European Journal of Emergency Medicine最新文献

Background and importance: Clavicle fractures account for about 3% of all fractures in adults, and have reportedly good outcomes with conservative treatment for lateral and mid-shaft clavicle fractures. Whether the use of a simple two-point sling or a triangular bandage should be the optimal first choice procedure is unknown.

Objectives: The objective of this study was to compare patient satisfaction after 1 week in patients with lateral or mid-shaft clavicle fractures treated with a two-point sling vs. a triangular bandage.

Design, setting, and participants: In this single center, randomized controlled trial, patients with acute, isolated and conservatively treated clavicle fractures were included. The primary endpoint was patient satisfaction at 1 week, measured with the Dutch version of the Quebec User Evaluation of Satisfaction with Assistive Technology (D-QUEST) questionnaire. Secondary outcomes were pain and functional recovery at different time points, measured with the visual analogue scale and Disabilities of the Arm, Shoulder, and Hand scores, respectively.

Intervention: Patients were randomized for immobilization with a triangular bandage or a two-point sling.

Outcomes measure and analysis: Differences in numerical variables were calculated using the unpaired t -test or Mann-Whitney U test. Categorical variables were analyzed using the Chi-Square test. Absolute effect size and 95% confidence interval (CI) were calculated, and a minimal clinically important difference of 0.25 was defined.

Results: Between August 2020 and February 2023, 110 patients were included in this study. After excluding patients who underwent surgery or were lost to follow-up, 68 patients were analyzed. Statistically and clinically significant differences were found in patient satisfaction scores at week 1 after trauma, in favor of the two-point sling (D-QUEST scores of 2.48 (±0.48) vs. 3.20 (±0.45), absolute mean difference 0.72 (CI, 0.49-0.95). There was no significant difference in pain and disability related secondary outcomes.

Conclusions: This study identified a significant difference in patient satisfaction favoring a two-point sling compared to a triangular bandage 7 days posttrauma.

Background and importance: Vaso-occlusive crisis is the main reason for emergency department (ED) visits for patients with sickle cell disease. Therapeutic management involves multimodal analgesia, which often comprises the administration of morphine. Recently, the use of virtual reality (VR) has garnered growing interest as a nonpharmacological approach for pain modulation.

Objective: The objective of this study was to assess the impact of integrating VR on the reduction of the total dose of morphine administered during vaso-occlusive crisis.

Settings and participants: This was a prospective before-and-after study conducted in a French adult ED on patients with sickle cell disease and acute pain from vaso-occlusive crisis.

Intervention or exposure: During the first period, patients were managed according to the standard protocol, with no use of VR. During the second period, patients were able to benefit from VR sessions in addition to the usual care.

Outcome measures and analysis: The primary outcome was the total dose of morphine administered in the ED. Secondary objectives were to evaluate the feasibility, tolerance, acceptability, and effectiveness of VR in pain management, measured using a numeric rating scale.

Main results: A total of 97 patients were included in the study, 50 during the noninterventional phase and 47 during the interventional phase. The median morphine dose was 30.7 mg [interquartile range (IQR), 19.7-45.7] in the VR group and 37.7 mg (IQR, 24.7-53.3) in the control group. The median difference between the two groups was -7 mg [95% confidence interval (CI), (-18.6 to 4.6)]. In the VR group, 18.2% of patients (8 out of 44 responders) reported side effects, which included primarily dizziness (50%), followed by nausea (25%) and headaches (25%). Additionally, 83.3% (35 out of 42 responders) of patients expressed the desire to use this method again.

Conclusion: In this prospective study, the use of VR did not reduce the total morphine dose administered in the ED for patients with acute pain and vaso-occlusive crisis. However, the use of VR appeared to be effectively integrated into multimodal pain management, with a high level of patient satisfaction.

Background and importance: Crowded emergency departments (EDs) and long waiting times may lead to delayed care for acute conditions and increased mortality in patients leaving without being seen by a physician (LWBS).

Objectives: The aim of this study was to characterize patients LWBS from the ED at a Swedish university hospital and report their mortality.

Design, setting, and participants: A cohort study was conducted. Data from electronic medical records of patients LWBS (exposure) were compared with those who stayed through completion of treatment. Data were gathered from 151 228 patients making 363 308 visits to the Uppsala University Hospital ED from 1 January 2010 to 30 June 2017.

Outcome measures and analysis: Short- and long-term mortality of patients LWBS were studied using Cox regression analysis. Sex, age, triage level, arrival mode, length of stay, presenting complaint, crowding, and time of day were assessed as regards effect on the probability of LWBS and as covariates in the mortality analysis.

Results: In our dataset, 9058 patient visits to the ED (2.5% of all ED visits) ended in LWBS. These patients were younger than average and had lower triage levels. No significant difference was found between males and females. The highest rates were seen in patients presenting with a psychiatric disorder (12.8%), victims of physical assault (11.7%), or alcohol/drug withdrawal (9.9%). The likelihood of LWBS was highest in the evening and lowest in the early morning. Short-term mortality at 28 days was not significantly affected by LWBS, but a 34% lower long-term mortality risk was seen for patients LWBS (hazard ratio 0.66, 95% confidence interval 0.45-0.95, P  = 0.028) in median follow-up of 3.5 years.

Conclusion: Patients LWBS were younger, had lower triage levels, and more frequently presented with psychiatric or substance use-related complaints. They had lower short- and long-term mortality compared with those who completed treatment. This observation does not imply a causal relationship but highlights differences in patient characteristics.

Objective: Undiagnosed HIV infection remains a major driver of viral transmission in Western countries. Whether a systematic sex-based bias exists in HIV test ordering by physicians is unknown. We aimed to analyze the frequency of HIV testing among women and men attending 11 emergency departments (EDs) in Catalonia, Spain.

Methods: We recorded the total number of ED visits and HIV tests performed, both overall and for two specific diagnoses included in an opt-in testing strategy: community-acquired pneumonia (CAP) and herpes zoster. Data on patients' sex at birth and age were retrieved from administrative records, along with hospital (large vs. medium-small, metropolitan vs. nonmetropolitan) and ED characteristics (high vs. nonhigh activity, with vs. without gynecological facilities). The primary objective was to compare HIV testing rates between women and men, overall and by diagnosis. Secondary analyses evaluated results by age strata and institutional characteristics.

Results: A total of 1.8 million patients (55% women) attended the 11 EDs over a combined period of 335 months (median: 33 months per ED). During this time, 11 250 HIV tests were ordered (38% in women), averaging 34 tests per ED per month. Women were significantly less likely to be tested than men [0.43 vs. 0.86%; odds ratio (OR): 0.50, 95% confidence interval (CI): 0.48-0.52]. Among 31 515 CAP and 2990 herpes zoster cases, women also had lower testing rates (10.6 vs. 13.5% in CAP, OR: 0.76; 6.4 vs. 11.3% in herpes zoster, OR: 0.51). Results were consistent across all age groups and hospital/ED types.

Conclusion: We identified a consistent sex-based disparity in HIV testing by emergency physicians, with women less likely to be tested than men, regardless of age or institutional setting. The causes of this bias remain unclear and warrant urgent investigation and corrective action.