Pub Date : 2026-01-17DOI: 10.1016/j.ajem.2026.01.021
Jacob N. Watson MD , AJ Graham DO
Acute airway foreign bodies are an uncommon but life-threatening pathology encountered in the emergency department.
We present the case of a 41 year old female who presented for acute obstruction of the posterior pharynx following attempted ingestion of a glass methamphetamine pipe in efforts to conceal evidence from law enforcement officers. She exhibited mild trismus and muffled voice. No respiratory distress, stridor or hypoxia was appreciated. Workup revealed a vertically oriented cylindrical glass foreign body, approximately 10 cm spanning the distance between the proximal esophagus and posterior nasopharynx.
Treatment was initiated with low-dose benzodiazepine therapy for anxiolysis, administered nebulized lidocaine while preparations were made for emergency cricothyroidotomy and rapid sequence intubation with fiberoptic support. Otolaryngology was emergently consulted and ultimately the decision was made to attempt removal, with a plan for emergent surgical airway placement if unsuccessful. The patient was positioned with the neck hyperextended and ketamine was given for sedation. Using a pair of rubberized Magill forceps that we created, the glass pipe was successfully removed. The patient returned to her pre-procedural baseline and was discharged.
Patients with acute airway obstruction can rapidly decline and otolaryngology support is often not readily available. In this report we will discuss the considerations in managing acute airway foreign bodies, maneuvers and specialized tools to assist with bedside removal.
{"title":"Acute pharyngeal obstruction from a glass methamphetamine pipe: A case report","authors":"Jacob N. Watson MD , AJ Graham DO","doi":"10.1016/j.ajem.2026.01.021","DOIUrl":"10.1016/j.ajem.2026.01.021","url":null,"abstract":"<div><div>Acute airway foreign bodies are an uncommon but life-threatening pathology encountered in the emergency department.</div><div>We present the case of a 41 year old female who presented for acute obstruction of the posterior pharynx following attempted ingestion of a glass methamphetamine pipe in efforts to conceal evidence from law enforcement officers. She exhibited mild trismus and muffled voice. No respiratory distress, stridor or hypoxia was appreciated. Workup revealed a vertically oriented cylindrical glass foreign body, approximately 10 cm spanning the distance between the proximal esophagus and posterior nasopharynx.</div><div>Treatment was initiated with low-dose benzodiazepine therapy for anxiolysis, administered nebulized lidocaine while preparations were made for emergency cricothyroidotomy and rapid sequence intubation with fiberoptic support. Otolaryngology was emergently consulted and ultimately the decision was made to attempt removal, with a plan for emergent surgical airway placement if unsuccessful. The patient was positioned with the neck hyperextended and ketamine was given for sedation. Using a pair of rubberized Magill forceps that we created, the glass pipe was successfully removed. The patient returned to her pre-procedural baseline and was discharged.</div><div>Patients with acute airway obstruction can rapidly decline and otolaryngology support is often not readily available. In this report we will discuss the considerations in managing acute airway foreign bodies, maneuvers and specialized tools to assist with bedside removal.</div></div>","PeriodicalId":55536,"journal":{"name":"American Journal of Emergency Medicine","volume":"102 ","pages":"Pages 123-125"},"PeriodicalIF":2.2,"publicationDate":"2026-01-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146068813","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-16DOI: 10.1016/j.ajem.2026.01.014
Ryota Inokuchi, Akinori Maeda, Yohei Komaru, Toshiya Takahashi, Kent Doi
Background: Sodium bicarbonate is a common household compound often promoted for unproven health benefits. However, excessive ingestion can result in severe toxicity. This report describes a case of life-threatening metabolic alkalosis and hypernatremia following self-medication and presents a systematic review of sodium bicarbonate toxicity.
Case report: A previously healthy man in his 30s presented with nausea and progressive weakness after ingesting 60 g of sodium bicarbonate daily for 2 months, escalating to 480 g immediately before admission for intestinal cleansing. Laboratory evaluation demonstrated severe metabolic alkalosis (pH 7.54; HCO₃- 54.5 mmol/L), hypernatremia (serum sodium 162 mEq/L), and chloride-resistant alkalosis. Supportive therapy, including oral acetazolamide, resulted in rapid biochemical normalization and complete clinical recovery.
Review: Our systematic review of 78 cases of sodium bicarbonate toxicity identified a shift in reported indications from dyspepsia to diverse uses, including pica, drug test avoidance, and natural remedies. Clinical presentations differed by ingestion pattern: acute, massive ingestion was often complicated by gastric rupture and was associated with high mortality, whereas chronic ingestion predominantly caused severe metabolic alkalosis and electrolyte abnormalities.
Conclusion: Excessive sodium bicarbonate ingestion can cause life-threatening complications. Clinicians should be alert to the risks of misuse driven by widely circulating unproven health claims.
