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Emergency department (ED) visits can be divided into urgent and non-urgent. A delay in seeking medical help, especially in urgent cases, can lead to fatal consequences, along with a higher rate of complications and morbidity. Coronavirus disease 2019 (COVID-19) pandemic spread led to restrictions and eventually quarantines. We investigated the impact of the COVID-19 spread and quarantine on ED visits rates comparing to parallel periods in preceding years (2013–2019). In addition, we compared this decrease to holidays and weekends, times in which a decrease in ED visits is seen. This was a descriptive retrospective study. Causes of ED referrals were divided into urgent and non-urgent, then into different subcategories including infectious, cardiac, etc. For the spring COVID-192020 quarantine period, a 56.3% decrease of mean ED visits per day was seen, as compared to preceding years (55.7% and 98.9% respectively). This decrease was also statistically evident when comparing the urgent and non-urgent causes separately and for all sub-categories. This pattern of decrease also showed statistical evidence of fewer ED visits during holidays for most comparisons, in which lower ED visit rates are expected. Significantly lower rates of ED visits were demonstrated during the COVID-19 quarantine period, as compared to preceding years and main holidays and weekends, a decrease that was also demonstrated for urgent life-threatening causes. Our findings can be used to inform a wide range of stakeholders, including regional planners, historians, sociologists, and international healthcare organizations. Healthcare providers should understand the reasons for this ED visit decline pattern, attempt to address patients' concerns, and increase awareness regarding alarming symptoms in urgent medical situations. • We investigated the impact of the COVID-19 spread and quarantine on emergency department (ED) visits rates. • For the COVID-19 quarantine period, a 56.3% decrease of mean ED visits per day was seen, as compared to preceding years. • This decrease was also evident when comparing the urgent and non-urgent causes separately and for all sub-categories. • Our findings can be used to inform a wide range of stakeholders, including international healthcare organizations. • Healthcare providers should understand the reasons for this ED visit decline and attempt to address patients concerns. [ABSTRACT FROM AUTHOR]

CT is the gold standard for triaging critically ill patients, including in trauma, and its use has increased over time. CT turnaround times (TATs) are frequently targeted for improvement. As opposed to linear reductionist processes such as Lean and Six Sigma, a high-reliability organization (HRO) approach focuses on culture and teams to enable rapid problem solving. The authors evaluated the HRO model to rapidly generate, trial, select, and implement improvement interventions to improve trauma patient CT performance. All trauma patients presenting to a single institution's emergency department during a 5-month period were included. Project periods included 2-month preintervention, 1-month wash-in, and 2-month postintervention. Each initial trauma CT encounter during the wash-in and postintervention periods created job briefs in which the radiologist ensured that all involved had the pertinent clinical information and agreed on the imaging needed, thereby creating a shared mental model as well as an opportunity to raise concerns and provide ideas for improvement. A total of 447 patients were included: 145 preintervention, 68 wash-in, and 234 postintervention. The seven selected interventions were trauma text alert; scripted CT technologist-radiologist communication; modification of CT acquisition, processing, sending, and interpretation; and trauma mobile phones. The seven selected interventions reduced trauma patient CT median TATs by 60% (78 vs 31 min, P <.001), demonstrating the effectiveness of an HRO approach to improvement. An HRO-based approach was rapid in generating, trialing, selecting, and implementing improvement interventions, and the interventions were effective at substantially decreasing trauma patient CT TATs. [Display omitted] [ABSTRACT FROM AUTHOR]

Hypoxia is a common presentation in the Emergency Department (ED) worldwide. It affects 9-12% of hospitalized adults in Sub-Saharan Africa. Timely diagnosis of the multiple causes such as pneumonia, heart failure among others is challenging. Chest X-Ray (CXR), one of the most utilized imaging modalities has many limitations, and the gold standard (Computed Tomography scan) is inaccessible. Point of care ultrasound (PoCUS) is more available and increasingly being used, however little is known of its performance in resource limited EDs. The study aimed to assess the diagnostic performance of PoCUS compared with CXR in identifying the causes of hypoxia in the medical ED. 49 adults presenting with hypoxia (SP02 ≤ 88%) in the medical ED were evaluated. Ultrasound of the lungs and heart (PoCUS) was done, then CXR obtained. Lung ultrasound (LUS) was compared with CXR (first reference standard). Chest X-Ray and PoCUS were each compared to the physician diagnosis (second reference standard) to determine agreement using an acceptable disagreement cut-off of 15%. 31% more abnormalities were identified by LUS than CXR. Lung ultrasound findings agreed with CXR in 86% of the participants with moderate reliability (ĸ=0.75). There was no significant difference between the actual findings of the two tests (X2= 2, p 0.1). Using the second reference, 82% of the CXRs were similar with weak reliability (ĸ=0.5) compared to 98% of PoCUS findings with strong reliability (ĸ=0.9). Compared to PoCUS, CXRs significantly differed from the physician diagnosis (X2= 0.85, p 0.38 vs X2= 8.5, p 0.004 respectively). Overall, PoCUS was not inferior to CXR when compared to final physician diagnosis in identifying causes of hypoxia, and LUS and CXR had comparable performance. Significantly more abnormalities were identified on PoCUS and it demonstrated better agreement and strong reliability with the physician diagnosis than CXR. We recommend PoCUS use in patients with hypoxia attending resource limited in- and pre-hospital settings. [ABSTRACT FROM AUTHOR]

Long waiting times in emergency departments (EDs) are a major challenge for healthcare systems worldwide. These extended delays can have a profound negative impact on patient quality of life, leading to increased stress, anxiety, and even deterioration in health conditions. identify factors that contribute to low satisfaction levels and long waiting times in EDs in the United Arab Emirates (UAE). A retrospective cross-sectional study was conducted. Patients who visited the ER at public and private hospitals in the Northern Emirates, including Sharjah, Fujairah, Khorfakkan, and Kalba, were asked to complete an online questionnaire. A total of 394 patients participated in the study, with an overall satisfaction rate of 6.82 (SD ± 2.62) on a scale of 0 to 10. Medication information received the highest satisfaction score (78.6 %), followed by discharge information and doctor care. Waiting time was a significant area of dissatisfaction, with nearly 63.3 % of participants expressing dissatisfaction. Patients who visited private hospitals reported significantly higher satisfaction levels than those who visited public hospitals. There was a negative association between waiting time and patient satisfaction. The four most frequently indicated barriers to long waiting times were reliance on computer systems and digital recording (46%), crowded waiting lounges (42.7%), understaffing, including doctors (38.1%), and an inadequate number of examination/consultation rooms (37.3%).Conclusion: Patient satisfaction is significantly impacted by waiting times in EDs. To improve patient satisfaction, hospital management should address the barriers to long waiting times that were identified in this study. [ABSTRACT FROM AUTHOR]

• Patients with acute HF are frequently hospitalized when they present to the ED. • EHMRG estimates 7-day mortality for patients with acute HF specifically in the ED. • EHMRG stratifies patients into risk groups to augment clinical decisions. • Lower risk patients with acute HF may be considered for discharge or care in EDOUs. Heart Failure (HF) is a primary diagnosis for hospital admission from the Emergency Department (ED), although not all patients require hospitalization. The Emergency Heart Failure Mortality Risk Grade (EHMRG) estimates 7-day mortality in patients with acute HF in ED settings, but further validation is needed in the United States (US). To validate EHMRG scores by risk-stratifying patients with acute HF in a large tertiary healthcare center in the US and analyze outcome measures to determine if EHMRG risk scores safely identify low-risk groups that may be discharged or managed in ED observation units (EDOUs). A retrospective cohort analysis of 304 patients with acute HF presenting to an ED at a large, tertiary healthcare center was completed. EHMRG scores were calculated to stratify patients according to published thresholds. Mortality and major adverse cardiac event (MACE) rates were analyzed. No deaths occurred in very low and low-risk EHMRG groups at 7 days post discharge. 30-day mortality was significantly less in the lower risk groups (3.1%) when compared to all other patients (11.1%). MACE rates at 30 days in the very low risk group (15%) were significantly less when compared to all other patients (31.3%). Hospitalizations occurred in 23.4% of patients in lower risk groups. ED risk stratification with EHMRG differentiates high-risk patients requiring hospitalization from lower risk patients who can be safely managed in alternative settings with good outcomes. Data supports improved pathways for patients with acute HF during a time of high hospital volumes. [ABSTRACT FROM AUTHOR]

