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Introduction: Our aim was to measure hepatitis C virus (HCV) screening and linkage-to-care rates in an urban emergency department (ED) before and after implementing an HCV viral RNA (vRNA) reflex testing protocol within a HCV screening program for at-risk patients. Our hypothesis was that using a reflex testing protocol would increase HCV testing rates of at-risk patients in the ED, which would increase the linkage-to-care rate. Methods: In August 2018, our institution implemented an automated, electronic health record-based HCV screening protocol in the ED for at-risk patients. In January 2019, we implemented an HCV vRNA reflex testing protocol (reflex testing) for all positive HCV antibody (Ab) tests that were initiated through the screening protocol. We compared completion rates of HCV vRNA testing and the rate of linkage to care for patients with positive HCV Ab test results before and after implementation of reflex testing (five months per study period). Results: Prior to reflex testing implementation, 233/425 (55%) patients with a positive HCV Ab test had an HCV vRNA test performed, whereas 270/323 (84%) patients with a positive HCV Ab test result had vRNA testing after reflex testing implementation (odds ratio [OR], 4.2; 95% confidence interval (CI): 3.0-6.0; P < 0.001). Of the eligible patients with positive HCV Ab test results who could be linked to care, 45 (10.6%) were linked to care before HCV reflex implementation and 46 (14.2%) were linked to care with reflex testing (OR, 1.4; 95% CI: 0.9-2.2; P = 0.13). Conclusion: Implementing a reflex testing initiative into an HCV screening program in the ED can result in an increase of the percentage of patients who receive an HCV vRNA test after having had a positive HCV Ab. Hepatitis C virus vRNA reflex testing was not associated with a statistically significant increase in linkage-to-care rates for HCV Ab-positive patients; however, further studies are required.

ObjectiveTo do a systematic review and critical appraisal of the ongoing clinical trials that are assessing various therapeutic interventions against SARS-CoV-2 with an aim to provide insight into the various interventions tested, clinical rationale, geographical distribution of the trials as well as the endpoints assessed in the studies.DesignRapid systematic review and critical appraisal of the ongoing clinical trials against SARS-CoV-2.Data sourcesClinicalTrials.gov, World health organization (WHO) International Clinical Trials Registry Platform (ICTRP) and Cochrane COVID registry were assessed till May 11th 2020.Study selectionStudies on any intervention based randomized controlled trials (RCTs), prospective clinical studies on SARS-CoV-2 in patients ≥18 years of age. Studies on autopsy series, preclinical studies, diagnostic methods, mathematical modelling, epidemiology and health services research, pediatric populations were excluded.Data extractionThe data was extracted by two authors independently into pre-defined forms based on the SPIRIT 2013 checklist. The data was extracted on various domains such as trial number, study title, abstract of the study, interventions assessed, sample size, phase of the study, study sponsor, primary endpoint assessed and country of study.ResultsThe search resulted in 3242 ongoing studies of which 829 studies were included. There are 134 different drug-based interventions being assessed in 463 clinical trials as treatment options. Seventy-two studies assessed preventive options of which 53 are drug-based prophylaxis and 19 assessed vaccines. Herbal medicines are being assessed in 79 studies; convalescent plasma therapy in 56 studies; stem cell-based interventions in 42 studies; anesthesia-based interventions in 31 studies, machine-based interventions in 24 studies, mental health-based interventions in18 studies, rehabilitation-based interventions in 12 studies and miscellaneous interventions in 32 studies. China accounts for 35% of all ongoing clinical studies followed by USA 23%, France 7%, Spain 3.3%,Canada 2%, multi-country studies account only for 1.5% (13) and other countries together account for 28%.Amongst the 463 studies assessing drug-based treatment options, studies that are funded by federal and academic institutions are 79.6%, pharmaceutical company funded studies are 15.11% and no funding information is available in 5.10%. The definitive outcomes like mortality are being assessed as primary outcome in 22.8% of the studies only and need for ventilator in 6.2% of the studies. Rest of the studies has primary outcomes such as clinical recovery (15.9%), viral clearance(17.4%), time to recovery (10.1%), oxygen improvement (5.6%), ICU admission (1.9%), lab and imaging(6.4%), adverse effects (5.3%) and symptom reduction(1.5%),no outcome reported(6.2%) which account for 71% of the studies. Amongst the pharmaceutical company funded drug-based studies, only 20% of the studies had mortality as the primary outcome. Only 5.5% of the ongoing clinical trials are specifically designed to assess the most vulnerable population like elderly, patients with comorbidities and cancer. The most common intervention being tested against COVID-19 are antimalarial medications with 105 clinical studies. Hydroxychloroquine is the most common drug being tested with 83 ongoing studies.ConclusionMultiple intervention based clinical studies against SARS-CoV-2 are being performed throughout the world with a high concentration of clinical trials in the developed world. There is a high concern that most of the studies maybe repetitive; elderly and patients with comorbidities are being underrepresented; definite endpoints like mortality are being assessed in only one-fifth of the studies.

