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Comment & Response B To the Editor b We have several questions about the recent trial[1] about robot-assisted vs open radical cystectomy for patients with bladder cancer. Additionally, the authors mention that length of readmission was similar for both groups, but we would like to know how many emergency department (ED) visits these patients had after surgery. Furthermore, ED boarding has worsened since the COVID-19 pandemic,[3] which is particularly troublesome for patients with urological issues because they face even more delays than other patients in the ED[4] due to the sensitive nature of their examinations. [Extracted from the article]

Abstract: Rho‐associated kinase (ROCK) is an emerging target in acute ischemic stroke. Early pre‐hospital treatment with ROCK inhibitors may improve their efficacy, but their antithrombotic effects raise safety concerns in hemorrhagic stroke, precluding use prior to neuroimaging. Therefore, we tested whether ROCK inhibition affects the bleeding times, and worsens hematoma volume in a model of intracerebral hemorrhage (ICH) induced by intrastriatal collagenase injection in mice. Tail bleeding time was measured 1 h after treatment with isoform‐nonselective inhibitor fasudil, or ROCK2‐selective inhibitor KD025, or their vehicles. In the ICH model, treatments were administered 1 h after collagenase injection. Although KD025 but not fasudil prolonged the tail bleeding times, neither drug expanded the volume of ICH or worsened neurological deficits at 48 h compared with vehicle. Although more testing is needed in aged animals and comorbid models such as diabetes, these results suggest ROCK inhibitors may be safe for pre‐hospital administration in acute stroke. [ABSTRACT FROM AUTHOR]

Introduction: The American College of Emergency Physicians guidelines recommend more aggressive workup beyond imaging alone in patients with a high pretest probability (PTP) of pulmonary embolism (PE). However, the ability of multiple tests to safely rule out PE in high PTP patients is not known. We sought to measure the ability of negative computed tomography pulmonary angiography (CTPA) along with negative D-dimer to rule out PE in these high-risk patients. Methods: We analyzed data from a previous prospective observational study conducted in 12 emergency departments (ED). Wells score criteria were entered by providers before final PE testing. PE was diagnosed by imaging on the index ED visit, or within 45 days, demonstrating either PE or deep vein thrombosis (DVT), or if the patient died of PE during the 45-day, follow-up period. Testing threshold was set at 1.8%. Results: A total of 7,940 patients were enrolled and tested for PE, and 257 had high PTP (Wells >6). Sixteen of these high-risk patients had negative CTPA and negative D-dimer, of whom two were positive for PE (12.5% [95% confidence interval {2.2%-40.0%}]). One of these patients had a DVT on CT venogram and the other was diagnosed at follow-up. Conclusion: Our analysis suggests that in patients with high PTP of PE, neither negative CTPA by itself nor a negative CTPA plus a negative D-dimer are sufficient to rule out PE. More aggressive workup strategies may be required for these patients. [ABSTRACT FROM AUTHOR]

The article provides information on medical complaint of atraumatic headache in patients with benign conditions of pain. Topics discussed include description of type of headache associated with unruptured cerebral aneurysm, International Classification of Headache Disorders (ICHD), and cerebral venous sinus thrombosis (CVST).

2022; 5(2): e220115-e220115. doi:10.1001/jamanetworkopen.2022.011535195698 4 Duong DK, Samuels EA, Boatright D, Wilson T. Association between emergency medicine clerkship diversity scholarships and residency diversity. Comment & Response B To the Editor b A recent study[1] that examined racial and ethnic differences in resident selection in 11 competitive US medical and surgical specialty programs from 2013 to 2018 showed a significant difference in minority match rates - compared with application rates - for our field of emergency medicine. 2020; 5(3):e10547.34099994 5 Hill A, Jones D, Woodworth L. Physician-patient race-match reduces patient mortality. [Extracted from the article]