Background: Workforce reform has placed a significant focus on the role of non-medical prescribers in the healthcare system. Pharmacists are trained in pharmacology and therapeutics, and therefore well placed to act as non-medical prescribers.Objectives: To assess the safety and accuracy of inpatient medication charts within a pharmacist collaborative prescribing model (intervention), compared to the usual medical model (control) in the emergency department (ED). Another objective compared venous thromboembolism (VTE) risk assessment and prescribing, between intervention and control groups.Methods: Adult patients in ED referred for hospital admission were randomised into control or intervention by a block randomisation method, until the required sample size was reached. Medication charts were audited retrospectively by an independent auditor, using validated audit forms.Results: Intervention group medication charts contained significantly fewer prescribing errors, omissions and discrepancies compared to the control group, and improved documentation of adverse drug reactions. VTE risk assessment and prescribing had higher guideline concordance in the intervention group compared to the control group.Conclusions: This collaborative prescribing trial showed excellent results in safety and accuracy of pharmacist prescribing when compared to the usual medical model of prescribing. The admitting medical practitioner and extended scope pharmacist prescriber worked as a collaborative team in emergency, which improved Australian national prescribing safety indicators. [ABSTRACT FROM AUTHOR]

Background: Urinary tract infection (UTI) is frequently encountered in the emergency department (ED). We assessed an antibiotic stewardship intervention tailored for the ED. The primary objective was improving overall adherence to agent choice and treatment duration. The secondary objective was a decrease in fluoroquinolone prescription.Methods: This pre-post study included patients discharged from the ED with a UTI diagnosis. The intensive intervention period lasted three months and involved dissemination of guidelines, short lectures, incorporation of order sets into electronic ED charts and weekly personal audit and feedback. The following 11-month phase was a booster period consisting of monthly text messages of the treatment protocol. Assessment of adherence to the protocol was compared between the three-month pre-intervention period and the last two months of the intensive intervention period, as well as with the last two months of the booster period.Results: A total of 177 patients were included in the pre-intervention period, 156 in the intervention period, and 94 in the late follow-up assessing the booster period. Median age was 49 (18-94) years, 78.2% were female, 84.8% had cystitis. During the intervention period, protocol adherence with antibiotic selection and duration increased from 41% to 84% (p < 0.001). Adherence remained high in the late follow-up period (73.4% vs. 41%, p < 0.001). Fluoroquinolone use decreased from 19.1% pre-intervention, to 5% in the intervention and 7.4% in the late follow-up periods (p < 0.001).Conclusions: An antibiotic stewardship intervention in a busy ED resulted in adherence to treatment protocols, including a decrease in fluoroquinolone use. A monthly reminder preserved most of the effect for a year. [ABSTRACT FROM AUTHOR]

The objective of this review was to collate, summarise and report evidence on the use of VR as an interventional tool for pain and anxiety management during ED procedures. Guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) we searched Medline, Embase, CINAHL, Scopus and PsychInfo databases, grey literature and reference lists of included studies. From 162 articles, 4 fulfilled the selection criteria and demonstrated VR was effective as an intervention for management of pain and anxiety during ED procedures. The level of evidence was variable: 2 randomised controlled trials (RCT); a descriptive study; and a commentary on a literature review. Participants were aged 4–17 years and the sample sizes were small (n = 20, 59, 64). One RCT compared efficacy of VR to 2 other standard of care (SOC) distractors while the other RCT assessed for VR efficacy and safety. All four articles cited benefits of VR distraction as a procedural intervention in ED. A small number of studies involving children undergoing needle insertion in ED found VR to be a safe and effective means of managing procedural anxiety, providing a more effective strategy than standard care. Studies with larger samples, involving different procedures and across age groups are required. [ABSTRACT FROM AUTHOR]

Background: BRASH syndrome, a relatively new entity, has been described in the recent literature. It is defined as a combination of bradycardia, renal failure, atrioventricular nodal blockade, shock, and hyperkalemia. Although it is apparent that clinical symptomatology includes shock, it is still unclear whether all patients will initially present with all five components mentioned in the BRASH acronym.Case Report: An elderly woman presented to our Emergency Department (ED) with hyperkalemia, acute renal failure, and metabolic acidosis with bradycardia, which was refractory to antikalemic measures and atropine. The montage of clinical features put together showed a clear picture of BRASH syndrome, which helped us to streamline the management and achieve a better patient outcome. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Renal failure with various metabolic derangements is commonly seen in the ED. We should be aware of this new clinical entity, as its incidence will certainly increase, and the management is a bit different. Prognosis is excellent with timely recognition and management of this rare clinical entity. [ABSTRACT FROM AUTHOR]

To compare the proportion of nursing home residents dispatched to an emergency department (ED) after a call to the emergency medical communication center (EMCC) according to the availability or nonavailability of telemedicine. This prospective, observational trial was conducted in the EMCC and 74 nursing homes in a French county. All nursing home residents who needed to contact the EMCC between June 2019 and April 2020 were included in the study. We excluded calls notifying the death of a resident, for completing data from a previous call, and for nursing home staff. The primary outcome was the proportion of residents dispatched to an ED after their first call to the EMCC. The secondary outcomes were the proportion of second calls, proportion of residents dispatched to an ED after a second call, and proportion of death within 30 days. We included 3103 calls in the final analysis (355 from equipped nursing homes and 2748 from unequipped nursing homes). The proportion of patients dispatched to an ED after the first call was lower among telemedicine-equipped than among telemedicine-unequipped nursing homes (41% vs 50%; odds ratio, 0.71; 95% CI, 0.56–0.90). The proportion of a second call for the same purpose within 72 hours, proportion of dispatching to an ED at the second call, and proportion of deaths within 30 days were similar between the groups. The use of telemedicine by nursing home residents requiring a call to the EMCC is associated with a reduction in the number of dispatches to an ED without any increase in the number of 72-hour callbacks or 30-day mortality rates. [ABSTRACT FROM AUTHOR]

Background: Lactate and lactate clearance are being used as biomarkers in several critical conditions. The aim of this study was to examine the value of sixth hour lactate clearance in patients who were hospitalized with chronic obstructive pulmonary disease (COPD) exacerbations.Methods: This single-center, cross-sectional study was conducted in a tertiary emergency department (ED) on patients who presented with acute exacerbation of COPD. Discharge or admission decisions were specified according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria and the clinician's decision. In the study, lactate clearance was defined as the percent decrease in lactate from the time of presentation to the ED to the sixth hour.Results: A total of 495 patients were evaluated and 397 patients were excluded. Among included patients, 53 (54.1%) were admitted to the hospital and 45 (45.9%) were discharged. The median lactate clearance was found to be -11.8% (95% CI: -50.0 to 34.5) in the admitted group and 14.7% (95% CI: -11.3 to 42.3) in the discharged group. Between the two groups, the median difference of lactate clearance was found to be 26.5% (95% CI: 0.6 to 52.4). Multivariate logistic regression analysis revealed that the delta lactate value can determine the hospitalization need of patients (OR: 0.91, 95% CI: 0.85 to 0.97).Conclusion: Lactate clearance can be evaluated as a useful marker in patients with COPD exacerbations. This study suggests that lactate monitoring in the ED has clinical benefits in addition to GOLD guidelines when deciding whether to discharge or hospitalize a patient. [ABSTRACT FROM AUTHOR]

