and ultimately antibiotics. [ABSTRACT FROM AUTHOR]

Objectives: The emergence of SARS‐CoV‐2 has presented clinicians with a difficult therapeutic dilemma. With supportive care as the current mainstay of treatment, the fatality rate of COVID‐19 is 6.9%. There are currently several trials assessing the efficacy of different antivirals as treatment. Of these, chloroquine (CQ) and its derivative hydroxychloroquine (HCQ) have garnered the most attention. Methods: In this study, the literature currently available on CQ and HCQ as treatment of COVID‐19 was surveyed using EMBASE, PubMed, Cochrane Library, MedRxiv, and one clinical trial registry. Upon gathering published and preprint trials, risk of bias was assessed using Cochrane Risk of Bias Tool 2.0. Results: There are currently seven completed clinical trials and 29 registered clinical trials focusing on HCQ or CQ as a therapeutic avenue for COVID‐19. Of these, five of seven trials have shown favorable outcomes for patients using CQ or HCQ and two of seven have shown no change compared to control. However, all seven trials carried varying degrees of bias and poor study design. Conclusion: There are currently not enough data available to support the routine use of HCQ and CQ as therapies for COVID‐19. Pending further results from more extensive studies with more stringent study parameters, clinicians should defer from routine use of HCQ and CQ. There are several clinical trials currently under way with results expected soon. [ABSTRACT FROM AUTHOR]

Background: Biomarkers such as C‐reactive protein (CRP) and procalcitonin may help distinguish community‐acquired pneumonia (CAP) from other causes of lower respiratory tract infection. Methods: We performed a systematic review of the literature to identify prospective studies evaluating the accuracy of a biomarker in patients with acute cough or suspected CAP. We performed parallel abstraction of data regarding study inclusion, characteristics, quality, and test accuracy. Study quality was evaluated using QUADAS‐2. Bivariate meta‐analysis was performed using the mada package in R, and summary receiver operating characteristic (ROC) curves were created. Results: Fourteen studies met our inclusion and exclusion criteria; three were at low risk of bias and four at moderate risk of bias, largely due to failure to prespecify diagnostic thresholds. Considering all studies regardless of the cutoff used, CRP was most accurate (area under the ROC curve = 0.802), followed by leukocytosis (0.777) and procalcitonin (0.771). Lipopolysaccharide‐binding protein and fibrinogen are promising, but were only studied in a single report. For CRP and procalcitonin, the positive and negative likelihood ratios (LR+ and LR–, respectively) varied inversely based on the cutoff. For CRP, LR+ and LR− were 2.08 and 0.32 for a cutoff of 20 mg/L, 3.64 and 0.36 for a cutoff of 50 mg/L, and 5.89 and 0.47 for a cutoff of 100 mg/L. For procalcitonin, LR+ and LR− were 2.50 and 0.39 for a cutoff of 0.10 µg/L, 5.43 and 0.62 for a cutoff of 0.25 µg/L, and 8.25 and 0.76 for a cutoff of 0.50 µg/L. The combination of CRP >49.5 mg/L and procalcitonin >0.1 µg/L had LR+ of 2.24 and LR− of 0.44. Conclusions: The best evidence supports CRP as the preferred biomarker for diagnosis of outpatient CAP given its accuracy, low cost, and point‐of‐care availability. [ABSTRACT FROM AUTHOR]

Objectives: The Global Emergency Medicine Literature Review (GEMLR) conducts a systematic annual search of peer‐reviewed and gray literature relevant to global emergency medicine (EM) to identify, review, and disseminate the most rigorously conducted and widely relevant research in global EM. Methods: An electronic search of PubMed, a comprehensive retrieval of articles from specific journals, and search of the gray literature were conducted. Title and abstracts retrieved by these searches were screened by a total of 22 reviewers based on their relevance to the field of global EM, across the domains of disaster and humanitarian response (DHR), emergency care in resource‐limited settings (ECRLS), and emergency medicine development (EMD). All articles that were deemed relevant by at least one reviewer, their editor, and the managing editor underwent formal scoring of overall methodologic quality and importance to global EM. Two independent reviewers scored all articles; editors provided a third score in cases of widely discrepant scores. Results: A total of 19,102 articles were identified by the searches and, after screening and removal of duplicates, a total of 517 articles underwent full review. Twenty‐five percent were categorized as DHR, 61% as ECRLS, and 15% as EMD. Inter‐rater reliability testing between the reviewers revealed a Cohen's kappa score of 0.213 when considering the complete score or 0.426 when excluding the more subjective half of the score. A total of 25 articles scored higher than 17.5 of 20; these were selected for a full summary and critique. Conclusions: In 2018, the total number of articles relevant to global EM that were identified by our search continued to increase. Studies and reviews focusing on pediatric infections, several new and traditionally underrepresented topics, and landscape reviews that may help guide clinical care in new settings represented the majority of top‐scoring articles. A shortage of articles related to the development of EM as a specialty was identified. [ABSTRACT FROM AUTHOR]

Background: Childhood pneumonia is a leading cause of mortality worldwide. Growing evidence suggests that lung ultrasound (LUS) may be a reliable diagnostic alternative to chest x‐ray for childhood pneumonia. However, it is unclear whether sonographer experience affects the diagnostic accuracy of LUS. We summarize the diagnostic accuracy of LUS for pneumonia and compare the performance between novice and advanced sonographers with a systematic review and meta‐analysis. Methods: We searched PubMed and EMBASE from inception to February 2018 for eligible studies that evaluated the utility of LUS in children suspected of having pneumonia against the reference standard of either imaging results alone or a combination of clinical, laboratory, and imaging results. We reported the study using the Preferred Reporting Items for a Systematic Review and Meta‐analysis of Diagnostic Test Accuracy Studies. We used QUADAS‐2 to appraise the included studies' methodologic quality. We employed a random‐effect bivariate model and a hierarchical summary receiver operating characteristic curve to evaluate LUS's performance characteristics. We conducted subgroup analyses and meta‐regression based on level of sonographer training to summarize and compare LUS's diagnostic accuracy for pneumonia between novice (training ≤ 7 days) and advanced sonographers. Results: Twenty‐five studies (n = 3,353) were included in the meta‐analysis. For diagnosing pneumonia, LUS demonstrated an overall sensitivity of 0.94 (95% confidence interval [CI] = 0.89 to 0.97), specificity of 0.92 (95% CI = 0.78 to 0.98), positive likelihood ratio of 12.40 (95% CI = 4.00 to 38.10), and negative likelihood ratio of 0.07 (95% CI = 0.04 to 0.12), with an area under ROC curve of 0.97 (95% CI = 0.95 to 0.98). Meta‐regression revealed a significant difference in the diagnostic accuracy for pneumonia for LUS between novice and advanced sonographers (p < 0.01). Conclusion: LUS can accurately diagnose pneumonia in children. However, this test demonstrates operator‐dependent variability, with more experienced sonographers having higher diagnostic accuracy. Further work on evidence‐based educational methods to train novice sonographers in LUS is required. [ABSTRACT FROM AUTHOR]