Management of acute shoulder dislocation in the emergency department (ED) is common. This study describes the rate, risk factors, and length of stay (LOS) associated with shoulder dislocation reduction failure in the ED. The study was a retrospective case–control study of patients 18 years and older presenting to the ED with acute shoulder dislocation who underwent attempted reduction. Patients with successful reduction on post-reduction first confirmatory imaging are compared with those requiring multiple attempts. Of 398 ED encounters when a shoulder reduction was attempted in the ED, 18.8% (75/398 [95% CI 15.2–22.9%]) required multiple reduction attempts. Patients with successful reduction on first confirmatory imaging were more commonly male (80.2% [95% CI 75.6–84.3%] vs. 68.0% [95% CI 56.8–77.8%]; p = 0.0220), discharged home from the ED (95.4% [95% CI 92.6–97.3%] vs. 84.0% [95% CI 74.4–91.0%]; p = 0.0004), reduced using a traction/countertraction technique (42.1% [95% CI 36.8–47.6%] vs. 29.3% [95% CI 19.9–40.4%]; p = 0.0415), and less likely to have a pre-reduction fracture (26.0% [95% CI 21.4–31.0%] vs. 45.3% [95% CI 34.4–56.7%]; p = 0.0010). Mean length of stay (LOS) for those with successful reduction on first confirmatory imaging was 2 hours and 8 minutes shorter than for those with more than one attempt (p < 0.001). The rate of failed first-pass reduction is higher than previously reported. Furthermore, the ED LOS was significantly longer in patients requiring multiple attempts. Knowledge of the failure rate and risk factors may raise physician awareness and guide future studies evaluating approaches for verification of reduction success. [ABSTRACT FROM AUTHOR]

Interpretation of the electrocardiogram (ECG) is fundamental in the practice and teaching of emergency medicine. Previous studies have shown that providers of all levels have expressed interest in additional education with ECGs. Asynchronous learning has been shown to be beneficial for improving residents' ability to recognize findings of acute myocardial ischemia. The goal of the study was to know whether a new format based on free, online content would improve residents' ability to interpret ECGs. In this 1-year educational pilot study at a single urban teaching hospital, resident physicians participated in a longitudinal curriculum based on free, online content, which was delivered to them electronically on a weekly basis. The study was conducted during the 2016–2017 academic year. Prior to and after the study period, their subjective attitudes toward ECG interpretation, and their objective ability to interpret them successfully, were assessed. Of 42 residents, 25 (59.5%) completed the pre- and post-ECG testing. During the study period, trainees demonstrated improvement in both their subjective attitude toward ECG interpretation and their objective ability to interpret various abnormalities. Despite some important limitations, we believe this study represents an essential step in the development of training methods for the modern emergency medicine trainee. [ABSTRACT FROM AUTHOR]

The end of 2019 marked the emergence of the COVID-19 pandemic. Public avoidance of health care facilities, including the emergency department (ED), has been noted during prior pandemics. This study described pandemic-related changes in adult and pediatric ED presentations, acuity, and hospitalization rates during the pandemic in a major metropolitan area. The study was a cross-sectional analysis of ED visits occurring before and during the pandemic. Sites collected daily ED patient census; monthly ED patient acuity, as the Emergency Severity Index (ESI) score; and disposition. Prepandemic ED visits occurring from January 1, 2019 through December 31, 2019 were compared with ED visits occurring during the pandemic from January 1, 2020 through March 31, 2021. The change in prepandemic and pandemic ED volume was found using 7-day moving average of proportions. The study enrolled 83.8% of the total ED encounters. Pandemic adult and pediatric visit volume decreased to as low as 44.7% (95% CI 43.1–46.3%; p < 0.001) and 22.1% (95% CI 19.3–26.0%; p < 0.001), respectively, of prepandemic volumes. There was also a relative increase in adult and pediatric acuity (ESI level 1–3) and the admission percentage for adult (20.3% vs. 22.9%; p < 0.01) and pediatric (5.1% vs. 5.6%; p < 0.01) populations. Total adult and pediatric encounters were reduced significantly across a major metropolitan area. Patient acuity and hospitalization rates were relatively increased. The development of strategies for predicting ED avoidance will be important in future pandemics. [ABSTRACT FROM AUTHOR]