{"title":"Severe metabolic alkalosis and hypernatremia induced by excessive sodium bicarbonate intake: A case report and literature review.","authors":"Ryota Inokuchi, Akinori Maeda, Yohei Komaru, Toshiya Takahashi, Kent Doi","doi":"10.1016/j.ajem.2026.01.014","DOIUrl":"https://doi.org/10.1016/j.ajem.2026.01.014","url":null,"abstract":"<p><strong>Background: </strong>Sodium bicarbonate is a common household compound often promoted for unproven health benefits. However, excessive ingestion can result in severe toxicity. This report describes a case of life-threatening metabolic alkalosis and hypernatremia following self-medication and presents a systematic review of sodium bicarbonate toxicity.</p><p><strong>Case report: </strong>A previously healthy man in his 30s presented with nausea and progressive weakness after ingesting 60 g of sodium bicarbonate daily for 2 months, escalating to 480 g immediately before admission for intestinal cleansing. Laboratory evaluation demonstrated severe metabolic alkalosis (pH 7.54; HCO₃<sup>-</sup> 54.5 mmol/L), hypernatremia (serum sodium 162 mEq/L), and chloride-resistant alkalosis. Supportive therapy, including oral acetazolamide, resulted in rapid biochemical normalization and complete clinical recovery.</p><p><strong>Review: </strong>Our systematic review of 78 cases of sodium bicarbonate toxicity identified a shift in reported indications from dyspepsia to diverse uses, including pica, drug test avoidance, and natural remedies. Clinical presentations differed by ingestion pattern: acute, massive ingestion was often complicated by gastric rupture and was associated with high mortality, whereas chronic ingestion predominantly caused severe metabolic alkalosis and electrolyte abnormalities.</p><p><strong>Conclusion: </strong>Excessive sodium bicarbonate ingestion can cause life-threatening complications. Clinicians should be alert to the risks of misuse driven by widely circulating unproven health claims.</p>","PeriodicalId":55536,"journal":{"name":"American Journal of Emergency Medicine","volume":"103 ","pages":"45-49"},"PeriodicalIF":2.2,"publicationDate":"2026-01-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146133552","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-16DOI: 10.1016/j.ajem.2026.01.022
Bin Wang , Jian-lei Fu , Ci-ren Zhuoma , Qu-zhen Danzeng , Feng-xue Zhu , Guo-ying Lin
Background
Neurocritical care patients residing in high-altitude regions such as the Xizang Autonomous Region encounter distinct physiological and logistical challenges, including hypobaric hypoxia, limited medical infrastructure, and delayed access to specialized care. Despite these factors, few studies have systematically characterized their clinical profiles or developed region-specific mortality prediction models. This study aimed to investigate the clinical features of neurocritical care patients admitted to a tertiary hospital in Lhasa, Xizang Autonomous Region, and to construct a predictive model for in-hospital mortality tailored to this high-altitude population.
Methods
This single-center retrospective study included 400 neurocritical care patients admitted between October 2021 and December 2023. Demographic data, types of neurological disorders, clinical scores and comorbidities, laboratory examination, pharmacological treatments and blood product transfusion conditions were collected. Univariate and multivariate logistic regression analyses were performed to identify independent predictors of in-hospital mortality. A nomogram-based prediction model was developed and internally validated using bootstrap resampling. Model performance was evaluated using the area under the receiver operating characteristic curve (AUC), calibration plots, and decision curve analysis (DCA).
Results
The overall in-hospital mortality rate was 15.8%. Multivariate analysis identified younger age (95% CI: 0.95–0.97, p = 0.013), higher APACHE II scores (95% CI: 1.02–1.16, p = 0.007), Glasgow Coma Scale ≤8 (95% CI: 1.17–4.56, p = 0.016), and elevated APTT levels (95% CI: 1.00–1.02, p = 0.007) as independent risk factors for mortality. Diuretic use was associated with a protective effect (95% CI: 0.20–0.77, p = 0.007).The final model demonstrated good discrimination (AUC = 0.749), calibration, and clinical utility. The nomogram provides a practical tool for early risk stratification in resource-limited high-altitude neurocritical care settings.
Conclusion
Neurocritical care patients in Xizang exhibit distinct clinical profiles and mortality risks. The developed prediction model may assist clinicians in early identification of high-risk patients and guide targeted interventions to improve outcomes in high-altitude regions.
