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Benton R Hunter,1 Timothy J Ellender1,2 1Department of Emergency Medicine, 2Department of Critical Care Medicine, Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA Abstract: Landmark trials in 2002 showed that therapeutic hypothermia (TH) after out-of-hospital cardiac arrest due to ventricular tachycardia or ventricular fibrillation resulted in improved likelihood of good neurologic recovery compared to standard care without TH. Since that time, TH has been frequently instituted in a wide range of cardiac arrest patients regardless of initial heart rhythm. Recent evidence has evaluated how, when, and to what degree TH should be instituted in cardiac arrest victims. We outline early evidence, as well as recent trials, regarding the use of TH or targeted temperature management in these patients. We also provide evidence-based suggestions for the institution of targeted temperature management/TH in a variety of emergency medicine settings. Keywords: therapeutic hypothermia, cardiac arrest, heart arrest

Odontocetes obtain nutrients including essential elements through their diet and are exposed to heavy metal contaminants via ingestion of contaminated prey. We evaluated the prevalence, concentration, and tissue distribution of essential and non-essential trace elements, including heavy metal toxicants, in tissue (blubber, kidney, liver, skeletal muscle, skin) and fecal samples collected from 90 odontocetes, representing nine species, that stranded in Georgia and Florida, USA during 2007–2021. Samples were analyzed for concentrations of seven essential (cobalt, copper, iron, manganese, molybdenum, selenium, zinc) and five non-essential (arsenic, cadmium, lead, mercury, thallium) elemental analytes using inductively-coupled plasma mass spectrometry. Risso's dolphins (Grampus griseus) and short-finned pilot whales (Globicephala macrorhynchus) had the highest median concentrations of mercury, cadmium, and lead, while dwarf sperm whales (Kogia sima) had the lowest. Adult pygmy and dwarf sperm whales that stranded in 2019–2021 had higher concentrations of arsenic, copper, iron, lead, manganese, selenium, thallium, and zinc compared to those that stranded in 2010–2018, suggesting an increasing risk of exposure over time. The highest concentrations of many elements (e.g., cadmium, cobalt, copper, manganese, molybdenum, thallium, zinc) were in fecal samples, illustrating the usefulness of this noninvasively collected sample. Aside from fecal samples, hepatic tissues had the highest concentrations of iron, manganese, mercury, molybdenum, and selenium in most species; renal tissues had the highest concentrations of cadmium; skin had the highest concentrations of zinc; and copper, arsenic, and lead concentrations were primarily distributed among the liver and kidneys. Phylogenetic differences in patterns of trace element concentrations likely reflect species-specific differences in diet, trophic level, and feeding strategies, while heterogeneous distributions of elemental analytes among different organ types reflect differences in elemental biotransformation, elimination, and storage. This study illustrates the importance of monitoring toxic contaminants in stranded odontocetes, which serve as important sentinels of environmental contamination, and whose health may be linked to human health.

We report the discovery of a high-velocity, very low-mass star or brown dwarf whose kinematics suggest it is unbound to the Milky Way. CWISE J124909.08+362116.0 was identified by citizen scientists in the Backyard Worlds: Planet 9 program as a high-proper-motion ( μ = 0.″9 yr ^−1 ) faint red source. Moderate-resolution spectroscopy with Keck/NIRES reveals it to be a metal-poor early L subdwarf with a large radial velocity (−103 ± 10 km s ^−1 ), and its estimated distance of 125 ± 8 pc yields a speed of 456 ± 27 km s ^−1 in the Galactic rest frame, near the local escape velocity for the Milky Way. We explore several potential scenarios for the origin of this source, including ejection from the Galactic center ≳3 Gyr in the past, survival as the mass donor companion to an exploded white dwarf, acceleration through a three-body interaction with a black hole binary in a globular cluster, and accretion from a Milky Way satellite system. CWISE J1249+3621 is the first hypervelocity very low-mass star or brown dwarf to be found and the nearest of all such systems. It may represent a broader population of very high-velocity, low-mass objects that have undergone extreme accelerations.

We present the discovery of 118 new ultracool dwarf candidates, discovered using a new machine-learning tool, named SMDET , applied to time-series images from the Wide-field Infrared Survey Explorer. We gathered photometric and astrometric data to estimate each candidate’s spectral type, distance, and tangential velocity. This sample has a photometrically estimated spectral class distribution of 28 M dwarfs, 64 L dwarfs, and 18 T dwarfs. We also identify a T-subdwarf candidate, two extreme T-subdwarf candidates, and two candidate young ultracool dwarfs. Five objects did not have enough photometric data for any estimations to be made. To validate our estimated spectral types, spectra were collected for two objects, yielding confirmed spectral types of T5 (estimated T5) and T3 (estimated T4). Demonstrating the effectiveness of machine-learning tools as a new large-scale discovery technique.

After decades of brown dwarf discovery and follow-up, we can now infer the functional form of the mass distribution within 20 pc, which serves as a constraint on star formation theory at the lowest masses. Unlike objects on the main sequence that have a clear luminosity-to-mass correlation, brown dwarfs lack a correlation between an observable parameter (luminosity, spectral type, or color) and mass. A measurement of the brown dwarf mass function must therefore be procured through proxy measurements and theoretical models. We utilize various assumed forms of the mass function, together with a variety of birthrate functions, low-mass cutoffs, and theoretical evolutionary models, to build predicted forms of the effective temperature distribution. We then determine the best fit of the observed effective temperature distribution to these predictions, which in turn reveals the most likely mass function. We find that a simple power law ( ${dN}/{dM}\propto {M}^{-\alpha }$ ) with α ≈ 0.5 is optimal. Additionally, we conclude that the low-mass cutoff for star formation is ≲0.005 M _⊙ . We corroborate the findings of Burgasser, which state that the birthrate has a far lesser impact than the mass function on the form of the temperature distribution, but we note that our alternate birthrates tend to favor slightly smaller values of α than the constant birthrate. Our code for simulating these distributions is publicly available. As another use case for this code, we present findings on the width and location of the subdwarf temperature gap by simulating distributions of very old (8–10 Gyr) brown dwarfs.

