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Bacterial and viral causes of acute respiratory illness (ARI) are difficult to clinically distinguish, resulting in the inappropriate use of antibacterial therapy. The use of a host gene expression-based test that is able to discriminate bacterial from viral infection in less than 1 hour may improve care and antimicrobial stewardship.To validate the host response bacterial/viral (HR-B/V) test and assess its ability to accurately differentiate bacterial from viral infection among patients with ARI.This prospective multicenter diagnostic study enrolled 755 children and adults with febrile ARI of 7 or fewer days' duration from 10 US emergency departments. Participants were enrolled from October 3, 2014, to September 1, 2019, followed by additional enrollment of patients with COVID-19 from March 20 to December 3, 2020. Clinical adjudication of enrolled participants identified 616 individuals as having bacterial or viral infection. The primary analysis cohort included 334 participants with high-confidence reference adjudications (based on adjudicator concordance and the presence of an identified pathogen confirmed by microbiological testing). A secondary analysis of the entire cohort of 616 participants included cases with low-confidence reference adjudications (based on adjudicator discordance or the absence of an identified pathogen in microbiological testing). Thirty-three participants with COVID-19 were included post hoc.The HR-B/V test quantified the expression of 45 host messenger RNAs in approximately 45 minutes to derive a probability of bacterial infection.Performance characteristics for the HR-B/V test compared with clinical adjudication were reported as either bacterial or viral infection or categorized into 4 likelihood groups (viral very likely [probability score0.19], viral likely [probability score of 0.19-0.40], bacterial likely [probability score of 0.41-0.73], and bacterial very likely [probability score0.73]) and compared with procalcitonin measurement.Among 755 enrolled participants, the median age was 26 years (IQR, 16-52 years); 360 participants (47.7%) were female, and 395 (52.3%) were male. A total of 13 participants (1.7%) were American Indian, 13 (1.7%) were Asian, 368 (48.7%) were Black, 131 (17.4%) were Hispanic, 3 (0.4%) were Native Hawaiian or Pacific Islander, 297 (39.3%) were White, and 60 (7.9%) were of unspecified race and/or ethnicity. In the primary analysis involving 334 participants, the HR-B/V test had sensitivity of 89.8% (95% CI, 77.8%-96.2%), specificity of 82.1% (95% CI, 77.4%-86.6%), and a negative predictive value (NPV) of 97.9% (95% CI, 95.3%-99.1%) for bacterial infection. In comparison, the sensitivity of procalcitonin measurement was 28.6% (95% CI, 16.2%-40.9%; P .001), the specificity was 87.0% (95% CI, 82.7%-90.7%; P = .006), and the NPV was 87.6% (95% CI, 85.5%-89.5%; P .001). When stratified into likelihood groups, the HR-B/V test had an NPV of 98.9% (95% CI, 96.1%-100%) for bacterial infection in the viral very likely group and a positive predictive value of 63.4% (95% CI, 47.2%-77.9%) for bacterial infection in the bacterial very likely group. The HR-B/V test correctly identified 30 of 33 participants (90.9%) with acute COVID-19 as having a viral infection.In this study, the HR-B/V test accurately discriminated bacterial from viral infection among patients with febrile ARI and was superior to procalcitonin measurement. The findings suggest that an accurate point-of-need host response test with high NPV may offer an opportunity to improve antibiotic stewardship and patient outcomes.

This review describes strategies for the emergency department setting that help facilitate monitoring of patients with acute neurological injuries. Multiple invasive and non-invasive modalities are available for the emergency physician to utilize as adjuncts to the physical examination and imaging of patients with neurological injuries. The value of these modalities lies in detection of subtle changes that signal early neurological decompensation. This article focuses on the most common devices along with their adoption and implementation into the practice of emergency medicine. The field of non-invasive neuromonitoring techniques is rapidly flourishing with an emphasis on portability and reproducibility, enhancing adoption into the practice of emergency medicine. Devices such as the extra-ventricular drain have proven to be of both diagnostic and therapeutic benefit, allowing for both global ICP monitoring and CSF sampling. However, as emergency physicians become more facile in the use of ultrasound, procedures such as optic nerve sheath diameter evaluation and transcranial Doppler assessments add to the availability of bedside neuromonitoring. It is important to note that many of these devices still require further validation. The field of neuromonitoring encompasses invasive and non-invasive techniques. While useful, they require further validation to establish standardized protocols that would allow for consistent and reliable implementation in the emergency department.