Background Sepsis is a leading cause of morbidity, mortality, and health care costs worldwide. Methods We conducted a multicenter, prospective cohort study evaluating the yield of blood cultures drawn before and after empiric antimicrobial administration among adults presenting to the emergency department with severe manifestations of sepsis. Enrolled patients who had the requisite blood cultures drawn were followed for 90 days. We explored the independent association between blood culture positivity and its time to positivity in relation to 90-day mortality. Results Three hundred twenty-five participants were enrolled; 90-day mortality among the 315 subjects followed up was 25.4% (80/315). Mortality was associated with age (mean age [standard deviation] in those who died was 72.5 [15.8] compared with 62.9 [17.7] years among survivors; P <.0001), greater Charlson Comorbidity Index (2 [interquartile range {IQR}, 1–3] vs 1 [IQR, 0–3]; P =.008), dementia (13/80 [16.2%] vs 18/235 [7.7%]; P =.03), cancer (27/80 [33.8%] vs 47/235 [20.0%]; P =.015), positive quick Sequential Organ Failure Assessment score (57/80 [71.2%] vs 129/235 [54.9%]; P =.009), and normal white blood cell count (25/80 [31.2%] vs 42/235 [17.9%]; P =.02). The presence of bacteremia, persistent bacteremia after antimicrobial infusion, and shorter time to blood culture positivity were not associated with mortality. Neither the source of infection nor pathogen affected mortality. Conclusions Although severe sepsis is an inflammatory condition triggered by infection, its 90-day survival is not influenced by blood culture positivity nor its time to positivity. Clinical Trials Registration NCT01867905. [ABSTRACT FROM AUTHOR]

Purpose: Diagnostic computed tomography (CT) imaging, utilizing intravenous (IV) contrast administration, has become increasingly common. Potential IV contrast-associated complications include local skin and soft tissue reactions due to extravasation. The goal of this study is to describe the risk of contrast extravasation based on IV catheter anatomic location in patients receiving contrast-enhanced CT imaging.Methods: The study was conducted as a retrospective cohort study of patients receiving contrast-enhanced CT imaging performed over a 26-month period at a single institution. The rate of contrast extravasation was calculated by IV catheter vessel anatomic location and compared by relative risk (RR) and absolute risk reduction (ARR).Results: Of 17,767 contrast administrations for CT imaging studies performed, 14,558 met study inclusion criteria. Forty-nine (0.34%) extravasation events were identified. Forty-one (0.28%, 95% CI 0.21-0.39%) extravasation events were observed in 14,275 peripheral IV catheters placed in a non-upper arm location. Eight (2.8%, 95% CI 1.3-5.3%) extravasation events were observed in 283 IV catheters placed, most commonly with point-of-care ultrasound (POCUS) guidance, in upper arm vessels (RR 10.1, 95% CI 4.69-21.8). Non-upper arm located IV catheters were associated with an ARR of 2.54% (95% CI 0.61-4.47%) when compared to upper arm catheters.Conclusions: IV catheter placement in upper arm vessels is associated with a relatively minimal increase in extravasation risk when compared to catheters placed in a non-upper arm location. In patients without alternative available peripheral vascular access, POCUS-guided upper arm IV cannulation may be an appropriate approach. [ABSTRACT FROM AUTHOR]

Background: Administering antimicrobial agents before obtaining blood cultures could potentially decrease time to treatment and improve outcomes, but it is unclear how this strategy affects diagnostic sensitivity.Objective: To determine the sensitivity of blood cultures obtained shortly after initiation of antimicrobial therapy in patients with severe manifestations of sepsis.Design: Patient-level, single-group, diagnostic study. (ClinicalTrials.gov: NCT01867905).Setting: 7 emergency departments in North America.Participants: Adults with severe manifestations of sepsis, including systolic blood pressure less than 90 mm Hg or a serum lactate level of 4 mmol/L or more.Intervention: Blood cultures were obtained before and within 120 minutes after initiation of antimicrobial treatment.Measurements: Sensitivity of blood cultures obtained after initiation of antimicrobial therapy.Results: Of 3164 participants screened, 325 were included in the study (mean age, 65.6 years; 62.8% men) and had repeated blood cultures drawn after initiation of antimicrobial therapy (median time, 70 minutes [interquartile range, 50 to 110 minutes]). Preantimicrobial blood cultures were positive for 1 or more microbial pathogens in 102 of 325 (31.4%) patients. Postantimicrobial blood cultures were positive for 1 or more microbial pathogens in 63 of 325 (19.4%) patients. The absolute difference in the proportion of positive blood cultures between pre- and postantimicrobial testing was 12.0% (95% CI, 5.4% to 18.6%; P < 0.001). Sensitivity of postantimicrobial culture was 52.9% (CI, 42.8% to 62.9%). When the results of other microbiological cultures were included, microbial pathogens were found in 69 of 102 (67.6% [CI, 57.7% to 76.6%]) patients.Limitation: Only a proportion of screened patients were recruited.Conclusion: Among patients with severe manifestations of sepsis, initiation of empirical antimicrobial therapy significantly reduces the sensitivity of blood cultures drawn shortly after treatment initiation.Primary Funding Source: Vancouver Coastal Health, St. Paul's Hospital Foundation Emergency Department Support Fund, the Fonds de recherche Santé-Québec, and the Maricopa Medical Foundation. [ABSTRACT FROM AUTHOR]