A complete accounting of nearby objects—from the highest-mass white dwarf progenitors down to low-mass brown dwarfs—is now possible, thanks to an almost complete set of trigonometric parallax determinations from Gaia, ground-based surveys, and Spitzer follow-up. We create a census of objects within a Sun-centered sphere of 20 pc radius and check published literature to decompose each binary or higher-order system into its separate components. The result is a volume-limited census of ∼3600 individual star formation products useful in measuring the initial mass function across the stellar (

Peripheral nerve damage that results in lost segments requires surgery, but currently available hollow scaffolds have limitations that could be overcome by adding internal guidance support. A novel solution is to use filaments of absorbable metals to supply physical support and guidance for nerve regeneration that then safely disappear from the body. Previously, we showed that thin filaments of magnesium metal (Mg) would support nerve regeneration. Here, we tested another absorbable metal, zinc (Zn), using a proprietary zinc alloy with 2% iron (Zn-2%Fe) that was designed to overcome the limitations of both Mg and pure Zn metal. Non-critical-sized gaps in adult rat sciatic nerves were repaired with silicone conduits plus single filaments of Zn-2%Fe, Mg, or no metal, with autografts as controls. After seventeen weeks, all groups showed equal recovery of function and axonal density at the distal end of the conduit. The Zn alloy group showed some improvements in early rat health and recovery of function. The alloy had a greater local accumulation of degradation products and inflammatory cells than Mg; however, both metals had an equally thin capsule (no difference in tissue irritation) and no toxicity or inflammation in neighboring nerve tissues. Therefore, Zn-2%Fe, like Mg, is biocompatible and has great potential for use in nervous tissue regeneration and repair.

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Little is known about the intersesamoid crista in Hallux Valgus (HV). However, this structure directly interfaces with the sesamoids and surrounding soft tissues and might play an important role in HV deformity. Our primary objective was to compare the angulation between the crista and first metatarsal (M1) longitudinal axis in HV and controls. Our secondary objective was to assess its correlation with the Distal Metatarsal Articular Angle (DMAA). We hypothesized that the longitudinal axis of the crista will be deviated in valgus in HV and that its position will be correlated with the DMAA. Methods: This IRB approved retrospective case control study evaluated 9 HV and 8 controls matched on age, BMI, and gender. The DMAA was measured as initially described on X-Rays, and then on weight-bearing CT images using a previously validated technique including pronation correction of the M1 called 3d-DMAA. To identify the angle of the inter-sesamoid crista relative to the shaft of the 1st metatarsal, CT scans were semi-automatically segmented to create 3D models of the forefoot. The crista was selected in Geomagic Design X and the resulting STL models were imported into MATLAB for analysis. Principal component analysis was used to identify the direction of both the crista and the 1st metatarsal shaft. The crista-shaft angle is the angle between the directions of greatest variation. Normality was assessed using Shapiro-Wilk tests. Comparisons were made using Student T-tests for normal variables and Mann-Whitney for non-normals. Correlations were assessed using Pearson's coefficients. Results: The crista deviated from the 1st metatarsal shaft in valgus in all the cases (HV and controls). There was a significant increase in valgus deviation of the crista in HV compared to controls (respectively 14.4+/-8.7 degrees and 5.5+/-3.2 degrees; p=0.017). Mean DMAA were respectively 25.1+/-7.9 degrees in HV and 7.4+/-2.9 in controls (p

Cell-free systems enable the design of biosynthetic pathways for sustainable chemical synthesis. Here the authors create an integrated framework for accelerating design using extracts from genetically rewired strains.

Wildfires produce aerosols known to impact the climate, but the wider-reaching effects of this biomass burning are poorly constrained in models. Here the authors use a suite of observations from 12 campaigns around the globe to determine that the values used by most climate models overestimate the contribution of biomass burning aerosols.

Abstract Snow and ice albedo reduction due to deposition of absorbing particles (snow darkening effect [SDE]) warms the Earth system and is largely attributed to black carbon (BC) and dust. Absorbing organic aerosol (BrC) also contributes to SDE but has received less attention due to uncertainty and challenges in model representation. This work incorporates the SDE of absorbing organic aerosol (BrC) from biomass burning and biofuel sources into the Snow Ice and Aerosol Radiative (SNICAR) model within a variant of the Community Earth System Model. Additionally, 12 different emission regions of BrC and BC from biomass burning and biofuel sources are tagged to quantify the relative contribution to global and regional SDE. BrC global SDE (0.021–0.056 Wm−2 over land area and 0.0061–0.016 Wm−2 over global area) is larger than other model estimates, corresponding to 37%–98% of the SDE from BC. When compared to observations, BrC simulations have a range in median bias (−2.5% to +21%), with better agreement in the simulations that include BrC photochemical bleaching. The largest relative contributions to global BrC SDE are traced to Northern Asia (23%–31%), Southeast Asia (16%–21%), and South Africa (13%–17%). Transport from Southeast Asia contributes nearly half of the regional BrC SDE in Antarctica (0.084–0.3 Wm−2), which is the largest regional input to global BrC SDE. Lower latitude BrC SDE is correlated with snowmelt, in‐snow BrC concentrations, and snow cover fraction, while polar BrC SDE is correlated with surface insolation and snowmelt. This indicates the importance of in‐snow processes and snow feedbacks on modeled BrC SDE.

Using a sample of 361 nearby brown dwarfs, we have searched for 4.6 μ m variability, indicative of large-scale rotational modulations or large-scale, long-term changes on timescales of over 10 yr. Our findings show no statistically significant variability in Spitzer’s Infrared Array Camera (IRAC) channel 2 (ch2) or Wide-field Infrared Survey Explorer W2 photometry. For Spitzer the ch2 1 σ limits are ∼8 mmag for objects at 11.5 mag and ∼22 mmag for objects at 16 mag. This corresponds to no variability above 4.5% at 11.5 mag and 12.5% at 16 mag. We conclude that highly variable brown dwarfs, at least two previously published examples of which have been shown to have 4.6 μ m variability above 80 mmag, are very rare. While analyzing the data, we also developed a new technique for identifying brown dwarf binary candidates in Spitzer data. We find that known binaries have IRAC ch2 point response function (PRF) flux measurements that are consistently dimmer than aperture flux measurements. We have identified 59 objects that exhibit such PRF versus aperture flux differences and are thus excellent binary brown dwarf candidates.

Objective: To assess interobserver reliability of previously described coronal plane rotation measurements of medial column bones and to assess their ability to accurately quantify changes in rotational profile. Methods: Two cadaveric below-knee specimens were implanted with pins in each bone of the medial column. Weight-bearing computed tomography (CT) scans were acquired in a simulated standing position under neutral, supinated, and pronated conditions. For each specimen and condition, 2 observers measured the coronal plane rotation of the navicular, medial cuneiform, first metatarsal base, shaft, and head, and proximal phalanx of the hallux as previously described. The rotation of each pin was measured relative to the ground in the coronal plane for each condition. These measurements were defined as benchmarks for the rotational profile of each bone. The correlation between these benchmarks and direct bone measurements was then assessed. Intraclass correlation coeficiente was used to assess interobserver reliability. Pearson’s coefficient was used to evaluate correlations. Results: The interobserver reliability of direct bone measurements ranged from 0.98 to 0.99. Correlations between pin rotation and direct measurements ranged from ρ=0.87 to 0.99 across the neutral, supinated, and pronated conditions. Conclusion: Coronal plane rotation measurements of medial column bones described in this study are reliable tools. Level of Evidence III; Case-Control Study.