背景：居住在西藏自治区等高海拔地区的神经危重症患者面临着独特的生理和后勤挑战，包括低气压缺氧，有限的医疗基础设施，以及延迟获得专业护理。尽管有这些因素，很少有研究系统地描述了它们的临床特征或开发了特定区域的死亡率预测模型。本研究旨在探讨西藏自治区拉萨市某三级医院神经危重症患者的临床特征，并构建适合该地区高海拔人群的住院死亡率预测模型。方法：该单中心回顾性研究纳入了2021年10月至2023年12月住院的400例神经危重症患者。收集人口统计数据、神经系统疾病类型、临床评分和合并症、实验室检查、药物治疗和血液制品输血情况。进行单因素和多因素logistic回归分析以确定住院死亡率的独立预测因素。开发了基于模态图的预测模型，并使用自举重采样进行了内部验证。采用受试者工作特征曲线（AUC）下面积、校准图和决策曲线分析（DCA）来评估模型性能。结果：住院总死亡率为15.8%。多因素分析发现，年龄较小（95% CI: 0.95-0.97, p = 0.013）、APACHE II评分较高（95% CI: 1.02-1.16, p = 0.007）、格拉斯哥昏迷量表≤8 （95% CI: 1.17-4.56, p = 0.016）和APTT水平升高（95% CI: 1.00-1.02, p = 0.007）是死亡的独立危险因素。利尿剂的使用与保护作用相关（95% CI: 0.20-0.77, p = 0.007）。最终模型具有良好的鉴别性（AUC = 0.749）、校准性和临床实用性。nomogram为资源有限的高海拔神经危重症护理提供了一种实用的早期风险分层工具。结论：西藏省神经危重症患者具有明显的临床特点和死亡风险。建立的预测模型可以帮助临床医生早期识别高危患者，并指导有针对性的干预措施，以改善高海拔地区的预后。
{"title":"Clinical profiles and mortality risk modeling in neurocritical care: A retrospective cohort study from high-altitude Xizang","authors":"Bin Wang , Jian-lei Fu , Ci-ren Zhuoma , Qu-zhen Danzeng , Feng-xue Zhu , Guo-ying Lin","doi":"10.1016/j.ajem.2026.01.022","DOIUrl":"10.1016/j.ajem.2026.01.022","url":null,"abstract":"<div><h3>Background</h3><div>Neurocritical care patients residing in high-altitude regions such as the Xizang Autonomous Region encounter distinct physiological and logistical challenges, including hypobaric hypoxia, limited medical infrastructure, and delayed access to specialized care. Despite these factors, few studies have systematically characterized their clinical profiles or developed region-specific mortality prediction models. This study aimed to investigate the clinical features of neurocritical care patients admitted to a tertiary hospital in Lhasa, Xizang Autonomous Region, and to construct a predictive model for in-hospital mortality tailored to this high-altitude population.</div></div><div><h3>Methods</h3><div>This single-center retrospective study included 400 neurocritical care patients admitted between October 2021 and December 2023. Demographic data, types of neurological disorders, clinical scores and comorbidities, laboratory examination, pharmacological treatments and blood product transfusion conditions were collected. Univariate and multivariate logistic regression analyses were performed to identify independent predictors of in-hospital mortality. A nomogram-based prediction model was developed and internally validated using bootstrap resampling. Model performance was evaluated using the area under the receiver operating characteristic curve (AUC), calibration plots, and decision curve analysis (DCA).</div></div><div><h3>Results</h3><div>The overall in-hospital mortality rate was 15.8%. Multivariate analysis identified younger age (95% CI: 0.95–0.97, <em>p</em> = 0.013), higher APACHE II scores (95% CI: 1.02–1.16, <em>p</em> = 0.007), Glasgow Coma Scale ≤8 (95% CI: 1.17–4.56, <em>p</em> = 0.016), and elevated APTT levels (95% CI: 1.00–1.02, <em>p</em> = 0.007) as independent risk factors for mortality. Diuretic use was associated with a protective effect (95% CI: 0.20–0.77, p = 0.007).The final model demonstrated good discrimination (AUC = 0.749), calibration, and clinical utility. The nomogram provides a practical tool for early risk stratification in resource-limited high-altitude neurocritical care settings.</div></div><div><h3>Conclusion</h3><div>Neurocritical care patients in Xizang exhibit distinct clinical profiles and mortality risks. The developed prediction model may assist clinicians in early identification of high-risk patients and guide targeted interventions to improve outcomes in high-altitude regions.</div></div>","PeriodicalId":55536,"journal":{"name":"American Journal of Emergency Medicine","volume":"102 ","pages":"Pages 198-205"},"PeriodicalIF":2.2,"publicationDate":"2026-01-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146115168","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-16DOI: 10.1016/j.ajem.2026.01.023
Nick M. Murray MD , Paul D. Johnson MD , Gabriel V. Fontaine PharmD, MBA , Trina Johnson RN , Jami Hassler RN , Heidi Hafen RN, NP , Michelle Aucoin RN , Lesley Miller RN , Anne M. Anderson RN , Chamonix Johnston RN, MPH , Marilyn McKasson MD , Kyle Hobbs MD , H. Adrian Püttgen MD
Background
Rapid time to treatment of intracerebral hemorrhage (ICH) is important but not consistently achieved in emergency departments (EDs). The concept of CODE-ICH is now well-described, yet mechanisms to improve ED provider and system operation to reduce treatment times are lacking.
Objective
We aim to evaluate ICH treatment time metrics before and after a standardized ICH provider feedback intervention, individualized for each patient with an acute spontaneous ICH in the ED.
Methods
A multicenter retrospective cohort of consecutive patients ≥18 years old with an acute ICH were identified from March 1, 2022 to January 1, 2025 within a network of an integrated healthcare system in the U.S. A rapid feedback intervention for all providers involved in the patient case was developed to contain specific treatment times compared to goals, which, when not met, prompted a root cause analysis. Patients were grouped into pre- and post-intervention cohorts. The primary endpoints were CT scout time to antihypertensive and/or anticoagulation reversal agent administration and ICH orderset utilization. Secondary outcomes were effect of in-person daytime versus telehealth nighttime coverage, length of stay, and discharge disposition.
Results
A total of 226 patients met inclusion criteria, 108 pre- and 118 post-intervention, with similar age (median: 68 vs. 69 years) and 54% were female. Pre- to post-intervention median NIHSS was the same (10; p = 0.25), as were median ICH scores (pre: 2.0, interquartile range, IQR, 0–3 vs. post: 1.0, IQR 1–3; p = 0.90). Median post-intervention CT to antihypertensive treatment was 7 min faster (pre: 21 min, IQR 23–52 vs. post: 14 min, IQR 7–26; p = 0.0012), and median CT to anticoagulation reversal agent administration was 11 min faster (pre: 40 min, IQR 30–64 vs. post: 29 min, IQR 18–40; p = 0.03). The intervention was associated with increased orderset usage (54% pre- to 96% post-intervention; p = 0.0001).