There are numerous ongoing studies assessing treatment options for preventing, treating, and managing complications of coronavirus disease‐2019 disease. The objective of this study was to do a systematic review and critical appraisal of the ongoing clinical trials with an aim to provide insight into the various interventions tested, clinical rationale, geographical distribution of the trials as well as the endpoints assessed in the studies. ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform, and PubMed were assessed till 11 May 2020. The search resulted in 3242 ongoing studies of which 829 studies were included. There are 134 different drug‐based interventions being assessed in 463 clinical trials as treatment options China accounts for 35% of all ongoing clinical studies followed by USA 23% and other countries together account for 42%. Amongst the 463 studies assessing drug‐based treatment options, studies that are funded by federal and academic institutions are 79.6%, pharmaceutical company‐funded studies are 15.11%, and no funding information is available in 5.10%. The definitive outcomes like mortality are being assessed as primary outcome in 22.8% of the studies only and need for ventilator in 6.2% of the studies. Amongst the pharmaceutical company‐funded drug‐based studies, only 20% of the studies had mortality as the primary outcome. Only 5.5% of the ongoing clinical trials are specifically designed to assess the most vulnerable population like elderly, patients with comorbidities and cancer. Multiple intervention‐based clinical studies against severe acute respiratory syndrome‐related coronavirus‐2 are being performed throughout the world with a high concentration of clinical trials in the developed world with concern that of elderly and patients with comorbidities are being underrepresented and definite endpoints like mortality are being assessed in only one‐fifth of the studies., Highlights There are numerous drug based interventions are being tested against COVID‐19.China accounts for the majority on the ongoing followed by USA.Definitive outcomes like all cause mortality are being assessed in only 22.8% of the studies.There is concern of under representation of patients from middle and low income countries, elderly and patients with medical comorbidities in COVID‐19 clinical trials.

Importance Treatment options for Severe acute respiratory syndrome-related coronavirus-2 (SARS-CoV-2) are limited with no clarity on the efficacy and safety profiles. Objective To assess if the effect estimate of any intervention improves the outcomes and safety profile. Data sources PubMed, Embase, Cochrane Central were searched from December 1, 2019 to May 11, 2020. Study selection Any prospective/retrospective clinical study on SARS-CoV-2 patients ≥18 years of age with report on therapeutic interventions. Data synthesis and extraction Data was screened and extracted by two independent investigators. Main outcomes and measures The primary outcome was all-cause in-hospital mortality. The secondary outcomes were rates of mechanical ventilation, viral clearance, adverse events, discharge, progression to severe disease, median time for clinical recovery and anti-viral clearance. Pooled rates and odds ratios (OR) were calculated. Results A total of 29 studies with 5207 participants were included in the analysis. The pooled all-cause in-hospital mortality rate was 12.8% (95%CI: 8.1%-17.4%) in intervention arm. There was no significant difference in mortality between both arms overall (OR: 1.36, 95% CI: 0.97-1.89). The mortality was significantly higher in the Hydroxychloroquine (HCQ) group compared to control: (1.86, 95% CI: 1.38 – 2.50). The need for mechanical ventilation in patients with mild-moderate disease was 13.5% vs 9.8% in intervention and control groups, with no significant difference (OR: 1.58, 95% CI: 0.60 – 4.15).The median duration for viral clearance in the intervention arm was 6.1 (IQR: 4.3 – 8.8) days and control arm was 9 (IQR: 4.5 – 14) days, with no significant difference between the groups (p = 0.37). There was no significant difference between pooled adverse event rates in intervention and control groups: 34% vs 29.5% (OR: 1.44, 95% CI: 0.70 – 2.94), respectively. However, incidence of adverse events was significantly higher in HCQ sub-group (OR: 3.88, 95% CI: 1.60 – 9.45, I2 = 0%). There was no significant difference in other secondary outcomes. Conclusion and relevance The use of hydroxychloroquine was associated with increased mortality and adverse event rates. No other therapeutic intervention including Lopinavir/Ritonavir, Remdesivir or Tocilizumab seem to alter the natural course of the disease. There is a further need for well-designed randomized clinical trials. Article summary line The use of hydroxychloroquine was associated with increased mortality and adverse event rates in Severe acute respiratory syndrome-related coronavirus-2 infection and other therapeutic interventions did not show any difference in outcomes