To explore the impact of digoxin on hemodynamic parameters in patients with sepsis and tachycardia admitted to the intensive care unit.Retrospective review of adult patients admitted to the medical and mixed ICU at Mayo Clinic Rochester, Minnesota from March 2008 to February 2018, initiated on digoxin within 24 h of ICU stay. Hemodynamic parameters were reviewed before digoxin administration and at 6, 12 and 24 h after. Adverse events including new onset conduction abnormalities or arrhythmias during the first 48 h after digoxin administration were reviewed by a critical care cardiologist.Study included 180 patients. We observed significant decrease in heart rate from 124 (115-138) beats/min 1 h before digoxin to 101 (87-117) 6 h after digoxin and 94 (84-112) 12 h after (p .01). Median systolic blood pressure increased from 100 (91-112) mm Hg 1 h before to 110 (100-122) (p .01) and 111 (103-124) at 6 and 12 h respectively after digoxin.Early digoxin administration in patients with sepsis and tachycardia is uncommon but associated with improvements of hemodynamic parameters. These preliminary results will help formulate future hypotheses for focused trials on utility, efficacy and safety of digoxin in sepsis.

Introduction: Rotating shift patterns and night shifts are associated with fatigue and sleep deprivation, which in turn contribute to burnout. The aim of this quality improvement initiative at Mayo Clinic Rochester critical care fellowship programs was to implement a new critical care fellow shift schedule in the medical intensive care unit while evaluating the impact on self-reported burnout scores. Materials and Methods: Focus groups of fellows weighed pros and cons of the existing schedule and selected a revision of the schedule in which night shifts were grouped into blocks with limited frequency and incorporated a recovery period. Baseline self-reported burnout amongst critical care fellows was assessed using an abbreviated Maslach burnout inventory (MBI) screening questionnaire and re-evaluated at the end of the implementation period. Results: At baseline, 33 of 45 (73%) fellows responded to a survey with the abbreviated Maslach Burnout Index questionnaire. Median (IQR) scores for each of the domains were 10 (6-12) emotional exhaustion, 3 (1-9) depersonalization, and 15 (13-17) personal accomplishment. For the post-intervention survey, 17 out of 24 (71%) responded. The median (IQR) score for critical care internal medicine and pulmonary and critical care fellows was 7 (4-11), P=.06 and 9 (7-11), P=0.5 for emotional exhaustion; 3 (0-6), P=.07 and 5 (0-11), P=1.0 for depersonalization score; and 16 (11-17), P=.31 and 15 (12-17), P=.75 for personal accomplishment score. Discussion: Reducing the number of day-night rotations, incorporating a scheduled recovery period, and limiting the number of recurrent consecutive nights resulted in a trend towards improvement of self-reported burnout amongst critical care fellows.

Author(s): Pflaum-Carlson, Jacqueline; Gardner-Gray, Jayna; Jayaprakash, Namita; Hurst, Gina; Coba, Victor; Kinni, Harish; Rivers, Emanuel

Background The purpose of this study was to determine the ideal timing for providers to perform point-of-care ultrasound (POCUS) with the least increase in workload. Methods We conducted a pilot crossover study to compare 2 POCUS-assisted evaluation protocols for acutely ill patients: sequential (physical examination followed by POCUS) vs parallel (POCUS at the time of physical examination). Participants were randomly assigned to 2 groups according to which POCUS-assisted protocol (sequential vs parallel) was used during simulated scenarios. Subsequently, the groups were crossed over to complete assessment by using the other POCUS-assisted protocol in the same patient scenarios. Providers’ workloads, measured with the National Aeronautics and Space Administration Task Load Index (NASA-TLX) and time to complete patient evaluation, were compared between the 2 protocols. Results Seven providers completed 14 assessments (7 sequential and 7 parallel). The median (IQR) total NASA-TLX score was 30 (30–50) in the sequential and 55 (50–65) in the parallel protocol (P = .03), which suggests a significantly lower workload in the sequential protocol. When individual components of the NASA-TLX score were evaluated, mental demand and frustration level were significantly lower in the sequential than in the parallel protocol (40 [IQR, 30–60] vs 50 [IQR, 40–70]; P = .03 and 25 [IQR, 20–35] vs 60 [IQR, 45–85]; P = .02, respectively). The time needed to complete the assessment was similar between the sequential and parallel protocols (8.7 [IQR, 6–9] minutes vs 10.1 [IQR, 7–11] minutes, respectively; P = .30). Conclusions A sequential POCUS-assisted protocol posed less workload to POCUS operators than the parallel protocol.