Conclusions
A rapid, root-cause focused ICH feedback intervention improved standardized orderset usage and resultant faster treatment times for blood pressure and anticoagulation reversal in the ED.
背景：脑出血（ICH）的快速治疗很重要，但在急诊科（EDs）并不一致。CODE-ICH的概念现在已经得到了很好的描述，但缺乏改善ED提供者和系统操作以减少治疗时间的机制。目的：我们旨在评估ICH治疗前后的时间指标，标准化的ICH提供者反馈干预，针对ed的每位急性自发性ICH患者进行个体化治疗。方法：从2022年3月1日至1月1日，对连续≥18岁的急性ICH患者进行多中心回顾性队列研究。2025年，在美国一个综合医疗保健系统的网络中，针对所有涉及患者病例的提供者开发了一个快速反馈干预，以包含与目标相比的特定治疗时间，当未达到目标时，提示根本原因分析。患者被分为干预前和干预后两组。主要终点是CT检查时间到抗高血压和/或抗凝逆转药物的使用和脑出血医嘱的使用。次要结局是白天面对面与远程医疗夜间覆盖的效果、住院时间和出院处置。结果226例患者符合纳入标准，干预前108例，干预后118例，年龄相近（中位：68岁vs. 69岁），女性占54%。干预前后NIHSS中位数相同（10,p = 0.25）， ICH评分中位数相同（干预前：2.0，四分位数范围，IQR, 0-3，干预后：1.0,IQR - 1-3, p = 0.90）。干预后到降压治疗的CT中位数快了7分钟（干预前：21分钟，IQR 23-52，干预后：14分钟，IQR 7 - 26, p = 0.0012），到抗凝逆转剂给药的CT中位数快了11分钟（干预前：40分钟，IQR 30-64，干预后：29分钟，IQR 18-40, p = 0.03）。干预与订单使用量的增加相关（干预前为54%，干预后为96%；p = 0.0001）。结论快速、以根本原因为重点的脑出血反馈干预提高了标准化医嘱的使用，从而缩短了ED血压和抗凝逆转的治疗时间。
{"title":"Rapid feedback on my emergency department hemorrhagic stroke care? It improves telestroke and in-person treatment times","authors":"Nick M. Murray MD , Paul D. Johnson MD , Gabriel V. Fontaine PharmD, MBA , Trina Johnson RN , Jami Hassler RN , Heidi Hafen RN, NP , Michelle Aucoin RN , Lesley Miller RN , Anne M. Anderson RN , Chamonix Johnston RN, MPH , Marilyn McKasson MD , Kyle Hobbs MD , H. Adrian Püttgen MD","doi":"10.1016/j.ajem.2026.01.023","DOIUrl":"10.1016/j.ajem.2026.01.023","url":null,"abstract":"<div><h3>Background</h3><div>Rapid time to treatment of intracerebral hemorrhage (ICH) is important but not consistently achieved in emergency departments (EDs). The concept of CODE-ICH is now well-described, yet mechanisms to improve ED provider and system operation to reduce treatment times are lacking.</div></div><div><h3>Objective</h3><div>We aim to evaluate ICH treatment time metrics before and after a standardized ICH provider feedback intervention, individualized for each patient with an acute spontaneous ICH in the ED.</div></div><div><h3>Methods</h3><div>A multicenter retrospective cohort of consecutive patients ≥18 years old with an acute ICH were identified from March 1, 2022 to January 1, 2025 within a network of an integrated healthcare system in the U.S. A rapid feedback intervention for all providers involved in the patient case was developed to contain specific treatment times compared to goals, which, when not met, prompted a root cause analysis. Patients were grouped into pre- and post-intervention cohorts. The primary endpoints were CT scout time to antihypertensive and/or anticoagulation reversal agent administration and ICH orderset utilization. Secondary outcomes were effect of in-person daytime versus telehealth nighttime coverage, length of stay, and discharge disposition.</div></div><div><h3>Results</h3><div>A total of 226 patients met inclusion criteria, 108 pre- and 118 post-intervention, with similar age (median: 68 vs. 69 years) and 54% were female. Pre- to post-intervention median NIHSS was the same (10; <em>p</em> = 0.25), as were median ICH scores (pre: 2.0, interquartile range, IQR, 0–3 vs. post: 1.0, IQR 1–3; <em>p</em> = 0.90). Median post-intervention CT to antihypertensive treatment was 7 min faster (pre: 21 min, IQR 23–52 vs. post: 14 min, IQR 7–26; <em>p</em> = 0.0012), and median CT to anticoagulation reversal agent administration was 11 min faster (pre: 40 min, IQR 30–64 vs. post: 29 min, IQR 18–40; <em>p</em> = 0.03). The intervention was associated with increased orderset usage (54% pre- to 96% post-intervention; <em>p</em> = 0.0001).</div></div><div><h3>Conclusions</h3><div>A rapid, root-cause focused ICH feedback intervention improved standardized orderset usage and resultant faster treatment times for blood pressure and anticoagulation reversal in the ED.</div></div>","PeriodicalId":55536,"journal":{"name":"American Journal of Emergency Medicine","volume":"102 ","pages":"Pages 65-70"},"PeriodicalIF":2.2,"publicationDate":"2026-01-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146038936","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-16DOI: 10.1016/j.ajem.2026.01.018
Peter Victoria, Joshua Easter, Brit Long
Background
Acute appendicitis is among the most common emergency presentations and has traditionally been treated with appendectomy. However, recent randomized controlled trials suggest that antibiotic therapy is a reasonable, non-operative alternative for appropriately selected patients who understand the risks. The purpose of this review article was to summarize findings from a recent individual patient data meta-analysis comparing antibiotic therapy versus appendectomy in adults with imaging-confirmed acute appendicitis.
