Search

In this article, we describe a novel case of SARS-CoV-2-associated-hemophagocytic lymphohistiocytosis (HLH) complicated by posterior reversible encephalopathy syndrome (PRES). Initially diagnosed with multisystem inflammatory response in children (MIS-C), the patient received a large corticosteroid dose days before the onset of neurological symptoms. After developing PRES, the patient was treated with antihypertensives, anti-epileptics, dexamethasone, and anakinra, leading to neurologic normalization. We propose that given the challenging diagnostic picture of PRES developing in patients with HLH or MIS-C, institutionalized standards for blood pressure management during corticosteroid induction may significantly improve outcomes in patients being treated for hyperinflammatory syndromes who develop neurological symptoms.

Background Coronavirus disease 2019 (COVID‐19), the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), has extracted devastating tolls. Despite its pervasiveness, robust information on disease characteristics in the emergency department (ED) and how that information predicts clinical course remain limited. Methods We conducted a retrospective cohort study of the first ED visit from SARS‐CoV‐2‐positive patients in our health system, from February 21, 2020 to April 5, 2020. We reviewed each patient's ED visit(s) and included the first visit with symptoms consistent with COVID‐19. We collected demographic, clinical, and treatment variables from electronic health records and structured manual chart review. We used multivariable logistic regression to examine the association between patient characteristics and 2 primary outcomes: a critical outcome and hospitalization from index visit. Our critical outcome was defined as death or advanced respiratory support (high flow nasal cannula or greater) within 21 days. Results Of the first 1030 encounters, 801 met our inclusion criteria: 15% were over age 75 years, 47% were female, and 24% were non‐Hispanic white. We found 161 (20%) had a critical outcome and 393 (49%) were hospitalized. Independent predictors of a critical outcome included a history of hypertension, abnormal chest x‐ray, elevated neutrophil to lymphocyte ratio, elevated blood urea nitrogen (BUN), measured fever, and abnormal respiratory vital signs (respiratory rate, oxygen saturation). Independent predictors of hospitalization included abnormal pulmonary auscultation, elevated BUN, measured fever, and abnormal respiratory vital signs. Conclusions In this large, diverse study of ED patients with COVID‐19, we have identified numerous clinical characteristics that have independent associations with critical illness and hospitalization.

Study Objective: COVID-19 is commonly seen in the emergency department (ED). However, the association between key clinical variables and a patient’s downstream clinical course is incompletely understood. We sought to fill this knowledge gap in order to inform emergency management of the COVID-19 patient. Methods: We performed a retrospective cohort study of adults presenting to 21 U.S. community EDs with symptomatic COVID-19 from 2/21/2020 - 4/5/2020 with an in-system SARS-CoV-2 positive laboratory test 21 days before or after the index visit. Demographic, clinical, radiographic and laboratory variables were collected from electronic health records using a combination of manual chart review and electronic data extraction. We used multivariate logistic regression to examine the association between patient characteristics and two primary outcomes: (1) hospitalization from the index visit;and (2) critical illness, defined as either death or a requirement for respiratory support of high flow nasal cannula, non-rebreather mask, non-invasive ventilation or mechanical ventilation within 21 days. Results: Among 801 study-eligible patients, 28% were ≥65 years of age, 47% were female and 24% were non-Hispanic white. 393 patients (49%) were hospitalized and 161 (20%) had critical illness. Adjusted statistically significant predictors (p

