Emergency Medicine Journal最新文献

Background: Healthcare professionals commonly believe that saying the word 'quiet' can jinx a shift and lead to increased workload or particularly unwell patients. A previous small integrative review found no effect but had some methodological limitations. This narrative systematic review aimed to synthesise the evidence from studies on the impact of saying 'quiet' on clinical workload measures.

Methods: A comprehensive search was carried out across multiple electronic databases for any studies performed in a human healthcare setting investigating the impact of the use of 'the Q word' (or variations thereof) on workload. Outcomes of interest were objective measures of workload, such as patient volume, admissions or tasks.

Results: Eight randomised controlled trials (RCTs) were included. Settings included EDs, specialised hospital units and clinical support services. Outcome measures varied between studies, so meta-analysis was not possible. Seven RCTs found no significant differences in objective workload measures between intervention groups where 'q****" was uttered and control groups where it was not. One RCT in orthopaedics reported an increase in overnight admissions when 'q****" was said but had significant methodological limitations. Two RCTs noted potential impacts on subjective perceptions of workload among believers. Limitations of included studies include small sample sizes, lack of blinding and inadequate control for confounders.

Discussion: The available evidence does not support the assertion that saying the word 'quiet' affects clinical workload metrics. Healthcare professionals should be encouraged to prioritise communication based on evidence rather than myth, and there is insufficient evidence that saying 'quiet' while on shift will bring negative consequences for themselves or colleagues.

Background: Artificial intelligence (AI) tools could assist emergency doctors interpreting chest X-rays to inform urgent care. However, the impact of AI assistance on clinical decision-making, a precursor to enhanced care and patient outcomes, remains understudied. This study evaluates the effect of AI assistance on clinical decisions of emergency doctors interpreting chest X-rays.

Method: Junior and senior residents, emergency registrars and consultants working in Australian emergency departments were eligible. Doctors completed 18 clinical vignettes involving chest X-ray interpretation, representative of typical patient presentations. Vignettes were randomly selected from a bank of 49 based on the emergency medicine curriculum and contained a chest X-ray, presenting complaint, relevant symptoms and observations. Of the 18 vignettes, each doctor was randomly assigned to have half assisted by a commercial AI tool capable of detecting 124 different chest X-ray findings. Four vignettes contained X-rays known to produce incorrect AI findings. Primary outcomes were correct diagnosis and patient management. X-ray interpretation time, confidence of diagnosis, perceptions about the AI tool and the differential impact of AI assistance by seniority were also examined.

Results: 200 doctors participated. AI assistance increased correct diagnosis by 5.9% (95% CI 2.7 to 9.2%) compared with unassisted vignettes, with the largest increase among senior residents (11.8%; 95% CI 5.2% to 18.3%). Patient management increased by 3.2% (95% CI 0.1% to 6.4%). Confidence in diagnosis increased by 5% (95% CI 3.4% to 6.6%; p<0.001) and interpretation time increased by 4.9 s (p=0.08). Incorrect AI findings decreased correct diagnosis by 1% for false-positive (p=0.9) and 9% for false-negative findings (p=0.1). Participants found the AI tool helpful for interpreting chest X-rays, highlighting missed findings, but were neutral on its accuracy.

Conclusion: Improvements in diagnosis and patient management without meaningful increases in interpretation time suggest AI assistance could benefit clinical decisions involving chest X-ray interpretation. Further studies are required to ascertain if such improvements translate to improved patient care.

Background: This study aimed to evaluate the diagnostic accuracy of the STANDING algorithm for central vertigo across different emergency departments (EDs). Secondary outcomes compared STANDING with usual care in terms of diagnostic accuracy, resource utilisation and length of stay (LOS).

Methods: We prospectively enrolled adult patients presenting with vertigo at one 'hub' and three 'spoke' EDs in Tuscany. Patients were assessed using either STANDING or 'usual care', depending on the availability of a trained emergency physician. Imaging tests, consultations and dispositions were made independently of the study. The final diagnosis of central vertigo was determined by an expert panel, based on clinical data, along with a 30-day follow-up.

Results: A total of 456 patients were included, with 242 (53%) assessed by STANDING. There were no statistically significant differences in age, gender or cardiovascular risk factors between the STANDING and usual care groups. The prevalence of central vertigo was 8.6%, with ischaemic stroke (4.2%) as the leading cause, with no differences between groups. The STANDING algorithm had a sensitivity of 88.2%, specificity of 91.6%, positive predictive value of 44.1%, and negative predictive value of 99%. Usual care showed lower specificity and positive predictive value (36.5% and 14.7%, respectively, p<0.05). Additionally, the STANDING group had both fewer non-contrast head CT (NCCT) requests (48.3% vs 66.8%) and a shorter LOS (median 271 vs 339 min) (p<0.05).

Conclusions: The STANDING algorithm demonstrated high diagnostic accuracy and a very high negative predictive value for central vertigo across EDs and appears to be associated with improved specificity, reduced use of NCCT and shorter LOS compared with 'usual care'.

