Academic Emergency Medicine最新文献

Background: Syncope is a frequent reason for hospitalization from the emergency department (ED), but the benefit of hospitalization is unclear. This systematic review and meta-analysis (SRMA) aims to cohere and synthesize the best current evidence regarding the potential benefit of hospitalization for ED syncope patients for developing an evidence-based ED syncope management guideline.

Methods: We conducted a SRMA according to the patient-intervention-control-outcome (PICO) framework: In patients 16 years of age or older who present to the ED with syncope (population), does hospitalization (intervention) or direct ED discharge (comparison) improve short-term outcomes (outcome)? The primary outcome was a composite of all adverse events as defined by individual studies, up to 30 days. Two reviewers independently assessed articles for inclusion and methodological quality. We measured heterogeneity among included studies with I-squared statistic and used GRADE criteria to assess the quality of evidence.

Results: Our search strategy identified 2140 publications and included 18 publications (510,545 participants) in the analysis. All studies reported higher rates of adverse events in hospitalized patients (0.7%-43.8%) compared to discharged patients (0%-3.7%). Our meta-analysis detected considerable statistical heterogeneity. The GRADE assessment for all adverse events and all-cause mortality revealed risk ratios of >5 favoring ED discharge for both outcomes at a median follow-up of 30 days. However, point estimates are limited by serious risk of bias, inconsistency, imprecision, indirectness, and publication bias.

Conclusions: Due to the uncertainty of the available evidence, this SRMA's findings do not support a recommendation for or against hospitalizing patients presenting to ED with syncope. However, discharging low-risk patients with syncope from the ED is associated with a low risk of short-term adverse events.

Objective: Artificial intelligence (AI)-based clinical decision support (CDS) has the potential to augment high-stakes clinical decisions in the emergency department (ED). However, its current usage and translation to implementation remains poorly understood. We asked: (1) What is the current landscape of AI-CDS for individual patient care in the ED? and (2) What phases of development have AI-CDS tools achieved?

Methods: We performed a scoping review of AI for prognostic, diagnostic, and treatment decisions regarding individual ED patient care. We searched five databases (MEDLINE, EMBASE, Cochrane Central, Scopus, Web of Science) and gray literature sources from January 1, 2010, to December 11, 2023. We adhered to guidelines from the Joanna Briggs Institute and PRISMA Extension for Scoping Reviews. We published our protocol on Open Science Framework (DOI 10.17605/OSF.IO/FDZ3Y).

Results: Of 5168 unique records identified, we selected 605 studies for inclusion. The majority (369, 61%) were published in 2021-2023. The studies ranged over a variety of clinical applications, patient populations, and AI model types. Prognostic outcomes were most commonly assessed (270, 44.6%), followed by diagnostic (193, 31.9%) and disposition (115, 19%). Most studies remained in the earliest phase of preclinical development (572, 94.5%) with few advancing to later phases (33, 5.5%).

Conclusions: By thoroughly mapping the landscape of AI-CDS in the ED, we demonstrate a rapidly increasing volume of studies covering a breadth of clinical applications, yet few have achieved advanced phases of testing or implementation. A more granular understanding of the barriers and facilitators to implementing AI-CDS in the ED is needed.

Background/objective: Pediatric laceration repairs are common in the emergency department (ED) and often associated with significant procedural anxiety. Despite the increased use of intranasal midazolam (INM) prior to pediatric ED procedures, there is limited, real-world data on the effects of INM on anxiety. This study aimed to describe the proportion of children who were nonresponsive to INM (i.e., exhibited extreme anxiety) and identify factors associated with INM nonresponse.

Methods: This cross-sectional study included a sample of 102 children (ages 2-10 years) who received 0.2 mg/kg INM prior to laceration repair in the ED. Procedural anxiety was assessed using the modified Yale Preoperative Anxiety Scale (mYPAS). Children exhibiting extreme procedural anxiety (mYPAS score ≥72.91) when procedure started were labeled as INM nonresponders. Bivariate and multivariable logistic regression analyses explored associations between child age, temperament, laceration location, time from INM administration, and likelihood of INM nonresponse.

Results: In this sample, 45.1% of the children were classified as INM nonresponders, exhibiting extreme procedural anxiety. Bivariate analyses indicated that nonresponders were younger, had lower sociability temperament, longer delay between INM administration and the procedure, and were more likely to have extremity lacerations. In the logistic regression, younger age (odds ratio [OR] 0.79, p = 0.034), lower sociability temperament (OR 0.28, p = 0.002), and extremity lacerations (OR 8.04, p = 0.009) were significantly associated with likelihood of INM nonresponse.

Conclusions: Nearly half of the children in our sample exhibited extreme procedural anxiety despite receiving INM. The high incidence of nonresponse to INM has important clinical practice implications and suggests that 0.2 mg/kg INM alone may not be sufficient to manage all pediatric procedural anxiety in the ED. Findings highlight a need for further research examining multimodal strategies to manage procedural anxiety in the pediatric ED, particularly for younger children with low sociability temperament or extremity lacerations.

Objective: Transgender and gender-diverse (TGD) individuals have a gender identity or expression that differs from the sex assigned to them at birth. They are an underserved population who experience health care inequities. Our primary objective was to identify if there are treatment differences between TGD and cisgender lesbian/gay/bisexual/queer (LGBQ) or heterosexual individuals presenting with abdominal pain to the emergency department (ED).

Methods: Retrospective observational cohort study of patients ≥12 years of age presenting to 21 EDs within a health care system with a chief complaint of abdominal pain between 2018 and 2022. TGD patients were matched 1:1:1:1 to cisgender LGBQ women and men and cisgender heterosexual women and men, respectively. Propensity score matching covariates included age, ED site, mental health history, and gastrointestinal history. The primary outcome was pain assessment within 60 min of arrival. The secondary outcome was analgesics administered in the ED.

Results: We identified 300 TGD patients, of whom 300 TGD patients were successfully matched for a total cohort of 1300 patients. The median (IQR) age was 25 (20-32) years and most patients were treated in a community ED (58.2%). There was no difference between groups in pain assessment within 60 min of arrival (59.0% TGD vs. 63.2% non TGD, p = 0.19). There were no differences in the number of times pain was assessed (median [IQR] 2 [1-3] vs. 2 [1-4], p = 0.31) or the severity of pain between groups (5.5 [4-7] vs. 6 [4-7], p = 0.11). TGD patients were more likely to receive nonsteroidal anti-inflammatory drugs (32.0% vs. 24.9%, p = 0.015) and less likely to receive opioids than non-TGD patients (24.7% vs. 36.9%, p = <0.001). TGD and nonbinary patients, along with LGBQ cisgender women (24.7%) and heterosexual cisgender women (34%), were less likely to receive opioids than LGBQ cisgender men (54%) and heterosexual cisgender men (42.3%, p < 0.01).

Conclusion: There was no difference in frequency of pain assessment, regardless of gender identity or sexual orientation. More cisgender men, compared to TGD and cisgender women, received opioids for their pain.