Methods
The reviewed meta-analysis included six randomized controlled trials encompassing 2101 adult patients. A one-stage analysis was performed applying an intention-to-treat analysis. A mixed-effects model accounted for study-level clustering. Complications were standardized using the Clavien-Dindo classification, a widely used tool for classification of surgical complications. The primary endpoint was the overall complication rate at one year, and secondary outcomes included rate of step-up appendectomy, hospital length of stay, and time away from work.
Results
No significant difference in overall, major, or minor complication rates was found at one year between patients receiving initial antibiotic therapy and those undergoing appendectomy. 34% of patients treated with antibiotics required delayed appendectomy within one year and 25% of those patients were found to have complicated appendicitis. In contrast, patients with an appendicolith demonstrated significantly higher complication rates, and 49% required subsequent appendectomy.
Conclusions
Antibiotic therapy is a reasonable initial management strategy for adults with uncomplicated, imaging-confirmed acute appendicitis as long as patients understand the risks. However, caution is warranted in those with an appendicolith due to increased risk of complications and treatment failure with antibiotic therapy.
{"title":"Are antibiotics an effective initial treatment for acute appendicitis compared to appendectomy?","authors":"Peter Victoria, Joshua Easter, Brit Long","doi":"10.1016/j.ajem.2026.01.018","DOIUrl":"10.1016/j.ajem.2026.01.018","url":null,"abstract":"<div><h3>Background</h3><div>Acute appendicitis is among the most common emergency presentations and has traditionally been treated with appendectomy. However, recent randomized controlled trials suggest that antibiotic therapy is a reasonable, non-operative alternative for appropriately selected patients who understand the risks. The purpose of this review article was to summarize findings from a recent individual patient data meta-analysis comparing antibiotic therapy versus appendectomy in adults with imaging-confirmed acute appendicitis.</div></div><div><h3>Methods</h3><div>The reviewed meta-analysis included six randomized controlled trials encompassing 2101 adult patients. A one-stage analysis was performed applying an intention-to-treat analysis. A mixed-effects model accounted for study-level clustering. Complications were standardized using the Clavien-Dindo classification, a widely used tool for classification of surgical complications. The primary endpoint was the overall complication rate at one year, and secondary outcomes included rate of step-up appendectomy, hospital length of stay, and time away from work.</div></div><div><h3>Results</h3><div>No significant difference in overall, major, or minor complication rates was found at one year between patients receiving initial antibiotic therapy and those undergoing appendectomy. 34% of patients treated with antibiotics required delayed appendectomy within one year and 25% of those patients were found to have complicated appendicitis. In contrast, patients with an appendicolith demonstrated significantly higher complication rates, and 49% required subsequent appendectomy.</div></div><div><h3>Conclusions</h3><div>Antibiotic therapy is a reasonable initial management strategy for adults with uncomplicated, imaging-confirmed acute appendicitis as long as patients understand the risks. However, caution is warranted in those with an appendicolith due to increased risk of complications and treatment failure with antibiotic therapy.</div></div>","PeriodicalId":55536,"journal":{"name":"American Journal of Emergency Medicine","volume":"102 ","pages":"Pages 104-107"},"PeriodicalIF":2.2,"publicationDate":"2026-01-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146038937","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-16DOI: 10.1016/j.ajem.2026.01.020
Li-Hong Zheng, Yan Wang, Xue-Wen Huang, Miao Li, Hai-Ying Xian, Chun-Xia Guo, Zi-Yang He, Lin Ma
Objective
The aim of this study is to characterize the longest RR intervals and associated arrhythmias during the early phase of rapid ascent to high altitude environments using ambulatory electrocardiography (AECG), with the aim of informing strategies to prevent acute high-altitude illness and cardiovascular adverse events.
Methods
Participants residing at low altitude underwent rapid ascent to high-altitude locations at 3060 m, 3460 m, and 4014 m. Beginning on the first day at altitude, AECG monitoring was conducted for more than 24 h using a Model 401 wearable ECG monitor, enabling remote, real-time data transmission via a 4G network and immediate clinical response to high-risk arrhythmias. Cloud-based storage and analytic platforms facilitated statistical evaluation of the longest RR intervals and corresponding rhythm types.
Results
(1) The longest RR intervals and associated arrhythmias were primarily observed during nighttime sleep. (2) Statistically significant differences (p < 0.05) were found among the three altitude groups in the incidence of the longest RR intervals <1.00 s, abnormal rhythms associated with the longest RR intervals, premature beats corresponding to the longest RR intervals, and sinus pause episodes. (3) The primary arrhythmias associated with the longest RR intervals included ventricular premature beats, second-degree type II atrioventricular block, high-degree atrioventricular block, sinus pause, and atrial fibrillation.