Importance: Workplace violence (WPV) against health care workers (HCWs) is common and likely underreported. Reliable data on the incidence of WPV and its impact on victims are lacking., Objective: To prospectively define the frequency of WPV against HCWs in the emergency department (ED), examine whether HCW demographics are associated with increased risk, and explore the impact of these events on HCWs., Design, Setting, and Participants: This cross-sectional study was conducted over 2 months in 2023 (August 28 to October 22, 2023) in the ED of a large, urban, academic safety net hospital in the US. Participants included ED physicians, nurses, and other HCWs, who were asked to complete a brief so-called shift sheet for every ED shift worked during the study period., Exposure: WPV as recorded on shift sheets., Main Outcomes and Measures: The primary outcome was the number of events per shift. Events were coded for severity (types 1-5) and gender- or race and ethnicity-related bias. Shift sheets asked for the participant's demographics and whether they experienced verbal or physical abuse during the shift. If so, they were asked to provide a description; rate the impact the event had on them; and indicate whether they felt the event was sexist, racist, or otherwise biased. Perceived impact was recorded, and demographic characteristics associated with the likelihood of experiencing WPV were explored using multivariable logistic regression analysis., Results: Among 72 HCWs who participated in the study, 52 were female (72%). A total of 575 shift sheets were returned of an estimated 1250 possible (46%), with 155 events, including 77 type 1 events (50%; shouting, yelling, or insults), 29 type 2 events (19%; threats of physical or sexual violence, death threats, or use of slurs), and 39 type 3 events (25%; physical violence); there was a mean (SD) of 3.7 (1.9) shifts per 1 event. No type 4 or 5 events, which involve physical violence causing grievous injuries requiring medical attention and, in the case of type 5 events, permanent disability or death, were recorded. Ten events could not be coded. Sexist or racist bias occurred in 38 events (25%) and 11 events (7%), respectively. Participants reported how the event impacted them in 133 events. Of those, moderate or severe impact was reported in 32 (24%) and mild to no effect in 101 (76%). There was no association between self-reported impact and coded severity of events. In a multivariable logistic regression analysis, a higher likelihood of experiencing WPV on any given shift was independently associated with being in the nursing role (odds ratio, 3.1; 95% CI, 1.9-5.0) and being age 40 years or younger (odds ratio, 2.0; 95% CI, 1.2-3.5)., Conclusions and Relevance: In this cross-sectional study of HCWs in the ED, participants experienced WPV once every 3.7 shifts. The nursing role and younger age were associated with increased risk. These results highlight an urgent need to identify interventions to support and protect HCWs.

With over 1 million primary heart failure (HF) hospitalizations annually, nearly 80% of patients who present to the emergency department with decompensated HF (DHF) are hospitalized. Short stay units (SSU) present an alternative to hospitalization, yet the effectiveness of the SSU strategy of care is not well known. This study is to determine the effectiveness of a SSU strategy compared with hospitalization in lower-risk patients with DHF. Our primary outcome was a composite of 30-day mortality and re-hospitalization. Key secondary outcomes included 90-day mortality and re-hospitalization, costs, and 30-day days-alive-and-out-of-hospital (DAOOH). This is a systematic review and meta-analysis, following PRISMA guidelines. MEDLINE, EMBASE, CENTRAL, CINAHL, SCOPUS, and Web of Science were searched from inception through February 2024. Either randomized trials or comparative observational studies were included if they compared outcomes between low-risk ED DHF patients admitted to an SSU (defined as an observation unit with expected stay ≤ 48 h) vs. admitted to the hospital. Two authors independently screened all titles and abstracts and then identified full texts for inclusion. Data extraction and risk of bias assessments were performed by two authors in parallel. The primary outcome was a composite of death or readmission within 30 days, reported as relative risk (RR), where a RR < 1 favored the SSU strategy. Secondary outcomes included 90-day mortality and re-hospitalization, costs, and 1-month days-alive-and-out-of-hospital (DAOOH). Of the 467 articles identified by our search strategy, only 3 full text articles were included. In meta-analysis for the primary outcome of 30-day death or readmission, the RR was 0.95 (95% CI = 0.56 to 1.63; I 2  = 0%) for patients randomized to SSU vs hospitalization (2 studies, 241 patients). There were only 2 total deaths at 30 days in the 2 studies (total N = 258) which reported 30-day mortality, both in hospitalized patients. Only one study reported 90-day outcomes, showing no significant differences. Costs were lower in the SSU arm from one study, and 30-day DAOOH also favored SSU based on a single randomized trial. Based on very limited evidence, SSU provides similar efficacy for 30-day and 90-day mortality and readmission compared to hospitalization. An SSU strategy appears safe and may be cost effective., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background Pregnant laboring patients sometimes require interfacility transfer to a higher level of care. There is a paucity of evidence to inform when it is safe to transfer a laboring patient and when delivery may be too imminent to transfer. Methods This is a retrospective study of pregnant patients undergoing interfacility transfer with a specialized obstetric transport team deployed from a large Midwest regional healthcare system. The primary outcome was delivery prior to or within one hour of arrival at the receiving institution due to progression of labor. Data collected included basic demographics, vital signs, gravidity, parity, gestational age, contraction frequency if contractions were present, and cervical dilation. We sought to define the association between these variables and the primary outcome to inform risk assessment for precipitous delivery among patients being considered for interfacility transfer. Results Of the 370 pregnant patients for whom the specialized transfer team was requested, 11 (3%) met the primary outcome. Those with more advanced cervical dilation and those who did not receive regular prenatal care were more likely to meet the criteria for the primary outcome. For every centimeter of cervical dilation, the odds of meeting the primary outcome increased 2.3-fold (95% CI: 1.5-3.4). Conclusions We identified risk factors for early delivery among pregnant patients for whom an interfacility transfer was requested and described patients who were high-risk for obstetric interfacility transport due to the progression of labor. Our results can help inform risk assessments for transferring potentially high-risk laboring patients., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Indiana University Institutional Review Board issued approval 20146. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Lardaro et al.)

Source Citation: Connolly SJ, Sharma M, Cohen AT, et al; ANNEXA-I Investigators. Andexanet for factor Xa inhibitor-associated acute intracerebral hemorrhage. N Engl J Med. 2024;390:1745-1755. 38749032., Competing Interests: Disclosures: Disclosure forms are available with the article online.