Background Sex, race, and insurance status are associated with treatment and outcomes in several cardiovascular diseases. These disparities, however, have not been well-studied in out-of-hospital cardiac arrest (OHCA). Objective Our objective was to evaluate the association of patient sex, race, and insurance status with hospital treatments and outcomes following OHCA. Methods We studied adult patients in the 2011–2015 California Office of Statewide Health Planning and Development (OSHPD) Patient Discharge Database with a “present on admission” diagnosis of cardiac arrest (ICD-9-CM 427.5). Insurance status was classified as private, Medicare, and Medi-Cal/government/self-pay. Our primary outcome was good neurologic recovery at hospital discharge, which was determined by discharge disposition. Secondary outcomes were survival to hospital discharge, treatment at a 24/7 percutaneous coronary intervention (PCI) center, “do not resuscitate” orders within 24 h of admission, and cardiac catheterization during hospitalization. Data were analyzed with hierarchical multiple logistic regression models. Results We studied 38,163 patients in the OSHPD database. Female sex, non-white race, and Medicare insurance status were independently associated with worse neurologic recovery [OR 0.94 (0.89–0.98), 0.93 (0.88–0.98), and 0.85 (0.79–0.91), respectively], lower rates of treatment at a 24/7 PCI center [OR 0.89 (0.85–0.93), 0.88 (0.85–0.93), and 0.87 (0.82–0.94), respectively], and lower rates of cardiac catheterization [OR 0.61 (0.57–0.65), 0.90 (0.84–0.97), and 0.44 (0.40–0.48), respectively]. Female sex, white race, and Medicare insurance were associated with DNR orders within 24 h of admission [OR 1.16 (1.10–1.23), 1.14 (1.07–1.21), and 1.25 (1.15–1.36), respectively]. Conclusions Sex, race, and insurance status were independently associated with post-arrest care interventions, patient outcomes and treatment at a 24/7 PCI center. More studies are needed to fully understand the causes and implications of these disparities.

Introduction: Over 300,000 patients in the United States sustain low-trauma fragility hip fracturesannually. Multidisciplinary geriatric fracture programs (GFP) including early, multimodal painmanagement reduce morbidity and mortality. Our overall goal was to determine the effects of a GFPon the emergency department (ED) pain management of geriatric fragility hip fractures. Methods: We performed a retrospective study including patients age ≥65 years with fragility hipfractures two years before and two years after the implementation of the GFP. Outcomes were timeto (any) first analgesic, use of acetaminophen and fascia iliaca compartment block (FICB) in the ED,and amount of opioid medication administered in the first 24 hours. We used permutation tests toevaluate differences in ED pain management following GFP implementation. Results: We studied 131 patients in the pre-GFP period and 177 patients in the post-GFP period.In the post-GFP period, more patients received FICB (6% vs. 60%; difference 54%, 95% confidenceinterval [CI] 45-63%; p

Dry eye disorders, including Sjogren's syndrome, constitute a common problem in the aging population, with limited effective therapeutic options available. The cAMP-activated Cl(-) channel cystic fibrosis transmembrane conductance regulator (CFTR) is a major prosecretory channel at the ocular surface. We investigated whether compounds that target CFTR can correct the abnormal tear film in dry eye. Small-molecule activators of human wild-type CFTR identified by high-throughput screening were evaluated in cell culture and in vivo assays, to select compounds that stimulate Cl(-)-driven fluid secretion across the ocular surface in mice. An aminophenyl-1,3,5-triazine, CFTRact-K089, fully activated CFTR in cell cultures with EC50 ∼250 nM and produced an ∼8.5 mV hyperpolarization in ocular surface potential difference. When delivered topically, CFTRact-K089 doubled basal tear volume for 4 h and had no effect in CF mice. CFTRact-K089 showed sustained tear film bioavailability without detectable systemic absorption. In a mouse model of aqueous-deficient dry eye produced by lacrimal ablation, topical administration of 0.1 nmol CFTRact-K089 3 times daily restored tear volume to basal levels, preventing corneal epithelial disruption when initiated at the time of surgery and reversing it when started after development of dry eye. Our results support the potential utility of CFTR-targeted activators as a novel prosecretory treatment for dry eye.-Flores, A. M., Casey, S. D., Felix, C. M., Phuan, P. W., Verkman, A. S., Levin, M. H. Small-molecule CFTR activators increase tear secretion and prevent experimental dry eye disease.

In the emergency setting, the diagnosis of benign causes of acute abdominal pain can prevent unnecessary medical interventions. To illustrate this point, we report the case of a 28-year-old man who presented to the emer- gency department with symptoms suggestive of acute diverticulitis. Abdominal computed tomography (CT) established, instead, a diagnosis of primary epiploic appendagitis (PEA), which was managed expectantly. The patient’s symptoms resolved within one week of hospital discharge and he remained free of pain at a five-month phone follow-up. Increased awareness of PEA and its self-limited course can help the emergency physician avoid unnecessary imaging studies and expectantly manage this cause of acute abdominal pain.