Conclusion
Clinically significant bradyarrhythmia may occur during rapid ascent to altitudes between 3060 m and 4014 m, particularly during nocturnal hours. These findings highlight the need to consider targeted preventive attention during nighttime exposure, given the high prevalence of nocturnal bradyarrhythmias. Remote real-time AECG monitoring may serve as a useful tool for early detection and intervention in populations at risk of altitude-related cardiac rhythm disturbances.
{"title":"Remote real-time ambulatory ECG monitoring of the longest RR interval and corresponding arrhythmias during altitude ascent","authors":"Li-Hong Zheng, Yan Wang, Xue-Wen Huang, Miao Li, Hai-Ying Xian, Chun-Xia Guo, Zi-Yang He, Lin Ma","doi":"10.1016/j.ajem.2026.01.020","DOIUrl":"10.1016/j.ajem.2026.01.020","url":null,"abstract":"<div><h3>Objective</h3><div>The aim of this study is to characterize the longest RR intervals and associated arrhythmias during the early phase of rapid ascent to high altitude environments using ambulatory electrocardiography (AECG), with the aim of informing strategies to prevent acute high-altitude illness and cardiovascular adverse events.</div></div><div><h3>Methods</h3><div>Participants residing at low altitude underwent rapid ascent to high-altitude locations at 3060 m, 3460 m, and 4014 m. Beginning on the first day at altitude, AECG monitoring was conducted for more than 24 h using a Model 401 wearable ECG monitor, enabling remote, real-time data transmission via a 4G network and immediate clinical response to high-risk arrhythmias. Cloud-based storage and analytic platforms facilitated statistical evaluation of the longest RR intervals and corresponding rhythm types.</div></div><div><h3>Results</h3><div>(1) The longest RR intervals and associated arrhythmias were primarily observed during nighttime sleep. (2) Statistically significant differences (<em>p</em> < 0.05) were found among the three altitude groups in the incidence of the longest RR intervals <1.00 s, abnormal rhythms associated with the longest RR intervals, premature beats corresponding to the longest RR intervals, and sinus pause episodes. (3) The primary arrhythmias associated with the longest RR intervals included ventricular premature beats, second-degree type II atrioventricular block, high-degree atrioventricular block, sinus pause, and atrial fibrillation.</div></div><div><h3>Conclusion</h3><div>Clinically significant bradyarrhythmia may occur during rapid ascent to altitudes between 3060 m and 4014 m, particularly during nocturnal hours. These findings highlight the need to consider targeted preventive attention during nighttime exposure, given the high prevalence of nocturnal bradyarrhythmias. Remote real-time AECG monitoring may serve as a useful tool for early detection and intervention in populations at risk of altitude-related cardiac rhythm disturbances.</div></div>","PeriodicalId":55536,"journal":{"name":"American Journal of Emergency Medicine","volume":"102 ","pages":"Pages 98-103"},"PeriodicalIF":2.2,"publicationDate":"2026-01-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146039487","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-14DOI: 10.1016/j.ajem.2026.01.013
Robert James Adrian MD , Onyinyechi F. Eke MD, MPH , Nour Al Jalbout MD , Moustafa Al Hariri PhD , Kristofer Montoya MD , Patricia Hernandez MD , Hamid Shokoohi MD, MPH
Background
Patients with pulmonary hypertension (PHTN) (i.e., chronic PHTN) have right ventricular hypertrophy, elevated right-sided heart pressures, and frequently have pericardial effusions. When evaluating these patients for cardiac tamponade, the hypertrophy and elevated pressure in right heart may be protective from tamponade by counteracting the pressure from the pericardial effusion. However, these patients may be harmed if echocardiographic signs of tamponade (e.g., right ventricular diastolic collapse) are obscured.
Study objective
The effect of PHTN on patients with cardiac tamponade remains unclear. We aimed (1) to evaluate whether PHTN influences the echocardiographic findings of tamponade, and (2) to examine whether PHTN is associated with in-hospital mortality among patients undergoing pericardial drainage primarily for cardiac tamponade.
Methods
We conducted a retrospective observational study of adult patients who underwent pericardial drainage within 48 h of emergency department presentation at two academic centers. PHTN probability was classified using the 2022 European Society of Cardiology/European Respiratory Society (ESC/ERS) guidelines. We classified patients in four categories: no PHTN, low probability, intermediate probability, and high probability of PHTN. PHTN parameters were manually extracted from cardiologist-interpreted echocardiography reports. The primary outcome was in-hospital mortality. Secondary outcomes included the prevalence of echocardiographic findings of cardiac tamponade and their associations with mortality.
Results
A total of 249 patients met the inclusion criteria. In-hospital mortality did not significantly differ across PHTN probability categories: no PHTN (63.8%), low probability (9.3%), intermediate probability (20.9%), and high probability (5.3%) (p-values all >0.2). Among patients who died, 50.0% were in the no PHTN group compared to 7.1% in the high probability group (p = 0.222). The echocardiographic impression of cardiac tamponade was significantly lower among patients with high PHTN probability compared to those with no PHTN (64.3% vs. 85.4%, p = 0.041), with a weak negative correlation (r = −0.493) between increasing PHTN probability and tamponade impression.