Background and Objectives: Hospitals and clinicians increasingly are reimbursed based on quality of care through financial incentives tied to value-based purchasing. Patient-centered care, measured through patient experience surveys, is a key component of many quality incentive programs. We hypothesize that operational aspects such as wait times are an important element of emergency department (ED) patient experience. The objectives of this paper are to determine (1) the association between ED wait times and patient experience and (2) whether patient comments show awareness of wait times., Methods: This is a cross-sectional observational study from January 1, 2019, to December 31, 2020, across 16 EDs within a regional health care system. Patient and operations data were obtained as secondary data through internal sources and merged with primary patient experience data from our data analytics team. Dependent variables are (1) the association between ED wait times in minutes and patient experience ratings and (2) the association between wait times in minutes and patient comments including the term wait (yes/no). Patients rated their "likelihood to recommend (LTR) an ED" on a 0 to 10 scale (categories: "Promoter" = 9-10, "Neutral" = 7-8, or "Detractor" = 0-6). Our aggregate experience rating, or Net Promoter Score (NPS), is calculated by the following formula for each distinct wait time (rounded to the nearest minute): NPS = 100* (# promoters - # detractors)/(# promoters + # neutrals + # detractors). Independent variables for patient age and gender and triage acuity, were included as potential confounders. We performed a mixed-effect multivariate ordinal logistic regression for the rating category as a function of 30 minutes waited. We also performed a logistic regression for the percentage of patients commenting on the wait as a function of 30 minutes waited. Standard errors are adjusted for clustering between the 16 ED sites., Results: A total of 50 833 unique participants completed an experience survey, representing a response rate of 8.1%. Of these respondents, 28.1% included comments, with 10.9% using the term "wait." The odds ratio for association of a 30-minute wait with LTR category is 0.83 [0.81, 0.84]. As wait times increase, the odds of commenting on the wait increase by 1.49 [1.46, 1.53]. We show policy-relevant bubble plot visualizations of these two relationships., Conclusions: Patients were less likely to give a positive patient experience rating as wait times increased, and this was reflected in their comments. Improving on the factors contributing to ED wait times is essential to meeting health care systems' quality initiatives., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Lung ultrasound (LUS) reduces time to diagnosis and treatment of acute decompensated heart failure (ADHF) in emergency department (ED) patients with undifferentiated dyspnea. We conducted a systematic review to evaluate the diagnostic accuracy and clinical impact of LUS for ADHF in the prehospital setting., Methods: We performed a keyword search of multiple databases from inception through June 1, 2023. Included studies were those enrolling prehospital patients with undifferentiated dyspnea or suspected ADHF, and specifically diagnostic studies comparing prehospital LUS to a gold standard and intervention studies with a non-US comparator group. Title and abstract screening, full text review, risk of bias (ROB) assessments, and data extraction were performed by multiple authors. and adjudicated. The primary outcome was pooled sensitivity, specificity, and diagnostic likelihood ratios (LR) for prehospital LUS. A test-treatment threshold of 0.7 was applied based on prior ADHF literature in the ED. Intervention outcomes included mortality, mechanical ventilation, and time to HF specific treatment., Results: Eight diagnostic studies (n = 691) and two intervention studies (n = 70) met inclusion criteria. No diagnostic studies were low-ROB. Both intervention studies were critical-ROB, and not pooled. Pooled sensitivity and specificity of prehospital LUS for ADHF were 86.7% (95%CI:70.8%-94.6%) and 87.5% (78.2%-93.2%), respectively, with similar performance by physician vs. paramedic LUS and number of lung zones evaluated. Pooled LR+ and LR- were 7.27 (95% CI: 3.69-13.10) and 0.17 (95% CI: 0.06-0.34), respectively. Area under the summary receiver operating characteristic curve was 0.922. At the observed 42.4% ADHF prevalence (pre-test probability), positive pre-hospital LUS exceeded the 70% threshold to initiate treatment (post-test probability 84%, 80-88%)., Conclusions: LUS had similar diagnostic test characteristics for ADHF diagnosis in the prehospital setting as in the ED. A positive prehospital LUS may be sufficient to initiate early ADHF treatment based on published test-treatment thresholds. More studies are needed to determine the clinical impact of prehospital LUS., Competing Interests: Declaration of competing interest FMR is a consultant for Butterfly Network. NEH reports research funding from the National Institutes of Health National Center for Advancing Translational Sciences (NIH NCATS), the Indiana Clinical and Translational Sciences Institute (CTSI), the Doris Duke Foundation, Abbott, and Indiana University School of Medicine. NEH reports Honoraria from EB Medicine. All other authors report no conflict of interest., (Published by Elsevier Inc.)

Objective: This study describes the local Emergency Medical Services (EMS) response and patient encounters corresponding to the civil unrest occurring over a four-day period in Spring 2020 in Indianapolis, Indiana (USA)., Methods: This study describes the non-conventional EMS response to civil unrest. The study included patients encountered by EMS in the area of the civil unrest occurring in Indianapolis, Indiana from May 29 through June 1, 2020. The area of civil unrest defined by Indianapolis Metropolitan Police Department covered 15 blocks by 12 blocks (roughly 4.0 square miles) and included central Indianapolis. The study analyzed records and collected demographics, scene times, interventions, dispositions, EMS clinician narratives, transport destinations, and hospital course with outcomes from receiving hospitals for patients extracted from the area of civil unrest by EMS., Results: Twenty-nine patients were included with ages ranging from two to sixty-eight years. In total, EMS transported 72.4% (21 of 29) of the patients, with the remainder declining transport. Ballistic injuries from gun violence accounted for 10.3% (3 of 29) of injuries. Two additional fatalities from penetrating trauma occurred among patients without EMS contact within and during the civil unrest. Conditions not involving trauma occurred in 37.9% (11 of 29). Among transported patients, 33.3% (7 of 21) were admitted to the hospital and there was one fatality., Conclusions: While most EMS transports did not result in hospitalization, it is important to note that the majority of EMS calls did result in a transport. There was a substantial amount of non-traumatic patient encounters. Trauma in many of the encounters was relatively severe, and the findings imply the need for rapid extraction methods from dangerous areas to facilitate timely in-hospital stabilization.