Alcohol and other drug (AOD) diagnoses in the ED co-occur with injury-related presenting conditions including: falls, motor vehicle accidents, poisonings, and both intentional and unintentional injuries. Clinical attention to ED admissions resulting from hazardous AOD use can significantly improve patient care and reduce high cost utilization of ED visits and treatment. The EDRN-SBIRT project is designed to improve the knowledge and attitudes of ED nurses working in a large academic medical center to identify and address risky AOD use as it relates to an ED visit. ED nurses’ knowledge and attitudes toward patients with AOD use can be improved through SBIRT education. SBIRT education can establish an evidence-based standard of nursing practice to improve healthcare outcomes, but it must be reinforced with ongoing ED review and supportive educational sessions until practice is firmly established. [ABSTRACT FROM AUTHOR]

• Cardiac triage-specific educational program can improve nurse's practice in triage of acute coronary syndrome (ACS) patients. • Nurse triage training program did not have a significant effect on triage outcomes in ACS patients. • Cased-based learning (CBL) was successful in transferring triage learning to cardiac nursing in the ED. Accurate assessment and prompt management of patients with acute coronary syndrome (ACS) is a complex process for emergency department (ED) nurses and has variable clinical outcomes. The aim of the present study was to determine the effectiveness of an educational intervention on nurses' practice during the triage of patients with ACS and the triage outcomes in this group of patients. In this quasi-experimental study, a pretest-posttest group of 24 nurses were included by convenience sampling method and 960 patients with ACS were selected by sequential sampling during the pre-intervention (n = 480) and post-intervention (n = 480) phases. A case-based learning (CBL) intervention was performed for nurses for one month considering the role of the triage nurse according to the American College of Cardiology (ACC) and the American Heart Association (AHA) recommendations as well as the factors affecting the proper identification and management of patients with ACS. During patient triage in the pre- and post-intervention phases, the "Triage Nurse Practice Checklist" and the "Medical Electronic Records" were used to assess nurses' practice and the triage outcomes in patients, respectively. The overall mean score of the triage nurses' practice and its subscales, including Primary monitoring and assessment, cardiovascular risk factors assessment, evaluation of coronary heart disease (CHD) symptoms, chest pain management, and adherence to the ACC/AHA practice guidelines were significantly improved in the post-intervention phase compared with the pre-intervention phase (p < 0.001). There was no significant difference between the triage outcomes, including in-hospital mortality within 24 hours, death in ED, hospitalization in other wards, and discharge from ED in the pre and post-intervention phases (P = 0.723). The development of a cardiac triage-specific educational program could improve the performance of nurses in the evaluation and management of patients with ACS, but had no effect on the triage outcomes in this group of patients. We recommend a quality improvement project or a critical outcomes-based triage system to assess ACS patients' care needs in the ED. [ABSTRACT FROM AUTHOR]

Background: The Emergency Department (ED) is the portal of entry to the health care system for a large percentage of patients. This is especially true for victims and perpetrators of interpersonal violence. Frequently, law enforcement personnel (LEP) accompany patients to the ED or seek access to patients during their ED stay or subsequent hospitalization. The time-sensitive nature of both emergency care and criminal investigation motivates both health care personnel and LEP, and can lead to potential conflicts of interest regarding access to patients in the ED.Objectives: We hope to examine the relationship among patients, providers, and LEP in the ED, and the potential impact these interactions have on patient care. This article presents a review of the relevant literature and policy consideration as well as provides guidance on the development of such policies for EDs.Discussion: Hospitals, EDs, and trauma resuscitation rooms are highly regulated environments, but LEP largely fall outside the ethical and institutional guidelines of health care institutions. Many potential areas of conflict exist when LEP are present in the ED that can have detrimental effects on patient care, provider liability, and LEP efficacy. Patients' perceptions of collaboration between ED personnel and LEP can compromise emergency patient care.Conclusion: There is a need for hospital policies to govern interactions among patients, emergency health care providers, and LEP in the ED. [ABSTRACT FROM AUTHOR]

Highlights: [•] Patients developing UAP had overall more atherosclerosis as patients without any events. [•] Patients developing MACE had only more mixed plaque as those developing UAP. [•] Different atherosclerotic plaque components by CTA carry different prognostic value. [Copyright &y& Elsevier]

Abstract: Human respiratory and digestive illnesses can be caused by exposures to brevetoxins from blooms of the marine alga Karenia brevis, also known as Florida red tide (FRT). K. brevis requires macro-nutrients to grow; although the sources of these nutrients have not been resolved completely, they are thought to originate both naturally and anthropogenically. The latter sources comprise atmospheric depositions, industrial effluents, land runoffs, or submerged groundwater discharges. To date, there has been only limited research on the extent of human health risks and economic impacts due to FRT. We hypothesized that FRT blooms were associated with increases in the numbers of emergency room visits and hospital inpatient admissions for both respiratory and digestive illnesses. We sought to estimate these relationships and to calculate the costs of associated adverse health impacts. We developed environmental exposure–response models to test the effects of FRT blooms on human health, using data from diverse sources. We estimated the FRT bloom-associated illness costs, using extant data and parameters from the literature. When controlling for resident population, a proxy for tourism, and seasonal and annual effects, we found that increases in respiratory and digestive illnesses can be explained by FRT blooms. Specifically, FRT blooms were associated with human health and economic effects in older cohorts (≥55years of age) in six southwest Florida counties. Annual costs of illness ranged from $60,000 to $700,000 annually, but these costs could exceed $1.0million per year for severe, long-lasting FRT blooms, such as the one that occurred during 2005. Assuming that the average annual illness costs of FRT blooms persist into the future, using a discount rate of 3%, the capitalized costs of future illnesses would range between $2 and 24million. [Copyright &y& Elsevier]

Abstract: The cholesterol biosynthesis pathway, also known as the mevalonate (MVA) pathway, is an essential cellular pathway that is involved in diverse cell functions. The enzyme 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase (HMGCR) is the rate-limiting step in cholesterol biosynthesis and catalyzes the conversion of HMG-CoA to MVA. Given its role in cholesterol and isoprenoid biosynthesis, the regulation of HMGCR has been intensely investigated. Because all cells require a steady supply of MVA, both the sterol (i.e. cholesterol) and non-sterol (i.e. isoprenoid) products of MVA metabolism exert coordinated feedback regulation on HMGCR through different mechanisms. The proper functioning of HMGCR as the proximal enzyme in the MVA pathway is essential under both normal physiologic conditions and in many diseases given its role in cell cycle pathways and cell proliferation, cholesterol biosynthesis and metabolism, cell cytoskeletal dynamics and stability, cell membrane structure and fluidity, mitochondrial function, proliferation, and cell fate. The blockbuster statin drugs (‘statins’) directly bind to and inhibit HMGCR, and their use for the past thirty years has revolutionized the treatment of hypercholesterolemia and cardiovascular diseases, in particular coronary heart disease. Initially thought to exert their effects through cholesterol reduction, recent evidence indicates that statins also have pleiotropic immunomodulatory properties independent of cholesterol lowering. In this review we will focus on the therapeutic applications and mechanisms involved in the MVA cascade including Rho GTPase and Rho kinase (ROCK) signaling, statin inhibition of HMGCR, geranylgeranyltransferase (GGTase) inhibition, and farnesyltransferase (FTase) inhibition in cardiovascular disease, pulmonary diseases (e.g. asthma and chronic obstructive pulmonary disease (COPD)), and cancer. [Copyright &y& Elsevier]