Background Hospitalization for low‐risk pulmonary embolism (PE) is common, expensive, and of questionable benefit. Objective The objective was to determine if low‐risk PE patients discharged from the emergency department (ED) on rivaroxaban require fewer hospital days compared to standard of care (SOC). Methods Multicenter, open‐label randomized trial in low‐risk PE defined by Hestia criteria. Adult subjects were randomized to early ED discharge on rivaroxaban or SOC. Primary outcome was total number of initial hospital hours, plus hours of hospitalization for bleeding or venous thromboembolism (VTE), 30 days after randomization. A 90‐day composite safety endpoint was defined as major bleeding, clinically relevant nonmajor bleeding, and mortality. Results Of 114 randomized subjects, 51 were early discharge and 63 were SOC. Of 112 (98.2%) receiving at least one dose of study drug, 99 (86.8%) completed the study. Initial hospital LOS was 4.8 hours versus 33.6 hours, with a mean difference of –28.8 hours (95% confidence interval [CI] = –42.55 to –15.12 hours) for early discharge versus SOC, respectively. At 90 days, mean total hospital days (for any reason) were less for early discharge than SOC, 19.2 hours versus 43.2 hours, with a mean difference of 26.4 hours (95% CI = –46.97 to –3.34 hours). At 90 days, there were no bleeding events, recurrent VTE, or deaths. The composite safety endpoint was similar in both groups, with a difference in proportions of 0.005 (95% CI = –0.18 to 0.19). Total costs were $1,496 for early discharge and $4,234 for SOC, with a median difference of $2,496 (95% CI = –$2,999 to –$2,151). Conclusions Low‐risk ED PE patients receiving early discharge on rivaroxaban have similar outcomes to SOC, but fewer total hospital days and lower costs over 30 days.

To review community health worker (CHW) interventions tailored for hypertension management and to determine if the emergency department (ED) population would benefit from such interventions. When working with patients who have one or more chronic diseases, CHW interventions have been very successful in improving health outcomes and are cost-effective. CHWs use a variety of techniques to address social determinants that patients may face that effect how they manage their chronic disease(s). Current CHW interventions in the ED have targeted the “super-user” population. CHW-based interventions help address social determinants of patients in a variety of settings, especially in the ED where the physicians have limited resources and time. There is limited information about how CHWs can improve community health outcomes outside of the ED “super-user” population. Future research needs to determine if creating a data-driven CHW intervention for the ED would be effective.

Study objective We explore reproductive-aged women's acceptance of contraception counseling in the emergency department (ED). Methods This study is phase 1 of an exploratory sequential mixed methods study. We purposively interviewed 31 participants with the following criteria: black, white, or Latina race/ethnicity; nonpregnant; aged 15 to 44 years; receiving nonemergency care; not using highly effective contraception; and did not intend to become pregnant. We conducted semistructured interviews with a piloted interview guide until reaching thematic saturation. We coded transcripts with an iteratively developed codebook, maintaining intercoder agreement greater than 80%. Qualitative acceptance of ED contraception counseling was grouped into 3 categories: acceptable, unacceptable, and equivocal. We conducted a thematic text analysis to assess themes expressing support and concern for ED contraception counseling. Qualitative findings were stratified by age, race, and frequency of ED use. Using components of grounded theory, we developed a conceptual model. Results Most participants (81%) accepted ED contraception counseling. Themes expressing support and concern for ED contraception counseling included opportunity to address women's unmet contraception needs, contraception is within the scope of ED practice, the ED is a convenient setting with competent providers, contraception is a sensitive topic, and the ED may be an inappropriate setting for some women. Latina participants had lower acceptance of ED contraception counseling. Dominant subthemes varied slightly by race, age, and frequency of ED use. Conclusion Diverse women had high acceptance of contraception counseling in the ED. Perspectives expressing both support and concern in regard to ED contraception counseling were explored in detail.