Introduction: Sepsis identification and treatment is a priority for emergency department (ED) providers and payors alike. However, aggressive metrics aimed at improving sepsis care could have unintended consequences for patients who do not have sepsis., Methods: All ED patient visits for a one month period before and after a quality initiative to increase early antibiotic use in septic patients were included. Overall broad spectrum (BS) antibiotic use, admission rates, and mortality were compared in the 2 time periods. A more detailed chart review was performed on those who received BS antibiotics in the before and after cohorts. Patient were excluded for pregnancy, age < 18, COVID-19 infection, hospice patients, left ED against medical advice, and if antibiotics were given for prophylaxis. In BS antibiotic treated patients, we sought to determine mortality, rates of subsequent multidrug resistant (MDR) or Clostridium Difficile (CDiff) infections and rates of non-infected patients receiving BS antibiotics., Results: There were 7967 and 7407 ED visits in the pre- and post-implementation periods, respectively. Of those, BS antibiotics were administered in a total of 3.9% pre-implementation and 6.2% post-implementation (p ≤ 0.00001). Admission was more common in the post-implementation period, but overall mortality was unchanged (0.9% pre-implementation and 0.8% post-implementation, p = 0.41). After exclusions, 654 patients treated with BS antibiotics were included in the secondary analyses. Baseline characteristics were similar between the pre-implementation and post-implementation cohorts. There was no difference in the rate of CDiff infection or the proportion of patients receiving BS antibiotics who were not infected, but there was an increase in the post-implementation period in MDR infections after ED BS antibiotics, 0.72% vs. 0.35% of the entire ED cohorts, p = 0.0009., Conclusions: We found that a QI sepsis initiative was associated with an increase in the proportion of patients who received BS antibiotics in the ED, and a small absolute increase in associated subsequent MDR infections, with no apparent effect on mortality in all ED patients or the subset treated with BS antibiotics. Further research is needed to assess the impact on all patients affected by aggressive sepsis protocols and initiatives, rather than only those with sepsis., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Source Citation: Edlow JA, Carpenter C, Akhter M, et al. Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE-3): acute dizziness and vertigo in the emergency department. Acad Emerg Med. 2023;30:442-486. 37166022., Competing Interests: Disclosures: The commentators have reported no disclosures of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=J23-0060.

Background: Violence directed at healthcare workers (HCWs) is common and may be more frequent in the emergency department (ED). In addition to physical injury, other consequences of workplace violence in the ED include an increased risk of burnout, post-traumatic stress disorder, reduced job satisfaction, and feelings of avoidance and futility. Understanding behaviors underlying workplace violence is the first step to employing mitigation strategies. The objective of this descriptive study was to assess the prevalence and types of violence against HCWs in a large, urban ED., Methods: This study took place in the ED of an urban hospital with an annual ED census of approximately 100,000. A previously existing general patient safety incident "dropbox" for HCWs was utilized to capture workplace violence reports. At the completion of the study period, all data was collated into the electronic database and each report was categorized based on the nature and severity of the abuse. Further, all events were also coded as either involving or not involving specifically racist, sexist, or homophobic content. The primary outcomes were the number of reported events over the study period, and the percentage of total events that fell into each category. The secondary outcomes were the overall prevalence and ratio of events that included racist, sexist, or homophobic language or provocation., Results: Over the 5-month survey period, 130 reports of workplace violence were recorded, on average 0.85 per day. Perpetrators were mostly male, and most victims were nurses. Hospital security was involved in 26% of cases. At least 37% of incidents involved patients that were intoxicated and/or had history of psychiatric illness. Type I events (swearing provocatively, shouting, and legal threats) were the most common at 44% of encounters while 22% involved physical violence. Racist, sexist, and homophobic comments were involved in 8 (6%), 18 (14%), and 3 (2%) incidents respectively., Conclusion: We found that workplace violence against HCWs was common in this study, and sometimes involved a component of racist, sexist, or homophobic bias. Consistent with previous ED literature, we found that abusive events occurred almost daily and that approximately 20% of events involved physical violence. Future efforts toward policy change to address workplace violence in health care is needed at local, state, and national levels., Competing Interests: Declaration of Competing Interest The authors do not have any declarations of interest or conflicts of interest to report., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Endotracheal intubation is a high-risk procedure. Optimisation of all aspects of the procedure, including patient positioning, is important to facilitate success and minimise complications. The objective of this systematic review was to determine the association between inclined patient positioning and first-pass success and other clinically important outcomes among patients undergoing endotracheal intubation., Methods: A search of PubMed, CINAHL, SCOPUS, EMBASE and Cochrane, from inception through October 2020 was conducted. Studies were assessed independently by two authors to determine eligibility for inclusion. Included studies were any randomised or observational study that compared supine to inclined patient positioning for endotracheal intubation and assessed one of our predefined outcomes. Simulation studies were excluded. Study results were meta-analysed using a random effects model. The quality of the evidence for outcomes of interest was assessed using the Grading of Recommendations, Assessment, Development and Evaluations approach., Results: A total of 5113 studies were identified, of which 10 studies representing 18 371 intubations were included for meta-analysis. There was no statistically significant difference in the primary outcome of first-pass success rate (relative risk 1.02, 95% CI 0.98 to 1.05) or secondary outcomes of oesophageal intubation, glottic view, hypotension, hypoxaemia, mortality or peri-intubation arrest. Likewise, there were no statistically significant differences in any of the outcomes in predefined subgroup analyses of randomised controlled trials, intubations in acute settings or intubations performed with >45 degrees of incline. Overall quality of evidence was rated as low or very low for most outcomes., Conclusions: This systematic review and meta-analysis found no evidence of benefit or harm with inclined versus supine patient positioning during endotracheal intubation in any setting., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Patients with atrial fibrillation (AF) are frequently admitted from the emergency department (ED), and when discharged, are not reliably prescribed indicated anticoagulation. We report the impact of a novel computerized ED AF pathway orderset on discharge rate and risk-appropriate anticoagulation in patients with primary AF., Methods: The orderset included options for rate and rhythm control of primary AF, structured risk assessment for thrombotic complications, recommendations for anticoagulation as appropriate, and follow up with an electrophysiologist. All patients discharged from the ED in whom the AF orderset was utilized over an 18-month period comprised the primary study population. The primary outcome was the rate of appropriate anticoagulation or not according to confirmed CHADS-VASC and HASBLED scores. Additionally, the percentage of primary AF patients discharged directly from the ED was compared in the 18-month periods before and after introduction of the orderset., Results: A total of 56 patients, average age 57.8 years and average initial heart rate 126 beats/minute, were included in the primary analysis. All 56 (100%; 95% confidence interval, 94-100) received guideline-concordant anticoagulation. The discharge rates in the pre- and postorderset implementation periods were 29% and 41%, respectively (95% confidence interval for 12% difference, 5-18)., Conclusions: Our novel AF pathway orderset was associated with 100% guideline-concordant anticoagulation in patients discharged from the ED. Availability of the orderset was associated with a significant increase in the proportion of ED AF patients discharged., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Importance: Acute vertigo can be disabling. Antihistamines and benzodiazepines are frequently prescribed as "vestibular suppressants," but their efficacy is unclear., Objective: To assess the efficacy of antihistamines and benzodiazepines in the treatment of acute vertigo from any underlying cause., Data Sources: We searched the PubMed, CENTRAL, EMBASE, CINAHL, Scopus, and ClinicalTrials.gov databases from inception to January 14, 2019, without language restrictions. Bibliographies of the included studies and relevant reviews were also screened., Study Selection: We included randomized clinical trials (RCTs) comparing antihistamine or benzodiazepine use with another comparator, placebo, or no intervention for patients with a duration of acute vertigo for 2 weeks or less. Studies of healthy volunteers, prophylactic treatment, or induced vertigo were excluded, as were studies that compared 2 medications from the same class., Data Extraction and Synthesis: Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, data were extracted and risk of bias was assessed by 2 authors independently for each study. Data were pooled using a random-effects model., Main Outcomes and Measures: The predefined primary outcome was change in 10- or 100-point vertigo or dizziness visual analog scale (VAS) scores at 2 hours after treatment. Secondary outcomes included change in nausea VAS scores at 2 hours, use of rescue medication at 2 hours, and improvement or resolution of vertigo at 1 week or 1 month., Results: Of the 27 trials identified in the systematic review, 17 contributed to the quantitative meta-analysis and involved a total of 1586 participants. Seven trials with a total of 802 participants evaluated the primary outcome of interest: single-dose antihistamines resulted in significantly more improvement on 100-point VAS scores compared with benzodiazepines (difference, 16.1 [95% CI, 7.2 to 25.0]) but not compared with other active comparators (difference, 2.7 [95% CI, -6.1 to 11.5]). At 1 week and 1 month, neither daily benzodiazepines nor antihistamines were reported to be superior to placebo. RCTs comparing the immediate effects of medications (at 2 hours) after a single dose generally had a low risk of bias, but those evaluating 1-week and 1-month outcomes had a high risk of bias., Conclusions and Relevance: Moderately strong evidence suggests that single-dose antihistamines provide greater vertigo relief at 2 hours than single-dose benzodiazepines. Furthermore, the available evidence did not support an association of benzodiazepine use with improvement in any outcomes for acute vertigo. Other evidence suggested that daily antihistamine use may not benefit patients with acute vertigo. Larger randomized trials comparing both antihistamines and benzodiazepines with placebo could better clarify the relative efficacy of these medications.