Objectives: This study sought to evaluate if an undetectable (<5 ng/l) high-sensitivity cardiac troponin T (hs-cTnT) level and an electrocardiogram (ECG) without signs of ischemia can rule out myocardial infarction (MI) in the emergency department (ED). Background: Chest pain is a common symptom often associated with benign conditions, but may be a sign of MI. Because there is no rapid way to rule out MI, many patients are admitted to the hospital. Methods: All patients who sought medical attention for chest pain and had at least 1 hs-cTnT analyzed during 2 years at the Karolinska University Hospital, Stockholm, Sweden, were included. We calculated the negative predictive values of an undetectable hs-cTnT and ECG without ischemia for MI and death within 30 days. Results: We included 14,636 patients, of whom 8,907 (61%) had an initial hs-cTnT of <5 ng/l; 21% had 5 to 14 ng/l, and 18% had >14 ng/l. During 30-day follow-up, 39 (0.44%) patients with undetectable hs-cTnT had a MI, of whom 15 (0.17%) had no ischemic ECG changes. The negative predictive value for MI within 30 days in patients with undetectable hs-cTnT and no ischemic ECG changes was 99.8% (95% confidence interval [CI]: 99.7 to 99.9). The negative predictive value for death was 100% (95% CI: 99.9 to 100). Conclusions: All patients with chest pain who have an initial hs-cTnT level of <5 ng/l and no signs of ischemia on an ECG have a minimal risk of MI or death within 30 days, and can be safely discharged directly from the ED. [Copyright &y& Elsevier]

Objectives: To determine the clinical and forensic utility of head computed tomography (CT) in children younger than 2 years of age with an acute isolated extremity fracture and an otherwise-negative skeletal survey. Study design: Retrospective chart review of children younger than 2 years of age who obtained a skeletal survey in the Cincinnati Children’s Hospital Medical Center Emergency Department during the 159-month study period. Clinically important head injury was determined based on previously defined Pediatric Emergency Care Applied Research Network criteria. Forensically significant head injury was defined as that which increased the concern for inflicted injury. The rate of head CT relative to patient age and location of fracture (proximal vs distal extremity, upper vs lower extremity) was determined via χ2 tests. Results: Of the 320 children evaluated, 37% received neuroimaging, 95.7% of which had no signs of skull fracture or intracranial trauma. Five children (4.3%) with head imaging had traumatic findings but no children in the study had clinically significant head injury. Three of these children had previous concerns for nonaccidental trauma and findings on head CT that were forensically significant. There was a greater rate of head imaging in children in the younger age groups and those with proximal extremity fractures (P < .05). Conclusions: In young children who present with an isolated extremity fracture, clinicians should consider obtaining head CT in those who are younger than 12 months of age, have proximal extremity fractures, or who have previous evaluations for nonaccidental trauma. Evaluation with head CT in children without these risk factors may be low yield. [Copyright &y& Elsevier]

Background: Antiarrhythmic drugs (AADs) and anticoagulation are mainstays of atrial fibrillation (AF) treatment. Objective: To study the use and outcomes of AAD therapy in anticoagulated patients with AF. Methods: Patients in the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation trial (N = 14,264) were stratified by AAD use at baseline: amiodarone, other AAD, or no AAD. Multivariable adjustment was performed to compare stroke, bleeding, and death across AAD groups as well as across treatment assignment (rivaroxaban or warfarin). Results: Of 14,264 patients randomized, 1681 (11.8%) were treated with an AAD (1144 [8%] with amiodarone and 537 [3.8%] with other AADs). Amiodarone-treated patients were less often female (38% vs 48%), had more persistent AF (64% vs 40%), and more concomitant heart failure (71% vs 41%) than were patients receiving other AADs. Patients receiving no AAD more closely resembled amiodarone-treated patients. Time in therapeutic range was significantly lower in warfarin-treated patients receiving amiodarone than in those receiving no AAD (50% vs 58%; P < .0001). Compared with no AAD, neither amiodarone (adjusted hazard ratio [HR] 0.98; 95% confidence interval [CI] 0.74–1.31; P = .9) nor other AADs (adjusted HR 0.66; 95% CI 0.37–1.17; P = .15) were associated with increased mortality. Similar results were observed for embolic and bleeding outcomes. Treatment effects of rivaroxaban vs warfarin in patients receiving no AAD were consistent with results from the overall trial (primary end point: adjusted HR 0.82; 95% CI 0.68–0.98; P interaction = .06; safety end point: adjusted HR 1.12; 95% CI 0.90–1.24; P interaction = .33). Conclusion: Treatment with AADs was not associated with increased morbidity or mortality in anticoagulated patients with AF. The effect of amiodarone on outcomes in patients receiving rivaroxaban requires further investigation. [Copyright &y& Elsevier]

Supply/demand (type 2) myocardial infarction is a commonly encountered clinical challenge. It is anticipated that it will be detected more frequently once high-sensitivity cardiac troponin assays are approved for clinical use in the United States. We provide a perspective that is based on available data regarding the definition, epidemiology, etiology, pathophysiology, prognosis, management, and controversies regarding type 2 myocardial infarction. Understanding these basic concepts will facilitate the diagnosis and treatment of these patients as well as ongoing research efforts. [ABSTRACT FROM AUTHOR]

Highlights: [•] DTaP–IPV vaccine safety was monitored through weekly surveillance activities. [•] Eight potentially serious adverse event groups were assessed. [•] More than 200,000 vaccine doses were given during the 3.5 year surveillance period. [•] None of the adverse events monitored was associated with DTaP–IPV vaccination. [•] These findings support the continued use of DTaP–IPV vaccine. [Copyright &y& Elsevier]

Abstract: Background: Rapid influenza diagnostic tests (RIDTs) can be used at the point-of-care and are often the only influenza tests readily available in outpatient facilities. Objectives: To determine the use of RIDTs and antiviral prescription practices in outpatient facilities. Study design: Surveys were mailed to U.S. physician's offices, emergency departments, and community health centers in 2008 (pre-2009 H1N1 pandemic) and 2010 (post-2009 H1N1 pandemic). The 2010 survey included questions to evaluate changes in testing and treatment practices among various risk groups subsequent to the 2009 H1N1 pandemic. Results: In both surveys, respondents using RIDTs relied on RIDT results to guide prescribing antiviral medications. Greater than two-thirds of these respondents reported prescribing antiviral medications both pre- and post-pandemic for patients within 48h of onset of flu-like symptoms with a positive RIDT (69% pre-pandemic; 67% post-pandemic). After the pandemic (2010 survey), outpatient providers also reported prescribing antivirals to those with flu-like symptoms for 31% of children <2 years, 23% of children 2–5 years, 37% of pregnant patients, and 74% of other patients at high risk; while these figures were higher than pre-pandemic, they represent a failure to use CDC guidelines to prescribe antivirals for patients with suspected influenza who are at higher risk for complications. Conclusions: Clinicians in outpatient facilities often relied on RIDT findings to aid in making antiviral treatment decisions; however their treatment practices were not always consistent with CDC guidelines. The use of RIDTs and antiviral medicines were influenced by the 2009 H1N1 pandemic. [Copyright &y& Elsevier]