Introduction: The emergency department (ED) serves as the primary access point to the healthcare system. ED throughput efficiency is critical. The percentage of patients who leave before treatment completion (LBTC) is an important marker of department efficiency. Our study aimed to assess the impact of an ED phlebotomist, dedicated to obtaining blood specimen collection on waiting patients, on LBTC rates. Methods: This study was conducted as a retrospective observational analysis over approximately 18 months (October 5, 2015-March 31, 2017) for patients evaluated by a triage provider with a door-to-room (DtR) time of > 20 minutes (min). LBTC rates were compared in 10-min DtR increments for when the ED phlebotomist collected the patient's specimen vs not. Results: Of 71,942 patient encounters occurring during the study period, 17,349 (24.1%) met study inclusion criteria. Of these, 1842 (10.6%) had blood specimen collection performed by ED phlebotomy. The overall LBTC rate for encounters included in the analysis was 5.26% (95% confidence interval [CI], 4.94%-5.60%). Weighting the LBTC rates for each 10-min DtR interval using the fixed effects model led to an overall LBTC rate of 2.74% (95% CI, 2.09%-3.59%) for patient encounters with ED phlebotomist collection vs 5.31% (95% CI, 4.97%-5.67%) in those which did not, yielding a relative reduction of 48% (95% CI, 34%-63%). The effect of the phlebotomist on LBTC rates increased as DtR times increased. The difference in the rate of the rise of LBTC percentages, per 10-min interval, was 0.50% (95% CI, 0.19%-0.81%) higher for non-ED phlebotomist encounters vs phlebotomist encounters. Conclusion: ED phlebotomy demonstrated a significant reduction in ED LBTC rates. Further, as DtR times increased, the impact of ED phlebotomy became increasingly significant. Adult EDs with increased rates of LBTC patient encounters may want to consider the implementation of ED phlebotomy. [ABSTRACT FROM AUTHOR]

B Introduction: b During the COVID-19 pandemic, the burden on the healthcare system makes it critical to examine readmission patterns. In this study, we evaluated the readmission rates and risk factors associated with COVID-19 from the large SCCM Discovery VIRUS: COVID-19 Registry. [Extracted from the article]

Introduction: Physicians dedicate substantial time to documentation. Scribes are sometimes used to improve efficiency by performing documentation tasks, although their impacts have not been prospectively evaluated. Our objective was to assess a scribe program's impact on emergency department (ED) throughput, physician time utilization, and job satisfaction in a large academic emergency medicine practice. Methods: We evaluated the intervention using pre- and post-intervention surveys and administrative data. All site physicians were included. Pre- and post-intervention data were collected in four-month periods one year apart. Primary outcomes included changes in monthly average ED length of stay (LOS), provider-specific average relative value units (RVUs) per hour (raw and normalized to volume), self-reported estimates of time spent teaching, self-reported estimates of time spent documenting, and job satisfaction. We analyzed data using descriptive statistics and appropriate tests for paired pre-post differences in continuous, categorical, and ranked variables. Results: Pre- and post-survey response rates were 76.1% and 69.0%, respectively. Most responded positively to the intervention, although 9.5% reported negative impressions. There was a 36% reduction (25%-50%; p<0.01) in time spent documenting and a 30% increase (11%-46%, p<0.01) in time spent in direct patient contact. No statistically significant changes were seen in job satisfaction or perception of time spent teaching. ED volume increased by 88 patients per day (32-146, p=0.04) pre- to post- and LOS was unchanged; rates of patients leaving against medical advice dropped, and rates of patients leaving without being seen increased. RVUs per hour increased 5.5% and per patient 5.3%; both were statistically significant. No statistically significant changes were seen in patients seen per hour. There was moderate correlation between changes in ED volume and changes in productivity metrics. Conclusion: Scribes were well received in our practice. Documentation time was substantially reduced and redirected primarily to patient care. Despite an ED volume increase, LOS was maintained, with fewer patients leaving against medical advice but more leaving without being seen. RVUs per hour and per patient both increased. [ABSTRACT FROM AUTHOR]