Source Citation: The DISCHARGE Trial Group. CT or invasive coronary angiography in stable chest pain. N Engl J Med. 2022;386:1591-602. 35240010.

Source Citation: Gray AJ, Roobottom C, Smith JE, et al. Early computed tomography coronary angiography in patients with suspected acute coronary syndrome: randomised controlled trial. BMJ. 2021;374:n2106. 34588162.

Background: Coronavirus disease 2019 (COVID-19) is associated with respiratory symptoms and renal effects. Data regarding fluid resuscitation and kidney injury in COVID-19 are lacking, and understanding this relationship is critical., Objectives: To determine if there is an association between fluid volume administered in 24 h and development of renal failure in COVID-19 patients., Methods: Retrospective chart review; 14 hospitals in Indiana. Included patients were adults admitted between March 11, 2020 and April 13, 2020 with a positive test for severe acute respiratory syndrome coronavirus 2 within 3 days of admission. Patients requiring renal replacement therapy prior to admission were excluded. Volumes and types of resuscitative intravenous fluids in the first 24 h were obtained with demographics, medical history, and other objective data. The primary outcome was initiation of renal replacement therapy. Logistic regression modeling was utilized in creating multivariate models for determining factors associated with the primary outcome., Results: The fluid volume received in the first 24 h after hospital admission was associated with initiation of renal replacement therapy in two different multivariate logistic regression models. An odds ratio of 1.42 (95% confidence interval 1.01-1.99) was observed when adjusting for age, heart failure, obesity, creatinine, bicarbonate, and total fluid volume. An odds ratio of 1.45 (95% confidence interval 1.02-2.05) was observed when variables significant in univariate analysis were adjusted for., Conclusions: Each liter of intravenous fluid administered to patients with COVID-19 in the first 24 h of presentation was independently associated with an increased risk for initiation of renal replacement therapy, supporting judicious fluid administration in patients with this disease., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Source Citation: Metra B, Summer R, Brooks SE, et al. Racial disparities in COVID-19 associated pulmonary embolism: a multicenter cohort study. Thromb Res. 2021;205:84-91. 34274560.

The recent approval and distribution of vaccines against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been a major development in the fight against the current coronavirus disease 2019 (COVID-19) pandemic. The first two vaccines approved in the United States, mRNA-1273, and BNT162b2, are both messenger RNA (mRNA) based and highly effective in immunocompetent persons, but efficacy in patients on immunosuppressants has not been established. Additionally, data suggests these patients are less likely than immunocompetent people to develop neutralizing antibodies after COVID-19 infection. Given the high risk of poor outcomes in organ transplant and immunosuppressed patients, effective vaccination is paramount in this group. We present the first reported case of a solid organ transplant patient who failed to achieve seroconversion after two doses of mRNA vaccine. This case has significant implications about how immunosuppressed patients should be counseled about SARS-CoV-2 vaccination and the protection provided. Physicians should remain clinically suspicious for infection with SARS-CoV-2 despite vaccination status in solid organ transplant patients., (© 2021 Wiley Periodicals LLC.)

Source Citation: Qaseem A, Etxeandia-Ikobaltzeta I, Mustafa RA, et al. Appropriate use of point-of-care ultrasonography in patients with acute dyspnea in emergency department or inpatient settings: a clinical guideline from the American College of Physicians. Ann Intern Med. 2021;174:985-93. 33900792.

Introduction: The rate of bacterial coinfection with SARS-CoV-2 is poorly defined. The decision to administer antibiotics early in the course of SARS-CoV-2 infection depends on the likelihood of bacterial coinfection., Methods: We performed a retrospective chart review of all patients admitted through the emergency department with confirmed SARS-CoV-2 infection over a 6-week period in a large healthcare system in the United States. Blood and respiratory culture results were abstracted and adjudicated by multiple authors. The primary outcome was the rate of bacteremia. We secondarily looked to define clinical or laboratory features associated with bacteremia., Results: There were 542 patients admitted with confirmed SARS-CoV-2 infection, with an average age of 62.8 years. Of these, 395 had blood cultures performed upon admission, with six true positive results (1.1% of the total population). An additional 14 patients had positive respiratory cultures treated as true pathogens in the first 72 h. Low blood pressure and elevated white blood cell count, neutrophil count, blood urea nitrogen, and lactate were statistically significantly associated with bacteremia. Clinical outcomes were not statistically significantly different between patients with and without bacteremia., Conclusions: We found a low rate of bacteremia in patients admitted with confirmed SARS-CoV-2 infection. In hemodynamically stable patients, routine antibiotics may not be warranted in this population., (© 2021 Wiley Periodicals LLC.)

