Journal of Emergency Medicine最新文献

Background

The recent guidelines from the European Society of Cardiology recommends using high-sensitivity cardiac troponin (hs-cTn) in either 0/1-h or 0/2-h algorithms to identify or rule out acute myocardial infarction (AMI). Several studies have reported good diagnostic accuracy with both algorithms, but few have compared the algorithms directly.

Objective

We aimed to compare the diagnostic accuracy of the algorithms head-to-head, in the same patients.

Methods

This was a secondary analysis of data from a prospective observational study; 1167 consecutive patients presenting with chest pain to the emergency department at Skåne University Hospital (Lund, Sweden) were enrolled. Only patients with a hs-cTnT sample at presentation AND after 1 AND 2 h were included in the analysis. We compared sensitivity, specificity, and negative (NPV) and positive predictive value (PPV). The primary outcome was index visit AMI.

Results

A total of 710 patients were included, of whom 56 (7.9%) had AMI. Both algorithms had a sensitivity of 98.2% and an NPV of 99.8% for ruling out AMI, but the 0/2-h algorithm ruled out significantly more patients (69.3% vs. 66.2%, p < 0.001). For rule-in, the 0/2-h algorithm had higher PPV (73.4% vs. 65.2%) and slightly better specificity (97.4% vs. 96.3%, p = 0.016) than the 0/1-h algorithm.

Conclusion

Both algorithms had good diagnostic accuracy, with a slight advantage for the 0/2-h algorithm. Which algorithm to implement may thus depend on practical issues such as the ability to exploit the theoretical time saved with the 0/1-h algorithm. Further studies comparing the algorithms in combination with electrocardiography, history, or risk scores are needed.

Background

The use of potentially inappropriate medications (PIMs) is considered an important quality indicator for older adults seen in the ambulatory care setting.

Study Objectives

To evaluate the pattern of potentially inappropriate medication (PIMs) use as specified in the Beers Criteria, for older adults during emergency department (ED) visits in the United States.

Methods

Using data from the National Hospital Ambulatory Care Survey (NHAMCS) we identified older adults (age 65 or older) discharged home from an ED visit in 2019. We defined PIMs as those with an ‘avoid’ recommendation under the American Geriatrics Society (AGS) 2019 Beers Criteria in older adults. Logistic regression models were used to assess demographic, clinical, and hospital factors associated with the use of any PIMs upon ED discharge.

Results

Overall, 5.9% of visits by older adults discharged from the ED included administration or prescriptions for PIMs. Among those who received any PIMs, 25.5% received benzodiazepines, 42.5 % received anticholinergics, 1.4% received nonbenzodiazepine hypnotics, and 0.5% received barbiturates. A multivariable model showed statistically significant associations for age 65 to 74 (OR 1.91, 95% CI 1.39–2.62 vs. age >=75), dementia (OR 0.45, 95% CI 0.21–0.95), lower immediacy (OR 2.45, 95% CI 1.56–3.84 vs. higher immediacy), and Northeastern rural region (OR 0.34, 95% CI 0.21–0.55 vs. Midwestern rural).

Conclusion

We found that younger age and lower immediacy were associated with increased prescriptions of PIMs for older adults seen, while dementia and Northeastern rural region was associated with reduced use of PIMs seen and discharged from EDs in United States.

Background

With the widespread use of immune checkpoint inhibitors (ICIs) for cancer treatment, rare or uncommon immune-related adverse events (irAEs) are frequently being reported. As some of these irAEs can be severe or life-threatening with patients presenting to the emergency departments and acute care centers for care, understanding the presentation and management of these events is important. Here, a systematic review was conducted to examine the reported characteristics and management of myocarditis, myositis, and myasthenia gravis triad after ICI therapy.

Methods

Following PRISMA guidelines, we conducted a systematic review that included studies written in English published in PubMed and Embase up to August 1^st, 2023 that reported concurrent myocarditis, myositis, and myasthenia gravis in the setting of ICI. Data on presentation, patients’ characteristics, management, and outcomes were collected. Qualitative synthesis and descriptive statistics were used to analyze and report the main results.

Results

A total number of 61 cases with the M triad were identified, of which the majority had melanoma or lung cancer (51%) with a median age of 71 years. Almost all the patients (92%) were treated with PD-1 inhibitors. The main frequent complaints were dyspnea (50.8%), ptosis (49.2%), and diplopia (36.1%). Corticosteroids and intravenous immunoglobulin were the main treatment modalities. Twenty-one (34.4%) patients died in the hospital.