Background Current guidelines recommend obtaining blood cultures prior to antimicrobial therapy in patients with sepsis. Administering antimicrobials immediately without waiting for blood cultures could potentially decrease time to treatment and improve outcomes, but it is unclear the degree to which this strategy impacts diagnostic yield. Methods We performed a patient-level, single-arm, diagnostic trial. Seven urban emergency departments affiliated with academic medical centers across Canada and the United States participated in the study. Adults ≥18 years of age presenting to the emergency department with evidence of severe manifestations of sepsis, including a systolic blood pressure <90 mmHg and/or a serum lactate ≥4 mmol/L were included. Study participants had 2 sets of blood cultures drawn prior to and immediately following antimicrobial administration. The primary outcome was the difference in blood culture pathogen recovery rates before and after administration of antimicrobial therapy. Results Of the 3,164 participants screened, 325 were included in the study (mean age, 65.6 years; 63.0% men) and had repeat blood cultures drawn after the initiation of antimicrobial therapy (median time of 70 minutes, IQR 50 to 110 minutes). Pre-antimicrobial blood cultures were positive for one or more microbial pathogens in 102/325 (31.4%) patients. Fifty-four participants (52.9%) had matching blood culture results after initiation of antimicrobial treatment. The absolute difference in pathogen recovery rates was 14.5% ([95% CI 8.0 to 21.0%]; P < 0.0001) between pre- and post-antimicrobial blood cultures. Results were consistent in an analysis of the per-protocol population (absolute difference, 13.3% [95% CI 6.1 to 20.4%]; P < 0.0001). Including the results of other microbiological cultures done as part of routine care, microbial pathogens were recovered in 69 of 102 (67.7%) participants (absolute difference, 10.2% [95% CI 3.4 to 16.8%]; P < 0.0001). Conclusion Among patients with severe manifestations of sepsis, the administration of empiric antimicrobial therapy significantly reduces the yield of pathogen recovery when blood cultures are drawn shortly after treatment initiation. Disclosures All Authors: No reported Disclosures. [ABSTRACT FROM AUTHOR]

Sleep-wake disturbances are both a risk factor and reported morbidity for intracerebral hemorrhage (ICH). ICH begins with a ruptured blood vessel and blood leakage into the parenchyma. In response to initial damage, pathophysiological processes ensue that both exacerbate and repair damage. Inflammation is a hallmark process of ICH, which includes microglia activation and increased cytokine signaling. Due to the dual role of cytokines as inflammatory signaling proteins and sleep regulatory substances (SRSs), we hypothesized that ICH would activate microglia, increase SRSs, and alter sleep-wake patterns following an experimental model of ICH in the mouse. Male mice were randomized to receive an injection of collagenase (ICH; n = 8) or saline (sham; n = 11) in the striatum of the right hemisphere. Sleep-wake activity was recorded for 6 full days after ICH via noninvasive sleep cages. Blood and tissue were collected at 7 days after ICH to quantify pro-inflammatory cytokines/SRSs (IL-1β, TNF-α, IL-6) and microglia deramification by skeleton analysis. There was an overall injury effect on sleep in mice subjected to ICH at the transition from dark (wake) to light (sleep) at 2, 3, 4, 5, and 6 days after ICH compared with shams. Further analysis confirmed that ICH mice had significantly earlier wake offsets at the dark/light transition and more robust circadian patterns of wake behavior than saline control mice. Spatiotemporal skeleton analysis indicated an increase in microglial cell number with a decrease in endpoints per cell (decreased ramification) for the ipsilateral ICH perihematomal region compared with saline control. There were no changes to plasma cytokine levels at 7 days after ICH when comparing each condition. This is the first known study to show changes in sleep-wake patterns after experimental ICH. Elucidation of mechanisms that link sleep, inflammation, and ICH offers new pharmacological opportunities and rehabilitative strategies to improve recovery in stroke patients. • We investigated inflammation and sleep-wake patterns after ICH. • Experimental ICH increased sleep and reduced wake was time-of-day dependent. • Microglia were activated in the perihematomal region after experimental ICH. • Inflammation may contribute to ICH-induced sleep-wake patterns. [ABSTRACT FROM AUTHOR]