Background: Patients with COVID-19 can present to the emergency department (ED) at any point during the spectrum of illness, making it difficult to predict what level of care the patient will ultimately require. Admission to a ward bed, which is subsequently upgraded within hours to an intensive care unit (ICU) bed, represents an inability to appropriately predict the patient's course of illness. Predicting which patients will require ICU care within 24 hours would allow admissions to be managed more appropriately., Methods: This was a retrospective study of adults admitted to a large health care system, including 14 hospitals across the state of Indiana. Included patients were aged ≥ 18 years, were admitted to the hospital from the ED, and had a positive polymerase chain reaction (PCR) test for COVID-19. Patients directly admitted to the ICU or in whom the PCR test was obtained > 3 days after hospital admission were excluded. Extracted data points included demographics, comorbidities, ED vital signs, laboratory values, chest imaging results, and level of care on admission. The primary outcome was a combination of either death or transfer to ICU within 24 hours of admission to the hospital. Data analysis was performed by logistic regression modeling to determine a multivariable model of variables that could predict the primary outcome., Results: Of the 542 included patients, 46 (10%) required transfer to ICU within 24 hours of admission. The final composite model, adjusted for age and admission location, included history of heart failure and initial oxygen saturation of <93% plus either white blood cell count > 6.4 or glomerular filtration rate < 46. The odds ratio (OR) for decompensation within 24 hours was 5.17 (95% confidence interval [CI] = 2.17 to 12.31) when all criteria were present. For patients without the above criteria, the OR for ICU transfer was 0.20 (95% CI = 0.09 to 0.45)., Conclusions: Although our model did not perform well enough to stand alone as a decision guide, it highlights certain clinical features that are associated with increased risk of decompensation., (© 2021 by the Society for Academic Emergency Medicine.)

Healthcare employees were tested for antibodies against severe acute respiratory coronavirus virus 2 (SARS-CoV-2). Among 734 employees, the prevalence of SARS-CoV-2 antibodies was 1.6%. Employees with heavy coronavirus disease 2019 (COVID-19) exposure had similar antibody prevalence as those with limited or no exposure. Guidelines for PPE use seem effective for preventing COVID-19 infection in healthcare workers.

Background: Severe acute respiratory syndrome coronavirus 2 is a novel coronavirus first diagnosed in U.S. hospitals in January 2020. Typical presenting symptoms include fever, dry cough, dyspnea, and hypoxia. However, several other symptoms have been reported, including fatigue, weakness, diarrhea, and abdominal pain. We have identified a series of patients with diabetic ketoacidosis (DKA) likely precipitated by coronavirus disease 2019 (COVID-19)., Case Series: We describe 5 patients with previously known type 2 diabetes and no history of DKA, who presented to the emergency department with new-onset DKA and COVID-19. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Diabetes mellitus is a known risk factor for poor outcomes in viral respiratory illnesses, including COVID-19. Infection may precipitate DKA in patients with type 2 diabetes. Aggressive management of these patients is recommended; however, management guidelines have not yet been put forth for this unique subset of patients., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Importance: Endotracheal intubation of critically ill patients is a high-risk procedure. Checklists have been advocated to improve outcomes., Objective: To assess whether the available evidence supports an association of use of airway checklists with improved clinical outcomes in patients undergoing endotracheal intubation., Data Sources: For this systematic review and meta-analysis, PubMed (OVID), Embase, Cochrane, CINAHL, and SCOPUS were searched without limitations using the Medical Subject Heading terms and keywords airway; management; airway management; intubation, intratracheal; checklist; and quality improvement to identify studies published between January 1, 1960, and June 1, 2019. A supplementary search of the gray literature was performed, including conference abstracts and clinical trial registries., Study Selection: Full-text reviews were performed to determine final eligibility for inclusion. Included studies were randomized clinical trials or observational human studies that compared checklist use with any comparator for endotracheal intubation and assessed 1 of the predefined outcomes., Data Extraction and Synthesis: Data extraction and quality assessment were performed using the Newcastle-Ottawa Scale for observational studies and Cochrane risk of bias tool for randomized clinical trials. Study results were meta-analyzed using a random-effects model. Reporting of this study follows the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline., Main Outcomes and Measures: The primary outcome was mortality. Secondary outcomes included first-pass success and known complications of endotracheal intubation, including esophageal intubation, hypoxia, hypotension, and cardiac arrest., Results: The search identified 1649 unique citations of which 11 (3261 patients) met the inclusion criteria. One randomized clinical trial and 3 observational studies had a low risk of bias. Checklist use was not associated with decreased mortality (5 studies [2095 patients]; relative risk, 0.97; 95% CI, 0.80-1.18; I2 = 0%). Checklist use was associated with a decrease in hypoxic events (8 studies [3010 patients]; relative risk, 0.75; 95% CI, 0.59-0.95; I2 = 33%) but no other secondary outcomes. Studies with a low risk of bias did not demonstrate decreased hypoxia associated with checklist use., Conclusions and Relevance: The findings suggest that use of airway checklists is not associated with improved clinical outcomes during and after endotracheal intubation, which may affect practitioners' decision to use checklists in this setting.

Study Objective: There is a paucity of evidence to guide the diagnostic evaluation of emergency department (ED) patients presenting after nonfatal strangulation (manual strangulation or near hanging). We seek to define the rate of serious injuries in alert strangled patients and determine which symptoms and examination findings, if any, predict such injuries., Methods: Using prospectively populated databases and electronic medical record review, we performed a retrospective analysis of alert strangled patients treated in the ED of an academic Level I trauma center. Exclusions were Glasgow Coma Scale (GCS) score less than 13, younger than 16 years, and interhospital transfers. Trained researchers used structured forms to abstract demographics, symptoms, examination findings, radiology and operative findings, and final diagnoses. Injuries requiring greater than 24 hours' observation or specific treatment (surgery, procedure, specific medication) were considered clinically important. The electronic medical record was searched for 30 days after presentation to identify missed injuries., Results: Advanced imaging (computed tomography or magnetic resonance maging) was obtained in 60%. Injuries were identified in 6 patients (1.7%, 95% CI, 0.7% to 3.6%). Two injuries were clinically important (0.6%, 95% CI, 0.1% to 2.0%). Both were cervical artery dissections with no neurologic deficits, treated with aspirin. No additional injuries were identified within 30 days or at next medical contact. Of 343 uninjured patients, 291 (85%) had documented medical follow up confirming the absence of any new diagnosis of injury or stroke. The small number of injuries precluded analyses of associations., Conclusion: Alert, strangled patients had a low rate of injuries. All patients with neck injuries had concerning findings besides neck pain; specifically, GCS score less than 15 or dysphagia. Our findings suggest, but do not prove, that a selective imaging strategy is safe in alert patients after strangulation findings besides neck pain., (Copyright © 2019 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Importance: Diagnosing posterior chamber ocular abnormalities typically requires specialist assessment. Point-of-care ultrasonography (POCUS) performed by nonspecialists, if accurate, could negate the need for urgent ophthalmologist evaluation., Objective: This meta-analysis sought to define the diagnostic test characteristics of emergency practitioner-performed ocular POCUS to diagnose multiple posterior chamber abnormalities in adults., Data Sources: PubMed (OVID), MEDLINE, EMBASE, Cochrane, CINAHL, and SCOPUS were searched from inception through June 2019 without restrictions. Conference abstracts and trial registries were also searched. Bibliographies of included studies and relevant reviews were manually searched, and experts in the field were queried., Study Selection: Included studies compared ocular POCUS performed by emergency practitioners with a reference standard of ophthalmologist evaluation. Pediatric studies were excluded. All 116 studies identified during abstract screening as potentially relevant underwent full-text review by multiple authors, and 9 studies were included., Data Extraction and Synthesis: In accordance with PRISMA guidelines, multiple authors extracted data from included studies. Results were meta-analyzed for each diagnosis using a bivariate random-effects model. Data analysis was performed in July 2019., Main Outcomes and Measures: The outcomes of interest were diagnostic test characteristics of ocular POCUS for the following diagnoses: retinal detachment, vitreous hemorrhage, vitreous detachment, intraocular foreign body, globe rupture, and lens dislocation., Results: Nine studies (1189 eyes) were included. All studies evaluated retinal detachment, but up to 5 studies assessed each of the other diagnoses of interest. For retinal detachment, sensitivity was 0.94 (95% CI, 0.88-0.97) and specificity was 0.94 (95% CI, 0.85-0.98). Sensitivity and specificity were 0.90 (95% CI, 0.65-0.98) and 0.92 (95% CI, 0.75-0.98), respectively, for vitreous hemorrhage and were 0.67 (95% CI, 0.51-0.81) and 0.89 (95% CI, 0.53-0.98), respectively, for vitreous detachment. Sensitivity and specificity were high for lens dislocation (0.97 [95% CI, 0.83-0.99] and 0.99 [95% CI, 0.97-1.00]), intraocular foreign body (1.00 [95% CI, 0.81-1.00] and 0.99 [95% CI, 0.99-1.00]), and globe rupture (1.00 [95% CI, 0.63-1.00] and 0.99 [95% CI, 0.99-1.00]). Results were generally unchanged in sensitivity analyses of studies with low risk of bias., Conclusions and Relevance: This study suggests that emergency practitioner-performed ocular POCUS is an accurate test to assess for retinal detachment in adults. Its utility in diagnosing other posterior chamber abnormalities is promising but needs further study.