Studies of acute myocardial infarction, trauma, and stroke have resulted in improved outcomes through earlier diagnosis and application of therapy at the most proximal stage of hospital presentation. Most critical therapies for these diseases are frequently instituted prior to admission to an ICU. This systems-based approach to the sepsis patient has been lacking. To change this paradigm, a trial comparing early goal-directed therapy (EGDT) versus standard care was performed using specific criteria for the early identification of high-risk sepsis patients and a consensus-derived protocol to reverse the hemodynamic perturbations of hypovolemia, vasoregulation, myocardial suppression, and increased metabolic demands. One decade later, EGDT has been shown to modulate inflammation, decrease the progression of organ failure, improve microcirculatory function, and decrease health resource consumption and mortality. A standard operating procedure beginning with EGDT for severe sepsis and septic shock is a hospital-wide initiative.

We report a case of altered mental status secondary to acute Toxoplasma Gondii encephalitis. The patient had no medical or surgical history and presented with acute onset of lethargy with no clear precipitant. A physical exam revealed no focal neurological deficits and a subsequent medicalworkup revealed multiple intracranial lesions with a biopsy confirming the diagnosis of Toxoplasma Gondii encephalitis in the setting of newly diagnosed human immunodeficiency virus (HIV). A literature review revealed that this is a unique case of toxoplasmic encephalopathy in the United States in a previously undiagnosed HIV positive patient presenting to an emergency department. [West J Emerg Med. 2012;13(6):488-490]

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.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%, p0.05). After adjustment for potential confounders, predictive factors associated with bacteremic OHCA were lower initial arterial pH, higher lactate, WBC, BUN and creatinine.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.

Central venous catheterization is often necessary for the safe administration of medications that are caustic to peripheral veins, to place temporary transvenous pacemakers and to provide invasive hemodynamic monitoring in the critically ill. While a wide range of complications are known to occur with insertion of these catheters, there is a paucity of cases associated with cardiac arrest during the catheters placement. We describe an unusual case of sustained ventricular tachycardia and subsequent cardiac arrest that occurred during an ultrasound guided central venous catheter placement for a patient in septic shock. This case serves as a reminder of the rare, but potentially fatal complication of central venous access placement.

We present evidence, based particularly on studies of Peromyscus leucopus, that neonatal rodents in deep hypothermia (T b ≤ 7°C)—although apneic—steadily take up O2 across the lungs and distribute it via the circulatory system. We argue that the myocardium, respiratory rhythmogenic neurons, and possibly other vital tissues depend for their survival during deep hypothermia on this continuing O2 supply. In regards their steady O2 uptake and its significance, neonatal rodents resemble rodent hibernators during deep hypothermia. However, details differ strikingly. Neonates, having stopped breathing on entry to hypothermia, take up O2 via the mouth and nares by apneic mechanisms. Moreover, neonates lose sinoatrial (SA) pacing of ventricular contraction on entry to hypothermia and depend on quasi-rhythmic ventricular escape contractions to maintain cardiac activity. During deep hypothermia, physiologically limited mechanisms of respiratory and circulatory O2 transport combine to provide neonate tissues with a limited rate of O2 supply that is vitally important.

The use of antiemetics is a controversial topic in treatment of pediatric gastroenteritis. Although not recommended by the American Academy of Pediatrics, antiemetics are commonly prescribed by physicians. A review of the literature shows side effects of promethazine, prochlorperazine, and metoclopramide are common and potentially dangerous. Ondansetron has recently been studied as an adjunct to oral rehydration therapy in treatment of acute gastroenteritis with mild to moderate dehydration. Although studies are limited, early research suggests the medication is safe when used in a single dose and can be effective to prevent vomiting, the need for intravenous fluids, and hospital admission.