This review summarizes the latest science on hypertensive encephalopathy and posterior reversible encephalopathy syndrome (PRES). We review the epidemiology and pathophysiology of these overlapping syndromes and discuss best practices for diagnosis and management. Diagnosis of hypertensive encephalopathy largely relies on exclusion of other neurological emergencies. We review the extensive causes of PRES and its imaging characteristics. Management strategies have not changed substantially in the past decade, though newer calcium channel blockers simplify the approach to blood pressure reduction. While this alone may be sufficient for treatment of hypertensive encephalopathy in most cases, management of PRES also depends on modification of other precipitating factors. Hypertensive encephalopathy and PRES are overlapping disorders for which intensive blood pressure lowering is critical. Further research is indicated to both in diagnosis and additional management strategies for these critical conditions.

This chapter provides a summary of the landmark study known as the EGDT Trial. Among patients with severe sepsis or septic shock, does early goal-directed therapy (EGDT) reduce the incidence of multi-organ dysfunction and mortality and the use of health care resources? Starting with that question, the chapter describes the basics of the study, including funding, study location, who was studied, how many patients, study design, study intervention, follow-up, endpoints, results, and criticism and limitations. The chapter briefly reviews other relevant studies and information, discusses implications, and concludes with a relevant clinical case. Publication of the EGDT trial shifted the paradigm of sepsis diagnosis and care from the ICU to the point of earliest presentation. Sepsis is now recognized for its occult nature, which may be unmasked by vigilance and laboratory assessment with lactate measurement.

Introduction Current AHA/ACC guidelines on the management of ST-elevation myocardial infarction (STEMI) suggest that an ECG is indicated within 10 minutes of arrival for patients arriving to the Emergency Department (ED) with symptoms concerning for STEMI. In response, there has been a creep towards performing ECGs more frequently in triage. The objectives of this study were to quantify the number of triage ECGs performed at our institution, assess the proportion of ECGs performed within current hospital guidelines, and evaluate the rate of STEMI detection in triage ECGs. Methods A retrospective chart review of all emergency department patients presenting over a period of 8 days who had a triage ECG performed. Cases of bradycardia or tachycardia were excluded. Data collection included patient demographics, presenting complaint, cardiac risk factors, troponin values, and final diagnosis. Summary statistics are reported in a descriptive manner. Results During the study period, 538 patients had a triage ECG for possible STEMI with no STEMI identified and 16 NSTEMI diagnoses (confirmed as positive troponins following ED assessment). Sixty-three (11.7%) patients did not meet internal criteria for a triage ECG. A NSTEMI ED diagnosis was identified in 3% of patients who met internal triage ECG criteria and 1.6% who did not meet criteria (p = 0.29). A cost analysis was performed using an average of 50 STEMI cases diagnosed in our ED per given year. Current institutional ECG billing rates for ECGs performed and interpreted is $125 per ECG, providing an estimated triage ECG charge to detect one STEMI at $54,295. Discussion This retrospective study of 538 triage ECG's performed over an 8 day period identified no STEMIs and 16 NSTEMIs. A very large number of ECGs were done at triage overall and included patients who do not meet our own hospital criteria. Given the extremely low yield and high associated charges, current guidelines for triage ECG for identifying a possible STEMI should be reviewed.