Background: Cauda equina syndrome (CES) is a neurosurgical emergency, and suspected cases require urgent magnetic resonance imaging (MRI) scanning of the lumbosacral spine. This pilot study explores whether serum levels of neuron-specific enolase (NSE) can predict the degree of nerve compression seen on MRI scanning.

Methods: This was a prospective, diagnostic cohort pilot study of adult patients presenting to the emergency department (ED) in York between February 2024 and July 2024 with symptoms suggestive of CES in the opinion of the treating clinician (eg, back pain, sciatica, perianal paraesthesia, bladder or bowel dysfunction, sexual dysfunction). Patients either self-presented to the ED or had been referred by local primary care doctors or physiotherapists. All patients underwent MRI scanning (or fine-slice computed tomography scan if MRI contraindicated) of the lumbosacral spine and measurement of serum NSE. Imaging was classified as positive if the radiological report described cauda equina compression, nerve root compression or impingement and negative if none of these were described. We compared the serum levels of NSE in patients with positive imaging with those in patients with negative scans.

Results: 98 patients were included. 97 patients had urgent MRI of the lumbosacral spine and 1 patient had fine-slice CT. 52 patients had imaging classified as positive, and 46 patients had scans classified as negative. Patients with positive scans had a mean serum NSE level of 7.16 µg/L (SD 2.54) and those with negative imaging had a mean serum NSE level of 6.82 µg/L (SD 2.91). NSE did not demonstrate any ability to discriminate between patients with positive and negative imaging with an area under the receiver operating characteristic curve of 0.542.

Conclusion: The study shows that serum NSE is not a useful biomarker in the management of patients presenting to an ED with symptoms of CES.

Interstitial lung diseases (ILDs) represent a heterogenous group of disorders affecting the lung parenchyma. Patients with ILD are frequently admitted to hospital secondary to respiratory decompensation which can result in acute respiratory failure (ARF). High flow nasal oxygen (HFNO) has increasingly been used in other causes of ARF following the recommendations of the European Respiratory Society. A review was undertaken to evaluate the question: in adults with ILD and ARF without hypercapnia, is HFNO better than conventional oxygen therapy (COT) at reducing symptoms and all-cause mortality outcomes? Medline via PubMed, EMBASE via OVID and the Cochrane Library were searched between 1975 and 20 June 2025. 2362 papers were identified with 17 undergoing full-text review. Two systematic reviews met inclusion criteria and directly answered the three-part question. Study information, participant demographics, key results and study weaknesses were established for each paper. Neither systematic review found HFNO improved mortality outcomes, when compared with COT, to a statistically significant threshold for patients with ILD with ARF. Reported median survival with HFNO use was 21.0 days (95% CI 13.0 to 61.0) and COT use 133 days (95% CI 26.0 to 374.0, p=0.1323). Inpatient mortality with HFNO use ranged between 26.5% and 59.1%. Symptomatically, one review reported a numerical improvement in the Quality of Death and Dying Score for the HFNO group versus the COT group (4.58 ± 0.67 vs 4.09 ± 0.96). There is limited evidence to suggest that HFNO improves mortality outcomes for patients with ILD in ARF. However, it may be beneficial for symptom management. Mortality remains high despite HFNO use, thus careful discussions with patients and their relatives are required should a trial be used in the setting of ARF.

Background: Civilians in South Africa experience a high incidence of crush injury, or traumatic rhabdomyolysis. Community assault (CA) is a common mechanism of crush injury in South Africa, where victims are assaulted by multiple persons using a variety of objects. A crush injury places patients at risk of renal dysfunction. The study objective is to evaluate the association between CA and adverse renal outcomes (AROs) among patients with crush injury.

Methods: In this secondary analysis of abstracted medical records, we examined clinical data from adult crush patients who presented to one of six trauma centres in the Western Cape Province of South Africa from September 2021 to December 2023. ARO was defined as potassium >6 mEq/L, creatinine >4 mg/dL, initiation of dialysis or death due to renal failure. We used multivariable logistic regression to evaluate the association between CA and ARO.

Results: Of 976 crush patients (mean age 32 years, 89% male), half were victims of CA (n=464, 48%). 4% of the overall cohort had ARO, but less than 1% (n=7) received dialysis. More patients with CA developed ARO (n=27, 6%) compared with patients without CA (n=15, 3%) (unadjusted p=0.03). In-hospital all-cause mortality was not significantly different between CA and non-CA (8% vs 7%, p=0.58). After adjusting for age, sex, systolic blood pressure and injury severity, patients with CA had 2.42 times the odds of ARO than patients without CA (95% CI 1.20 to 4.85, p=0.01).

Conclusion: This study suggests that CA is an independent risk factor for AROs among patients with crush injury in South Africa. Victims of CA with renal dysfunction require aggressive resuscitation and may warrant early transfer to tertiary care centres.