Background: Elderly patients presenting to the emergency department (ED) with nonspecific complaints (NSCs) often undergo troponin testing to assess for atypical acute coronary syndrome (ACS). However, the rate of ACS and utility of troponin testing in this population is unknown. We sought to determine the rate of ACS and diagnostic yield of troponin testing in elderly patients with NSCs., Methods: We retrospectively identified all patients aged ≥ 65 years triaged in the ED with NSCs from January 1, 2017, to June 30, 2017. NSCs were defined a priori and included complaints such as weakness, dizziness, or fatigue. NSCs were verified in ED provider notes by trained abstractors blind to testing results. Exclusions were focal chief complaint in provider notes, fever, and no troponin ordered. ACS was strictly defined and independently adjudicated by two trained physician researchers blind to the study hypothesis. We calculated the proportion of patients with ACS within 30 days and the test characteristics of troponin to diagnose ACS., Results: Screening identified 1,146 encounters, and 552 were excluded for fever or focal chief complaints in the provider notes. Of the remaining 594 patients, troponin was ordered in 412 (69%), comprising the study cohort. The mean (±SD) age was 78.7 (±8.3) years, with 58% female and 75% admitted. Troponin elevation occurred in 81 patients (20%). ACS occurred in 5 of 412 (1.2%). Troponin was 100% sensitive (95% confidence interval [CI] = 48% to 100%) and 81% specific (95% CI = 77% to 85%) for ACS. Of patients with elevated troponin, 93.8% were false positives (no ACS). All patients with troponin elevation were admitted, but only one underwent angiography and no patients received reperfusion therapy., Conclusions: While consideration for ACS is prudent in selected elderly patients with NSCs, ACS was rare and no patients received reperfusion therapy. Given the false-positive rate in our study, our results may not support routine troponin testing for ACS in this population., (© 2019 by the Society for Academic Emergency Medicine.)

Objectives: Intravenous dextrose aids in the resolution of ketosis in dehydrated patients not tolerating oral glucose and is often recommended in this clinical scenario. Our aim was to determine whether the addition of dextrose to intravenous rehydration solutions results in decreased hospital admissions or other clinically important benefits among dehydrated children or adults., Methods: MEDLINE, EMBASE, Web of Science, SCOPUS, and the Cochrane Library were searched by a medical librarian from inception through November 2017. The inclusion criteria were randomized controlled trials comparing dextrose containing intravenous solutions with intravenous solutions without dextrose in patients being treated for dehydration, and not already hospitalized., Results: The database and bibliographies search identified 1,472 unique citations. Only two trials (N = 333) met the inclusion criteria. Both compared normal saline with solutions of dextrose in normal saline. There was no statistically significant difference in admission rates (relative risk = 0.83; 95% confidence interval = 0.62 to 1.10) or revisits (relative risk = 0.54; 95% confidence interval = 0.24 to 1.22). Heterogeneity was low (I2 = 0). No other outcome results were eligible for pooling, but neither study found differences in any clinical outcomes. No adverse events were reported in either trial., Conclusions: The addition of dextrose to intravenous saline has not been shown to improve clinical outcomes in dehydrated children presenting to the emergency department with gastroenteritis, but the confidence intervals around the estimate of effect are wide and include the possibility of substantial benefit.

Background: Identifying low-risk acute heart failure patients safe for discharge from the emergency department is a major unmet need., Methods and Results: A prospective, observational, multicenter pilot study targeting lower risk acute heart failure patients to determine whether hsTnT (high-sensitivity troponin T) identifies emergency department acute heart failure patients at low risk for rehospitalization and mortality. hsTnT was drawn at baseline and 3 hours. Phone follow-up occurred at 30 and 90 days. The primary end point composite of all-cause mortality, rehospitalization, and emergency department visits at 90 days (changed from 30 days because of lack of mortality events), analyzed using logistic regression. Secondary end points: 30- and 90-day all-cause mortality. hsTnT values less than the 99th percentile were defined as low hsTnT. Out of 527 enrolled patients, 499 comprised the initial analysis set. Of these, 332 had both 0- and 3-hour hsTnT drawn, of whom 319 completed 30 day follow-up. The average age was 62, 60% male, and 57% black. Median hsTnT was 26.4 ng/L (interquartile range, 15.1-44.3). There were 99 (21%) 30-day composite events, 13 (2.7%) deaths at 30 days, and 25 deaths (8.2%) at 90 days. Serial hsTnT values below the 99th percentile were not associated with a lower risk for the 90-day primary composite end point (odds ratio, 0.79; 95% CI, 0.42-1.50; P=0.4736). However, no deaths occurred in the low hsTnT group at 30 days with 1 death at 90 days., Conclusions: hsTnT did not identify patients at low risk for the primary outcome of rehospitalization, emergency department visits, and mortality at 90 days., Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02592135.