Conclusion

Concurrent M triad of myocarditis, myositis, and myasthenia gravis following ICI therapy is not uncommon and can present to the emergency department with a spectrum of complaints. As these concurrent irAEs are associated with high mortality rates, prompt recognition and thorough investigations by emergency department physicians are vital for effective management and early intervention. More research is needed to better identify risk factors that can be used as predictors to identify high-risk patients who may develop these events after ICI therapy, for which multidisciplinary collaboration and point-of-care testing in parallel with early recognition is necessary when evaluating these patients when they present to the emergency departments or acute care centers.

Background

Cutaneous leishmaniasis (CL) is a vector-borne parasitic infection endemic to many sub-tropical regions worldwide. In the Americas, Leishmania braziliensis is responsible for most reported CL cases. Variable symptom presentation and susceptibility to secondary infection make diagnosing CL a difficult proposition for physicians who may not encounter cases frequently.

Case Report

We present the case of a 50-year-old man with multiple progressive lesions, diagnosed initially as a bacterial infection, who presented to a North American emergency department after several unsuccessful trials of antibiotic therapy. Eventually, polymerase chain reaction testing of a wound biopsy sample confirmed the presence of L. braziliensis. After a complicated course, the patient's infection resolved after tailored antiparasitic therapy.

Why Should an Emergency Physician Be Aware of This?

This case highlights the need to include travel history in the evaluation of atypical dermatologic infections.

Background

A significant portion of oncology patients visit the emergency department (ED) in the last months of their life, often without advanced care plans (ACP). This leads to fragmented care and inconsistent adherence to patients’ end-of-life wishes.

Objective

To enhance the documentation and adherence to advanced care plans for oncology patients visiting the ED, particularly in the context of end-of-life care preferences.

Methods

This was a retrospective observational study. The data was extracted from Epic ED encounters that occurred during 04/01/2023 through 05/31/2023. Eligibility criteria included patients at least 19 years of age and having at least one of the following: a previous DNR, an out of hospital DNR (OOHDNR), a previous discharge to hospice or an ACP note with Full Code documented as “No”. Descriptive statistics using proportions were used to tabulate differences between the two months of data.

A multidisciplinary team, including clinicians, spiritual care providers, nurses, social workers, and data analysts, initiated a quality improvement project. The project focused on the integration of spiritual care providers in advanced care planning discussions, the optimization of electronic medical records (EMR) for real time identification and management of patients’ care and preferences, and the training of healthcare staff in ACP documentation.

Results

During the two-month study period, a total of 5,125 ED encounters occurred with 4,985 potentially eligible patients and 2,747 (55.1%) ED to hospital admissions. The combined number of patients meeting the patient criteria was 276 (5.5%). The intervention led to a 95% increase in the documentation of ACP notes and 46% increase in Do Not Resuscitate (DNR) orders for patients who had previously expressed a preference for a natural death. It highlighted the role of spiritual care providers as a crucial and underutilized resource in managing end-of -life care discussions.

Discussion

This project underscores the importance of interprofessional collaboration in end-of-life care. The utilization of spiritual care providers in ACP discussions and the use of a more integrated EMR system can improve the alignment of emergency care with oncology patients’ end-of-life preferences, leading to better patient outcomes and potentially reduced healthcare costs.

Background

Chest pain is among the most common reasons for presentation to the emergency department (ED) worldwide. Additional studies on most cost-effective ways of differentiating serious vs. benign causes of chest pain are needed.

Objectives

Our study aimed to evaluate the effectiveness of a novel risk stratification pathway utilizing 5^th generation high-sensitivity cardiac troponin T assay (Hs-cTnT) and HEART score (History, Electrocardiogram, Age, Risk factors, Troponin) in assessing nontraumatic chest pain patients in reducing ED resource utilization.

Methods

A retrospective chart review was performed 6 months prior to and after the implementation of a novel risk stratification pathway that combined hs-cTnT with HEART score to guide evaluation of adult patients presenting with nontraumatic chest pain at a large academic quaternary care ED. Primary outcome was ED length of stay (LOS); secondary outcomes included cardiology consult rates, admission rates, number of ED boarders, and number of eloped patients.

Results

A total of 1707 patients and 1529 patients were included pre- and postimplementation, respectively. Median overall ED LOS decreased from 317 to 286 min, an absolute reduction of 31 min (95% confidence interval 22–41 min), after pathway implementation (p < 0.001). Furthermore, cardiology consult rate decreased from 26.9% to 16.0% (p < 0.0001), rate of admission decreased from 30.1% to 22.7% (p < 0.0001), and number of ED boarders as a proportion of all nontraumatic chest pain patients decreased from 25.13% preimplementation to 18.63% postimplementation (p < 0.0001).

Conclusions

Implementation of our novel chest pain pathway improved numerous ED throughput metrics in the evaluation of nontraumatic chest pain patients.