Abstract: Objectives: Concentrations of troponin measured with high sensitivity troponin assays are raised in a number of emergency department (ED) patients; however many are not diagnosed with acute myocardial infarction (AMI). Clinical comparisons between the early use (2h after presentation) of high sensitivity cardiac troponin T (hs-cTnT) and I (hs-cTnI) assays for the diagnosis of AMI have not been reported. Design and methods: Early (0h and 2h) hs-cTnT and hs-cTnI assay results in 1571 ED patients with potential acute coronary syndrome (ACS) without ST elevation on electrocardiograph (ECG) were evaluated. The primary outcome was diagnosis of index AMI adjudicated by cardiologists using the local cTnI assay results taken ≥6h after presentation, ECGs and clinical information. Stored samples were later analysed with hs-cTnT and hs-cTnI assays. Results: The ROC analysis for AMI (204 patients; 13.0%) for hs-cTnT and hs-cTnI after 2h was 0.95 (95% CI: 0.94–0.97) and 0.98 (95% CI: 0.97–0.99) respectively. The sensitivity, specificity, PLR, and NLR of hs-cTnT and hs-cTnI for AMI after 2h were 94.1% (95% CI: 90.0–96.6) and 95.6% (95% CI: 91.8–97.7), 79.0% (95% CI: 76.8–81.1) and 92.5% (95% CI: 90.9–93.7), 4.48 (95% CI: 4.02–5.00) and 12.86 (95% CI: 10.51–15.31), and 0.07 (95% CI: 0.04–0.13) and 0.05 (95% CI:0.03–0.09) respectively. Conclusions: Exclusion of AMI 2h after presentation in emergency patients with possible ACS can be achieved using hs-cTnT or hs-cTnI assays. Significant differences in specificity of these assays are relevant and if using the hs-cTnT assay, further clinical assessment in a larger proportion of patients would be required. [Copyright &y& Elsevier]

Objective: There is cross-center variability with regard to timing repair of non–ductal-dependent tetralogy of Fallot (TOF). We hypothesized that earlier repair in the neonatal period is associated with increased mortality and morbidity. Methods: This was a retrospective analysis of the Pediatric Health Information System of tetralogy of Fallot patients undergoing complete repair from 2004 through 2010 between the ages of 1 day to younger than 19 years. Patients with pulmonary valve atresia, those who received prostaglandin during hospital admission, and those who underwent prior shunt palliation were excluded. Results: A total of 4698 patients met our inclusion criteria, of whom 202 were younger than 30 days old (group A), 861 were 31 to 90 days old (group B), 1796 were 91 to 180 days old (group C), and 1839 were older than 180 days (group D). In-hospital mortality, intensive care unit length of stay, and total hospital length of stay were significantly higher in group A. Patients in group A had a significantly increased postoperative requirement for mechanical ventilation, intravenous blood pressure support, medical diuresis, extracorporeal membrane oxygenation, gastrostomy tube insertion, heart catheterization, and surgical revision. Significant institutional variability was noted for timing of TOF complete repair, with one third of the centers performing 75% of the repairs at younger than 30 days old. The institutional approach to timing TOF complete repair showed no relation to surgical volume. Conclusions: Across all centers analyzed, primary neonatal elective TOF repair (<30 days of age) is associated with significantly higher postoperative in-hospital morbidity and mortality, although a few centers have shown an ability to use this strategy with excellent survivability. [Copyright &y& Elsevier]

Background: Anaphylaxis is a serious allergic reaction that can cause death; however, the actual risk of death is unclear. Objective: We sought to estimate the case fatality rate among hospitalizations or emergency department (ED) presentations for anaphylaxis and the mortality rate associated with anaphylaxis for the general population. Methods: This was a population-based epidemiologic study using 3 national databases: the Nationwide Inpatient Sample (NIS; 1999-2009), the Nationwide Emergency Department Sample (NEDS; 2006-2009), and Multiple Cause of Death Data (MCDD; 1999-2009). Sources for these databases are hospital and ED discharge records and death certificates, respectively. Results: Case fatality rates were between 0.25% and 0.33% among hospitalizations or ED presentations with anaphylaxis as the principal diagnosis (NIS+NEDS, 2006-2009). These rates represent 63 to 99 deaths per year in the United States, approximately 77% of which occurred in hospitalized patients. The rate of anaphylaxis-related hospitalizations increased from 21.0 to 25.1 per million population between 1999 and 2009 (annual percentage change, 2.23%; 95% CI, 1.52% to 2.94%), contrasting with a decreasing case fatality rate among hospitalizations (annual percentage change, −2.35%; 95% CI, −4.98% to 0.34%). Overall mortality rates ranged from 0.63 to 0.76 per million population (186-225 deaths per year, MCDD) and appeared stable in the last decade (annual percentage change, −0.31%; 95% CI, −1.54% to 0.93%). Conclusion: From 2006 to 2009, the overwhelming majority of hospitalizations or ED presentations for anaphylaxis did not result in death, with an average case fatality rate of 0.3%. Anaphylaxis-related hospitalizations increased steadily in the last decade (1999-2009), but this increase was offset by the decreasing case fatality rate among those hospitalized; both inpatient and overall mortality rates associated with anaphylaxis appeared stable and were well under 1 per million population. Although anaphylactic reactions are potentially life-threatening, the probability of dying is actually very low. With the prevalence of anaphylaxis on the increase, practitioners need to stay vigilant and follow the treatment guidelines to further reduce anaphylaxis-related deaths. [Copyright &y& Elsevier]

Abstract: Background: Despite continuous innovation in trauma care, fatal trauma remains a significant medical and socioeconomic problem. Traumatic cardiac arrest (tCA) is still considered a hopeless situation, whereas management errors and preventability of death are neglected. We analyzed clinical and autopsy data from tCA patients in an emergency-physician-based rescue system in order to reveal epidemiologic data and current problems in the successful treatment of tCA. Material and methods: Epidemiological and autopsy data of all unsuccessful tCPR cases in a one-year-period in Berlin, Germany (n =101, Group I) and clinical data of all cases of tCPR in a level 1 trauma centre in an 6-year period (n =52, Group II) were evaluated. Preventability of traumatic deaths in autopsy cases (n =22) and trauma-management failures were prospectively assessed. Results: In 2010, 23% of all traumatic deaths in Berlin received tCPR. Death after tCPR occurred predominantly prehospital (PH;74%) and only 26% of these patients were hospitalized. Of 52 patients (Group II), 46% required tCPR already PH and 81% in the emergency department (ED). In 79% ROSC was established PH and 53% in the ED. The survival rate after tCPR was 29% with 27% good neurological outcome. Management errors occurred in 73% PH; 4 cases were judged as potentially or definitive preventable death. Conclusion: Trauma CPR is beyond routine with the need for a tCPR-algorithm, including chest/pericardial decompression, external pelvic stabilization and external bleeding control. The prehospital trauma management has the highest potential to improve tCPR and survival. Therefore, we suggested a pilot prehospital tCPR-algorithm. [Copyright &y& Elsevier]

Abstract: Introduction: D-dimer is commonly used in the workup of suspected Pulmonary Embolism (PE), but its specificity decreases with age. We evaluated whether using a higher cutoff value for D-dimer could increase the test specificity without reducing its sensitivity for ruling-out PE in elderly and very elderly patients presenting to the Emergency Department (ED). Material and Methods: All patients with D-dimer and pulmonary Computed Tomography Angiography (CTA) performed in the ED of Vimercate Hospital, from 2010 through 2012 for clinical suspicion of PE were included in this retrospective cohort study. Results: Study population 481 patients (63.4% women, mean age 73.0±16.1years, confirmed PE 22.5%). In very elderly patients (aged 80 or more years, n=191), compared with standard 490ng/mL D-dimer threshold, both higher fixed (1000ng/mL) and age-adjusted cutoffs increase the specificity of D-dimer for the exclusion of PE maintaining a Negative Predictive Value of 100%. Potentially avoided CTAs were 12(6.3%) using 1000ng/mL cutoff and 10(5.2%) age-adjusted. In very elderly patients the Number Needed to Test was incalculable for the standard cutoff (0 cases), 16 for 1000ng/mL and 19 for age-adjusted. In patients with PE, index episode mortality was 6.5%, and death occurred only in subjects with D-dimer values above 1000ng/mL and age-adjusted thresholds. Conclusion: For very elderly patients with suspected PE in ED, both higher fixed D-dimer (1000ng/mL) and age-adjusted thresholds increase test specificity for excluding PE without reducing its sensitivity, leading to a safe reduction in the number of CTAs. [Copyright &y& Elsevier]