Purpose The aim of this study was to explore the association of an elevated modified shock index (MSI) in sepsis and myocardial dysfunction. Methods This single center exploratory retrospective cohort study was conducted at Mayo Clinic from 2011 to 2014. It includes adults admitted to the medical intensive care unit with severe sepsis or septic shock. The time MSI > 1.3, area under the curve, in the first 6 h was assessed using logistic regression for primary outcomes of myocardial dysfunction and depression and secondary outcomes including mortality and SOFA score. Results Overall 578 individuals met inclusion criteria, 169 (29%) developed myocardial dysfunction and 23 (4%) myocardial depression. Adjusted for age, gender, Charlson score, and baseline APACHE 3 score, area MSI > 1.3 was associated with increased odds of myocardial dysfunction (OR 1.10, 95% CI 1.00–1.21; p = 0.058) and depression (OR 1.28, 95% CI 1.07–1.53; p = 0.007). Associations were also seen with ICU mortality (OR 1.17, 95% CI 1.04–1.32; p = 0.011), hospital mortality (OR 1.13, 95% CI 1.02–1.25; p = 0.025) and SOFA score. Conclusion Elevated modified shock index during early sepsis is associated with the development of myocardial dysfunction and depression, SOFA score and mortality.

Prior to 2001 there was no standard for early management of severe sepsis and septic shock in the emergency department. In the presence of standard or usual care, the prevailing mortality was over 40-50 %. In response, a systems-based approach, similar to that in acute myocardial infarction, stroke and trauma, called early goal-directed therapy was compared to standard care and this clinical trial resulted in a significant mortality reduction. Since the publication of that trial, similar outcome benefits have been reported in over 70 observational and randomized controlled studies comprising over 70,000 patients. As a result, early goal-directed therapy was largely incorporated into the first 6 hours of sepsis management (resuscitation bundle) adopted by the Surviving Sepsis Campaign and disseminated internationally as the standard of care for early sepsis management. Recently a trio of trials (ProCESS, ARISE, and ProMISe), while reporting an all-time low sepsis mortality, question the continued need for all of the elements of early goal-directed therapy or the need for protocolized care for patients with severe and septic shock. A review of the early hemodynamic pathogenesis, historical development, and definition of early goal-directed therapy, comparing trial conduction methodology and the changing landscape of sepsis mortality, are essential for an appropriate interpretation of these trials and their conclusions.

Background Hyperglycemia is a frequent and important metabolic derangement that accompanies severe sepsis and septic shock. Matrix-Metalloproteinase 9 (MMP-9) has been shown to be elevated in acute stress hyperglycemia, chronic hyperglycemia, and in patient with sepsis. The objective of this study was to examine the clinical and pathogenic link between MMP-9 and blood glucose (BG) levels in patients with early severe sepsis and septic shock. Methods We prospectively examined 230 patients with severe sepsis and septic shock immediately upon hospital presentation and before any treatment including insulin administration. Clinical and laboratory data were obtained along with blood samples for the purpose of this study. Univariate tests for mean and median distribution using Spearman correlation and analysis of variance (ANOVA) were performed. A p value ≤ 0.05 was considered statistically significant. Results Patients were grouped based on their presenting BG level (mg/dL): BG 201 (n = 84). Rising MMP-9 levels were significantly associated with rising BG levels (p = 0.043). A corresponding increase in the prevalence of diabetes for each glucose grouping from 6.3 to 54.1 % (p = 0.0001) was also found. As MMP-9 levels increased a significantly (p

PUBLISHED, We report herein a case of a synchronous presentation of an adenocarcinoma of esophagago-gastric junction type II and an ampullary tumor that was treated by combined Whipple's pancreaticoduodenectomy, total gastrectomy and esophagectomy. The magnitude of this operation was safely achieved with meticulous surgical techniques and perioperative care without any major short or long term complications. Patient returned to a good quality of life at six-month follow up with no further gastrointestinal symptoms or evidence of disease recurrence.

Emergency department (ED) crowding is a multifactorial problem, resulting in increased ED waiting times, decreased patient satisfaction and deleterious domino effects on the entire hospital. Although difficult to define and once limited to anecdotal evidence, crowding is receiving more attention as attempts are made to quantify the problem objectively. It is a worldwide phenomenon with regional influences, as exemplified when analyzing the problem in Europe compared to that of the United States. In both regions, an aging population, limited hospital resources, staff shortages and delayed ancillary services are key contributors; however, because the structure of healthcare differs from country to country, varying influences affect the issue of crowding. The approach to healthcare delivery as a right of all people, as opposed to a free market commodity, depends on governmental organization and appropriation of funds. Thus, public funding directly influences potential crowding factors, such as number of hospital beds, community care facilities, and staffing. Ultimately ED crowding is a universal problem with distinctly regional root causes; thus, any approach to address the problem must be tailored to regional influences.