Conclusions
In this cohort of patients undergoing pericardial drainage primarily for cardiac tamponade, PHTN was not significantly associated with in-hospital mortality. However, patients with a high probability of PHTN showed fewer echocardiographic signs of tamponade, suggesting that PHTN may obscure typical sonographic findings of tamponade.
背景：肺动脉高压（PHTN）患者（即慢性PHTN）右心室肥厚，右侧心压升高，常有心包积液。在评估这些患者的心包填塞时，右心肥厚和血压升高可能通过抵消心包积液的压力来保护心包填塞。然而，如果心包填塞的超声心动图征象（如右心室舒张性塌陷）被掩盖，这些患者可能会受到伤害。研究目的：PHTN对心包填塞的影响尚不清楚。我们的目的是(1)评估PHTN是否影响心包填塞的超声心动图表现；(2)研究PHTN是否与主要因心包填塞而行心包引流的患者的住院死亡率相关。方法：我们对两个学术中心急诊就诊后48小时内行心包引流术的成年患者进行了回顾性观察研究。根据2022年欧洲心脏病学会/欧洲呼吸学会（ESC/ERS）指南对PHTN概率进行分类。我们将患者分为无PHTN、低概率、中概率和高概率四类。从心脏病专家解释的超声心动图报告中手动提取PHTN参数。主要终点是住院死亡率。次要结局包括超声心动图发现心脏填塞的流行程度及其与死亡率的关系。结果：249例患者符合纳入标准。住院死亡率在PHTN概率类别之间没有显著差异：无PHTN（63.8%）、低概率（9.3%）、中概率（20.9%）和高概率（5.3%）（p值均为bb0 0.2）。在死亡患者中，无PHTN组为50.0%，而高概率组为7.1% （p = 0.222）。PHTN概率高的患者超声心动图对心包填塞的印象明显低于无PHTN的患者（64.3% vs. 85.4%, p = 0.041）， PHTN概率增加与心包填塞印象呈弱负相关（r = -0.493）。结论：在这组主要因心包填塞而接受心包引流的患者中，PHTN与住院死亡率无显著相关性。然而，PHTN高概率的患者表现出较少的心包填塞的超声心动图征象，提示PHTN可能掩盖了典型的心包填塞的超声表现。
{"title":"Pulmonary hypertension in cardiac tamponade: An observational cohort study of in-hospital mortality and echocardiographic findings","authors":"Robert James Adrian MD , Onyinyechi F. Eke MD, MPH , Nour Al Jalbout MD , Moustafa Al Hariri PhD , Kristofer Montoya MD , Patricia Hernandez MD , Hamid Shokoohi MD, MPH","doi":"10.1016/j.ajem.2026.01.013","DOIUrl":"10.1016/j.ajem.2026.01.013","url":null,"abstract":"<div><h3>Background</h3><div>Patients with pulmonary hypertension (PHTN) (i.e., chronic PHTN) have right ventricular hypertrophy, elevated right-sided heart pressures, and frequently have pericardial effusions. When evaluating these patients for cardiac tamponade, the hypertrophy and elevated pressure in right heart may be protective from tamponade by counteracting the pressure from the pericardial effusion. However, these patients may be harmed if echocardiographic signs of tamponade (e.g., right ventricular diastolic collapse) are obscured.</div></div><div><h3>Study objective</h3><div>The effect of PHTN on patients with cardiac tamponade remains unclear. We aimed (1) to evaluate whether PHTN influences the echocardiographic findings of tamponade, and (2) to examine whether PHTN is associated with in-hospital mortality among patients undergoing pericardial drainage primarily for cardiac tamponade.</div></div><div><h3>Methods</h3><div>We conducted a retrospective observational study of adult patients who underwent pericardial drainage within 48 h of emergency department presentation at two academic centers. PHTN probability was classified using the 2022 European Society of Cardiology/European Respiratory Society (ESC/ERS) guidelines. We classified patients in four categories: no PHTN, low probability, intermediate probability, and high probability of PHTN. PHTN parameters were manually extracted from cardiologist-interpreted echocardiography reports. The primary outcome was in-hospital mortality. Secondary outcomes included the prevalence of echocardiographic findings of cardiac tamponade and their associations with mortality.</div></div><div><h3>Results</h3><div>A total of 249 patients met the inclusion criteria. In-hospital mortality did not significantly differ across PHTN probability categories: no PHTN (63.8%), low probability (9.3%), intermediate probability (20.9%), and high probability (5.3%) (<em>p</em>-values all >0.2). Among patients who died, 50.0% were in the no PHTN group compared to 7.1% in the high probability group (<em>p</em> = 0.222). The echocardiographic impression of cardiac tamponade was significantly lower among patients with high PHTN probability compared to those with no PHTN (64.3% vs. 85.4%, <em>p</em> = 0.041), with a weak negative correlation (<em>r</em> = −0.493) between increasing PHTN probability and tamponade impression.</div></div><div><h3>Conclusions</h3><div>In this cohort of patients undergoing pericardial drainage primarily for cardiac tamponade, PHTN was not significantly associated with in-hospital mortality. However, patients with a high probability of PHTN showed fewer echocardiographic signs of tamponade, suggesting that PHTN may obscure typical sonographic findings of tamponade.</div></div>","PeriodicalId":55536,"journal":{"name":"American Journal of Emergency Medicine","volume":"102 ","pages":"Pages 55-61"},"PeriodicalIF":2.2,"publicationDate":"2026-01-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146031711","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-12DOI: 10.1016/j.ajem.2026.01.006
Shun Liao , Yan Li , Haoran Tang , Zixiong Li , Tianqi Xu , Zongfang Ren