Abstract: Background: The most common etiology of cardiac arrest is presumed of myocardial origin. Recent retrospective studies indicate that preexisting pneumonia, a form of sepsis, is frequent in patients who decompensate with abrupt cardiac arrest without preceding signs of septic shock, respiratory failure or severe metabolic disorders shortly after hospitalization. The contribution of pre-existing infection on pre and post cardiac arrest events remains unknown and has not been studied in a prospective fashion. We sought to examine the incidence of pre-existing infection in out-of hospital cardiac arrest (OHCA) and assess characteristics associated with bacteremia, the goal standard for presence of infection. Methods and results: We prospectively observed 250 OHCA adult patients who presented to the Emergency Department (ED) between 2007 and 2009 to an urban academic teaching institution. Bacteremia was defined as one positive blood culture with non-skin flora bacteria or two positive blood cultures with skin flora bacteria. 77 met pre-defined exclusion criteria. Of the 173 OHCA adults, 65 (38%) were found to be bacteremic with asystole and PEA as the most common presenting rhythms. Mortality in the ED was significantly higher in bacteremic OHCA (75.4%) compared to non-bacteremic OHCA (60.2%, p <0.05). After adjustment for potential confounders, predictive factors associated with bacteremic OHCA were lower initial arterial pH, higher lactate, WBC, BUN and creatinine. Conclusions: Over one-third of OHCA adults were bacteremic upon presentation. These patients have greater hemodynamic instability and significantly increased short-term mortality. Further studies are warranted to address the epidemiology of infection as possible cause of cardiac arrest. [Copyright &y& Elsevier]

Abstract: Objective : Ubiquitin C-terminal hydrolase-L1 (UCH-L1) has been established as a reliable and potential biomarker of neuronal damage after acute neurologic insults, such as ischemic stroke, subarachnoid hemorrhage, and traumatic brain injury. However, the effect of serum UCH-L1 levels has not been investigated in carbon monoxide (CO)-poisoned patients. The aim of the present study was to evaluate whether serum UCH-L1 levels are a reliable marker of brain damage and the association of UCH-L1 with outcome. Design and methods : This case–control study enrolled 46 CO-poisoned subjects and 30 controls. Using an enzyme-linked immunosorbent assay (ELISA) kit, we studied the temporal profile of serum UCH-L1 levels at 6, 12, 24 and 48h after acute CO poisoning. Poisoning severity was assessed using the Glasgow Coma Scale (GCS) score. Long-term outcome was assessed using the Glasgow Outcome Scale (GOS) at 6months after poisoning. Results : Compared with controls, CO-poisoned patients had significantly elevated serum levels of UCH-L1 at each time point after poisoning. There were significantly higher levels of UCH-L1 in CO-poisoned patients with a lower GCS score as well as in those with a poor 6-month outcome dichotomized GOS. Conclusions : Serum levels of UCH-L1 appear to have potential clinical utility in providing valuable information about poisoning severity and outcome after CO poisoning. [Copyright &y& Elsevier]

Background: Traumatic brain injury (TBI) is one of the most common causes of injury-related morbidity and mortality. Access to neurosurgical services is critical to optimal outcomes through reduction of secondary injury. We sought to evaluate variations in access to neurosurgical care across a regional trauma system. Study Design: This is a population-based retrospective cohort study of patients who sustained isolated severe TBI from 2005 to 2009. Administrative datasets capturing all emergency department visits and hospitalizations were linked deterministically. Differences between access to a trauma center (TC), defined as direct transport from scene or transfer from a nontrauma center (NTC) as opposed to no access, were evaluated; this included patient level determinants of access to TC and delineation of mortality differences between TC and NTC care. Transfer patterns from NTC to TC were also evaluated. Results: We identified 9,448 patients with isolated severe TBI. Almost two-thirds (60%, n = 5,701) received initial care at an NTC. Of these patients, 30% (n = 1,737) were subsequently transferred to a TC. Thirty-day mortality rates of patients treated at a TC vs NTC were 19% vs 18%, respectively (p = 0.19). Among patients younger than 65 years, 67% received TC care; only 41% of patients older than 65 were treated at a TC (p < 0.01). Mechanism, age, brain hemorrhage, and injury severity were associated with TC care. Conclusions: Considerable variation in delivery of initial care to TBI patients was identified. Factors such as age and injury characteristics were associated with TC access. Because early TC care in TBI confers survival benefits, the demonstrated variability necessitates improvements in access to care for patients with severe head injuries. [Copyright &y& Elsevier]

Abstract: Recent upward trends in the prevalence of abuse of prescription drugs and illicit substances have resulted in increased demands for toxicology testing to support the emergency department and drug treatment in pain management programs. This review will discuss the challenges faced by clinical laboratories to manage the utilization of toxicology tests, particularly those ordered in managing poisoned patients in the emergency department and chronic pain patients on opioid therapy. Optimal utilization of toxicology tests to support the emergency department relies on selecting the appropriate tests for the patient, and the availability of the results in a timely fashion. Two tiers of toxicology testing systems with different requirements for turnaround time will be discussed. In patients with chronic pain urine drug testing, including screening and confirmation testing are used extensively in pain management to monitor patient compliance. A thorough understanding of the performance characteristics of the test methodologies and drug metabolism is a key to making a proper analytical and clinical interpretation of the test results and will contribute to effective utilization of these tests. In addition, the reimbursement system is an important factor in the decision making process for test selection utilization as significant costs can be incurred by both payers and patients. Collaboration, trust, and effective communication among clinicians, patients, and clinical laboratory professionals are essential for effective utilization of toxicology testing. [Copyright &y& Elsevier]

Background: Although indoor environmental conditions can affect pediatric asthmatic patients, few studies have characterized the effect of building interventions on asthma-related outcomes. Simulation models can evaluate such complex systems but have not been applied in this context. Objective: We sought to evaluate the impact of building interventions on indoor environmental quality and pediatric asthma health care use, and to conduct cost comparisons between intervention and health care costs and energy savings. Methods: We applied our previously developed discrete event simulation model (DEM) to simulate the effect of environmental factors, medication compliance, seasonality, and medical history on (1) pollutant concentrations indoors and (2) asthma outcomes in low-income multifamily housing. We estimated health care use and costs at baseline and subsequent to interventions, and then compared health care costs with energy savings and intervention costs. Results: Interventions, such as integrated pest management and repairing kitchen exhaust fans, led to 7% to 12% reductions in serious asthma events with 1- to 3-year payback periods. Weatherization efforts targeted solely toward tightening a building envelope led to 20% more serious asthma events, but bundling with repairing kitchen exhaust fans and eliminating indoor sources (eg, gas stoves or smokers) mitigated this effect. Conclusion: Our pediatric asthma model provides a tool to prioritize individual and bundled building interventions based on their effects on health and costs, highlighting the tradeoffs between weatherization, indoor air quality, and health. Our work bridges the gap between clinical and environmental health sciences by increasing physicians' understanding of the effect that home environmental changes can have on their patients' asthma. [Copyright &y& Elsevier]

Objective: To describe the variability in diagnostic testing and treatment of headaches in children presenting to the emergency department (ED) with use of a nationally representative sample. Study design: This was a retrospective cohort study using the National Hospital Ambulatory Medical Care Survey during 2005-2009. To assess the use of evidence-based treatment, we analyzed all patients <18 years old in 2 groups: (1) primary discharge diagnosis of headache and (2) discharge diagnosis of migraine. Results: Four hundred forty-eight sampled ED visits from 2005-2009 represented a national estimate of 1.7 million visits with a discharge diagnosis of headache. A total of 95 visits represented a national estimate of 340 000 visits with a discharge diagnosis of migraine. Median age was 13.1 years and 60% were female with a primary diagnosis of headache. In this group, neuroimaging was performed in 37% of patients and 39% underwent blood tests. Nonsteroidal anti-inflammatory drugs and opioids were most commonly used for treatment. For children with a discharge diagnosis of migraine, approximately 40% of patients received non–evidence-based treatment, most commonly with opioid medications, and >20% of patients underwent computed tomography scanning. Conclusions: There is significant variability in the evaluation and treatment of pediatric headache in the ED. Despite evidence-based clinical guidelines for migraine headache, a large number of children continue to receive opioids and ionizing radiation in the ED. [Copyright &y& Elsevier]

Abstract: Background: Septic arthritis of the temporomandibular (TM) joint is rare, but it is associated with high risk for significant morbidity. Objective: We reviewed the available literature regarding the presentation, evaluation, treatment, and clinical course of TM joint septic arthritis, focusing on elements relevant to emergency physicians. Case Reports: In the first case, a healthy 6-year-old boy presented with fever and trismus; computed tomography with contrast revealed a TM joint effusion. After empiric intravenous antibiotics, intraoperative arthrocentesis of the TM joint returned 1 mL of flocculent fluid, which was cultured and grew pan-sensitive Streptococcus pyogenes. He was discharged home with amoxicillin/clavulanate and experienced complete resolution of his symptoms. In the second case, more than 3 weeks after extraction of her third molars, an 18-year-old woman presented with facial pain, swelling, and trismus and was found to have a loculated abscess involving the left masseteric and pterygomandibular spaces with extension to the left deep temporal region and the skull base. She experienced a complicated postoperative course and required multiple procedures and intravenous antibiotics for growth of multiple bacteria. More than a month later she underwent TM joint arthrotomy for TM joint septic arthritis, and she was found to have acute osteomyelitis. She continued to require multiple treatment modalities; 20 months after her initial presentation, she underwent left total TM joint arthroplasty for fibrous ankylosis of the TM joint. Conclusion: Septic arthritis of the TM joint may be caused by hematogenous spread of distant infection or local spread of deep masticator space infections. Patients may present with TM joint septic arthritis acutely or sub-acutely. Septic arthritis of the TM joint should be considered in the differential diagnosis of patients who present with trismus and pain or fever. [Copyright &y& Elsevier]

Abstract: Introduction: Cardiac arrest is a common presentation to the emergency care system. The decision to terminate CPR is often challenging to heath care providers. An accurate, early predictor of the outcome of resuscitation is needed. The purpose of this systematic review is to evaluate the prognostic value of ETCO2 during cardiac arrest and to explore whether ETCO2 values could be utilised as a tool to predict the outcome of resuscitation. Method: Literature search was performed using Medline and EMBASE databases to identify studies that evaluated the relationship between ETCO2 during cardiac arrest and outcome. Studies were thoroughly evaluated and appraised. Summary of evidence and conclusions were drawn from this systematic literature review. Results: 23 observational studies were included. The majority of studies showed that ETCO2 values during CPR were significantly higher in patients who later developed ROSC compared to patients who did not. Several studies suggested that initial ETCO2 value of more than 1.33kPa is 100% sensitive for predicting survival making ETCO2 value below 1.33kPa a strong predictor of mortality. These studies however had several limitations and the 100% sensitivity for predicting survival was not consistent among all studies. Conclusion: ETCO2 values during CPR do correlate with the likelihood of ROSC and survival and therefore have prognostic value. Although certain ETCO2 cut-off values appears to be a strong predictor of mortality, the utility of ETCO2 cut-off values during CPR to accurately predict the outcome of resuscitation is not fully established. Therefore, ETCO2 values cannot be used as a mortality predictor in isolation. [Copyright &y& Elsevier]

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Abstract: Introduction: Soluble thrombomodulin (sTM) is a sensitive marker of endothelial damage. In this study we investigated the role of sTM in the evaluation of the severity and prognosis of septic patients in the emergency department (ED). Materials and Methods: A prospective, observational cohort study was performed in the ED of an urban, university hospital. Patients who had suspected infection with two or more criteria of systemic inflammatory response syndrome were consecutively enrolled. sTM, D-Dimer and procalcitonin levels were measured on enrollment, and the Mortality in Emergency Department Sepsis (MEDS) score was calculated. A 30-day follow-up was performed for all patients. Results: A total of 372 patients with sepsis, 210 patients with severe sepsis and 98 patients with septic shock were enrolled in this study. According to the disease severity, patients were divided into sepsis subgroup and severe sepsis subgroup (including septic shock). In addition, patients were divided into survivors subgroup and non-survivors subgroup according to the 30-day mortality. Plasma sTM levels in patients with severe sepsis were higher than those with sepsis (P<0.001). Compared with survivors, non-survivors has higher plasma sTM levels (P<0.001). Multivariate logistic regression analysis showed that sTM was an independent predictor of severe sepsis (odds ratio 1.11) and 30-day mortality (odds ratio 1.059). Receiver operating characteristic curve analysis showed that sTM was a useful parameter in prediction of severe sepsis (0.859) and 30-day mortality (0.78). Compared with the MEDS score alone, combination of sTM and the MEDS score can improve the accuracy in prediction of severe sepsis and 30-day mortality. Conclusions: sTM is a valuable biomarker in the risk stratification and prognosis evaluation of ED sepsis. Furthermore, sTM can enhance the ability of the MEDS score in prediction of severe sepsis and 30-day mortality. [Copyright &y& Elsevier]

Summary: Background & aims: The Geriatric Nutritional Risk Index (GNRI) is a screening tool for nutrition-related risk that correlates with mortality rate in hospitalized older patients and is simple, objective, and readily available to clinicians. In this study, we aimed to validate the performance of the GNRI in predicting short-term hospital mortality in older patients with sepsis. Methods: This observational study enrolled 401 older patients presenting with infection and systemic inflammatory response syndrome in an emergency department. Demographic, physiological, and laboratory data were collected. The GNRI score was categorized into five classes. The primary outcome was 28-day hospital mortality. Univariate and multivariate analyses were performed to identify clinical predictors of outcome. A logistic regression model was used. Results: 51 patients (12.7%) died in the hospital within 28 days. Co-morbid metastatic cancer, heart rate, respiratory rate, temperature, serum creatinine, total lymphocyte count, and GNRI (<87) were independently related to the outcome in the multivariable logistic regression analysis. Conclusions: The GNRI is a prognostic factor for short-term hospital mortality in older patients with sepsis. A GNRI below 87 can be suggested as an indicator of nutritional support need in an acute-care setting. [Copyright &y& Elsevier]

Background & Aims: Few studies have analyzed the safety of endoscopy in patients with inflammatory bowel disease (IBD). We aimed to determine the prevalence of procedure-related complications among these patients, compared with the general population, and estimate the lifetime risk of colonoscopy-related complications. Methods: We collected data on complications in 685 patients with IBD and 17,000 patients without IBD (controls) using an automated system to track all emergency department visits to the Beth Israel Deaconess Medical Center within 14 days of an endoscopic procedure, from March 1, 2007, to November 30, 2007. We reviewed charts of all IBD patients to determine health care use (telephone calls or visits to a gastroenterologist or primary care physician and visits to other emergency departments or hospitals) after endoscopy. The lifetime risk of procedure-related complications was estimated using a Markov Monte Carlo model. Results: Rates of complications were 1.17% among patients with IBD and 0.96% among controls (P = .55). The chart review showed that 3.8% of the IBD cohort received medical care within 14 days of the endoscopic procedure. Based on a Markov Monte Carlo simulation model, the lifetime risk of complications after a surveillance colonoscopy protocol was 12.7% among patients with IBD and 2.0% in the general population undergoing screening colonoscopy (P < .001). Conclusions: Although the risk of adverse events after each endoscopic procedure was similar for patients with IBD and the general population, IBD patients have an increased lifetime risk of complications after colonoscopies. A higher percentage of patients with IBD also seek medical care after endoscopic procedures than controls. [Copyright &y& Elsevier]