Background: Acute appendicitis poses diagnostic challenges due to symptom overlap with other abdominal conditions, often leading to misdiagnosis or missed diagnosis. This study aimed to develop and validate an interpretable machine learning model based on routine hematological indicators to facilitate rapid diagnosis. Methods: A retrospective analysis was conducted on 408 patients with acute abdominal pain, including both adult and pediatric patients. The median age of patients in the appendicitis group was 37.5 years (IQR: 26.5 years). Univariate logistic regression revealed significant group differences in hematological indicators (all P < 0.001). Three feature selection methods—LASSO, ElasticNet, and Random Forest—were applied, with neutrophil percentage (NE%) and eosinophil percentage (EO%) consistently identified across all methods, and red blood cell (RBC) and white blood cell (WBC) repeatedly selected by at least two methods. Eleven commonly used machine learning classifiers were developed and evaluated on an independent test set. Results: The support vector machine with a radial basis function kernel (SVM-RBF) using LASSO-selected features achieved the best performance, with an AUC (area under the curve) of 0.903 (95% CI: 0.84–0.96), accuracy of 90.2%, sensitivity of 80.3%, and specificity of 100%. The average precision exceeded 0.92, and the calibration curve demonstrated good agreement (Brier score: 0.092). Interpretability analyses with SHAP (Shapley additive explanations) and LIME (local interpretable model-agnostic explanations) applied to the LightGBM (Light Gradient Boosting Machine) model confirmed EO%, RBC, and WBC as the most influential predictors. Conclusion:This parsimonious and interpretable model, relying solely on routine blood indicators, may enable timely and accurate diagnosis of acute appendicitis while providing additional insights, particularly in resource-limited settings.
{"title":"Lightweight interpretable AI model using multiple blood parameters for emergency diagnosis of acute appendicitis","authors":"Shun Liao , Yan Li , Haoran Tang , Zixiong Li , Tianqi Xu , Zongfang Ren","doi":"10.1016/j.ajem.2026.01.006","DOIUrl":"10.1016/j.ajem.2026.01.006","url":null,"abstract":"<div><div>Background: Acute appendicitis poses diagnostic challenges due to symptom overlap with other abdominal conditions, often leading to misdiagnosis or missed diagnosis. This study aimed to develop and validate an interpretable machine learning model based on routine hematological indicators to facilitate rapid diagnosis. Methods: A retrospective analysis was conducted on 408 patients with acute abdominal pain, including both adult and pediatric patients. The median age of patients in the appendicitis group was 37.5 years (IQR: 26.5 years). Univariate logistic regression revealed significant group differences in hematological indicators (all <em>P</em> < 0.001). Three feature selection methods—LASSO, ElasticNet, and Random Forest—were applied, with neutrophil percentage (NE%) and eosinophil percentage (EO%) consistently identified across all methods, and red blood cell (RBC) and white blood cell (WBC) repeatedly selected by at least two methods. Eleven commonly used machine learning classifiers were developed and evaluated on an independent test set. Results: The support vector machine with a radial basis function kernel (SVM-RBF) using LASSO-selected features achieved the best performance, with an AUC (area under the curve) of 0.903 (95% CI: 0.84–0.96), accuracy of 90.2%, sensitivity of 80.3%, and specificity of 100%. The average precision exceeded 0.92, and the calibration curve demonstrated good agreement (Brier score: 0.092). Interpretability analyses with SHAP (Shapley additive explanations) and LIME (local interpretable model-agnostic explanations) applied to the LightGBM (Light Gradient Boosting Machine) model confirmed EO%, RBC, and WBC as the most influential predictors. Conclusion:This parsimonious and interpretable model, relying solely on routine blood indicators, may enable timely and accurate diagnosis of acute appendicitis while providing additional insights, particularly in resource-limited settings.</div></div>","PeriodicalId":55536,"journal":{"name":"American Journal of Emergency Medicine","volume":"102 ","pages":"Pages 39-48"},"PeriodicalIF":2.2,"publicationDate":"2026-01-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146031718","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-10DOI: 10.1016/j.ajem.2026.01.010
Rachel E Bridwell, Ali Pourmand, Michael Gottlieb, Brit Long
{"title":"Practice changing articles: Efficacy of albuterol-budesonide inhaler compared with albuterol alone in mild asthma.","authors":"Rachel E Bridwell, Ali Pourmand, Michael Gottlieb, Brit Long","doi":"10.1016/j.ajem.2026.01.010","DOIUrl":"https://doi.org/10.1016/j.ajem.2026.01.010","url":null,"abstract":"","PeriodicalId":55536,"journal":{"name":"American Journal of Emergency Medicine","volume":" ","pages":""},"PeriodicalIF":2.2,"publicationDate":"2026-01-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146031688","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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