Abstract: Objective: To compare the rate and nature of rehospitalization in a cohort of patients enrolled in the National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems (TBIMS) who have disorders of consciousness (DOC) at the time of rehabilitation admission with those in persons with moderate or severe traumatic brain injury (TBI) but without DOC at rehabilitation admission. Design: Prospective observational study. Setting: Inpatient rehabilitation within TBIMS with annual follow-up. Participants: Of 9028 persons enrolled from 1988 to 2009 (N=9028), 366 from 20 centers met criteria for DOC at rehabilitation admission and follow-up data, and another 5132 individuals met criteria for moderate (n=769) or severe TBI (n=4363). Interventions: Not applicable. Main Outcome Measures: Participants and/or their family members completed follow-up data collection including questions about frequency and nature of rehospitalizations at 1 year postinjury. For the subset of participants with DOC, additional follow-up was conducted at 2 and 5 years postinjury. Results: The DOC group demonstrated an overall 2-fold increase in rehospitalization in the first year postinjury relative to those with moderate or severe TBI without DOC. Persons with DOC at rehabilitation admission have a higher rate of rehospitalization across several categories than persons with moderate or severe TBI. Conclusions: Although the specific details of rehospitalization are unknown, greater injury severity resulting in DOC status on rehabilitation admission has long-term implications. Data highlight the need for a longitudinal approach to patient management. [Copyright &y& Elsevier]

Objectives: To assess the knowledge and practice preferences of anaphylaxis in pediatric emergency medicine (PEM) physicians by practice setting, and to identify factors associated with intramuscular (IM) epinephrine administration and admission of patients with anaphylaxis. Study design: The cohort was a cross-sectional convenience sample; potential participants were recruited using contact information obtained from the American Board of Pediatrics and American Board of Medical Specialties membership databases and were asked to complete a 12 item survey. Board-certified PEM physicians were categorized by practice setting: university hospital, non-university hospital with a residency training program, or community hospital with no residency training program. Management practices based on practice setting are presented as proportions. Multivariate logistic regression identified factors associated with IM epinephrine administration and admission of patients with anaphylaxis for observation. Results: Of the 1114 PEM physicians solicited, 620 (56%) completed the survey. The majority (93.5%) correctly identified epinephrine as the treatment of choice for anaphylaxis, yet only 66.9% used the IM route of administration, and only 37.4% admitted affected patients for observation. Factors associated with the use of IM epinephrine included the presence of a residency program at the site of care (OR, 2.28, 95% CI, 1.3-4.04) and higher volume of anaphylaxis cases (OR, 1.21; 95% CI, 1.06-1.38). Increasing anaphylaxis case volume was associated with decreased likelihood of admission of patients with anaphylaxis (OR, 0.81; 95% CI, 0.72-0.92). Conclusion: Even though the majority of PEM physicians correctly report using epinephrine in pediatric anaphylaxis, not all use the preferred administration route, and many discharge patients home after an abbreviated period. [Copyright &y& Elsevier]

Highlights: [•] We examine previously reported associations between TIV and GI illness. [•] We conducted a large case–control study among children ages 24–59 months. [•] We observed an association between medical visits without TIV and GI illness. [•] Co-occurring exposures in vaccine safety studies may cause confounding. [ABSTRACT FROM AUTHOR]

Objectives: This study was designed to assess the effects on resource utilization of routine coronary computed tomographic angiography (CCTA) in triaging chest pain patients in the emergency department (ED). Background: The routine use of CCTA for ED evaluation of chest pain is feasible and safe. Methods: We conducted a retrospective multivariate analysis of data from two risk-matched cohorts of 894 ED patients presenting with chest pain to assess the impact of CCTA versus standard evaluation on admissions rate, length of stay, major adverse cardiovascular event rates, recidivism rates, and downstream resource utilization. Results: The overall admission rate was lower with CCTA (14% vs. 40%; p < 0.001). Standard evaluation was associated with a 5.5-fold greater risk for admission (odds ratio [OR]: 5.53; p < 0.001). Expected ED length of stay with standard evaluation was about 1.6 times longer (OR: 1.55; p < 0.001). There were no differences in the rates of death and acute myocardial infarction within 30 days of the index visit between the two groups. The likelihood of returning to the ED within 30 days for recurrent chest pain was 5 times greater with standard evaluation (OR: 5.06; p = 0.022). Standard evaluation was associated with a 7-fold greater likelihood of invasive coronary angiography without revascularization (OR: 7.17; p < 0.001), while neither group was significantly more likely to receive revascularization (OR: 2.06; p = 0.193). The median radiation dose with CCTA was 5.88 mSv (n = 1039; confidence interval: 5.2 to 6.4). Conclusions: The routine use of CCTA in ED evaluation of chest pain reduces healthcare resource utilization. [Copyright &y& Elsevier]

Abstract: Objectives: ST-elevation and non-ST-elevation myocardial infarction (STEMI, NSTEMI) are considered two distinct pathophysiologic entities. We evaluated cardiac troponin I (cTnI) release in STEMI and NSTEMI using a “contemporary” (CV>10 to 20% at the 99th percentile concentration) cTnI assay for patients undergoing early percutaneous coronary intervention (PCI). Design and methods: 856 patients with suspected acute coronary syndrome consecutively admitted to the Emergency Department of the Maggiore Hospital of Novara (225 STEMI and 135 NSTEMI) were selected according to: 1) early (≤4h from admission) and successful PCI; and 2) cTnI measurements at ED presentation and within 24h. The influence of the MI type on cTnI concentrations at baseline and after PCI as well as the velocity of cTnI [cTnI V=absolute increase (after log conversion of cTnI measurements)/delay between the two measurements] was studied by multiple regression analysis, adjusting for patient parameters. Results: A statistically significant interaction between MI type and time from symptoms was reported on cTnI concentrations (p<0.0001): STEMI and NSTEMI differed for cTnI releases at admission and after revascularization. Higher cTnI V in STEMI was detectable in patients admitted within 6h from symptoms. Baseline cTnI concentrations were lower in patients with a history of coronary artery disease (CAD) and increased with aging (p<0.0001). In the elderly (>75years), the cTnI V was significantly increased. Conclusion: STEMI and NSTEMI patients have different patterns and dynamics of cTnI release influenced by the interaction with time from symptoms, by aging and history of CAD. [Copyright &y& Elsevier]

Objective: To review and describe the current literature pertaining to the incidence, classification, severity, preventability, and impact of medication-related emergency department (ED) and hospital admissions in pediatric patients. Study design: A systematic search of PubMED, Embase, and Web of Science was performed using the following terms: drug toxicity, adverse drug event, medication error, emergency department, ambulatory care, and outpatient clinic. Additional articles were identified by a manual search of cited references. English language, full-reports of pediatric (≤18 years) patients that required an ED visit or hospital admission secondary to an adverse drug event (ADE) were included. Results: We included 11 studies that reported medication-related ED visit or hospital admission in pediatric patients. Incidence of medication-related ED visits and hospital admissions ranged from 0.5%-3.3% and 0.16%-4.3%, respectively, of which 20.3%-66.7% were deemed preventable. Among ED visits, 5.1%-22.1% of patients were admitted to hospital, with a length of stay of 24-72 hours. The majority of ADEs were deemed moderate in severity. Types of ADEs included adverse drug reactions, allergic reactions, overdose, medication use with no indication, wrong drug prescribed, and patient not receiving a drug for an indication. Common causative agents included respiratory drugs, antimicrobials, central nervous system drugs, analgesics, hormones, cardiovascular drugs, and vaccines. Conclusion: Medication-related ED visits and hospital admissions are common in pediatric patients, many of which are preventable. These ADEs result in significant healthcare utilization. [Copyright &y& Elsevier]