JEM reports最新文献

英文中文

Modeling the value of an emergency department influenza vaccination program 急诊科流感疫苗接种计划的价值建模

JEM reports

Pub Date : 2023-09-01 DOI: 10.1016/j.jemrpt.2023.100048

Erin L. Simon , Bethany Crouse , Thomas Langlois , Jaideep M. Karamchandani , Christopher S. Ramos , McKinsey Muir , Stephen Sayles III , Michael P. Phelan

Background

Seasonal influenza continues to present a significant annual burden as the vaccination rate in the United States is 51.8%. Emergency Department (ED) based influenza programs have been successfully implemented and improve vaccine uptake, reduce incidence and costs, and improve outcomes.

Objective

To develop a predictive model to assess preventable influenza cases, hospitalizations, fatalities, and incremental cost avoidance based on the unvaccinated population.

Methods

A retrospective cohort of ED encounters limited to Medicare and Medicaid populations was performed across 14 tertiary care hospital EDs and six freestanding EDs for 2020. The total number of unvaccinated individuals was identified to determine the potential impact of an ED vaccination campaign. The average cost and loss per inpatient stay was identified from prior industry Medicare benchmark data and was utilized to extrapolate Medicaid losses. Results from published cost-effectiveness studies identified the vaccination thresholds to prevent one additional case of influenza, one additional hospitalization, and one additional fatality.

Results

A total of 39,463 unvaccinated individuals were identified, with 14,064 classified as Medicare, and 25,379 classified as Medicaid. Assuming a 95% target outreach, 90% medical eligibility, and 70% acceptance rate, 414 influenza cases would be prevented (266 Medicaid, 148 Medicare), 28 hospitalizations would be prevented (18 Medicaid, 10 Medicare), and eight deaths would be prevented (5 Medicaid, 3 Medicare). Accordingly, a reduction in admissions would prevent $409,360 in total inpatient medical costs and $36,232 in losses to healthcare systems.

Conclusion

An ED-based influenza vaccination program would have a measurable impact on patient influenza disease burden and associated medical expenditures.

背景季节性流感仍然是一个重大的年度负担，因为美国的疫苗接种率为51.8%。基于急诊科的流感计划已经成功实施，提高了疫苗的接种率，降低了发病率和成本，并改善了结果。目的建立一个预测模型，以评估未接种疫苗人群中可预防的流感病例、住院人数、死亡人数和增量成本规避情况。方法2020年，对14家三级护理医院急诊室和6家独立急诊室进行了一项仅限于医疗保险和医疗补助人群的急诊遭遇回顾性队列研究。确定未接种疫苗的总人数，以确定ED疫苗接种活动的潜在影响。每次住院的平均成本和损失是从以前的行业医疗保险基准数据中确定的，并用于推断医疗补助损失。已发表的成本效益研究结果确定了预防一例新增流感、一例新增住院和一例新增死亡的疫苗接种阈值。结果共有39463名未接种疫苗的人被确认，其中14064人被归类为医疗保险，25379人被归类于医疗补助。假设95%的目标覆盖率、90%的医疗资格和70%的接受率，414例流感病例将得到预防（266例医疗补助，148例医疗保险），28例住院（18例医疗援助，10例医疗保险，8例死亡（5例医疗援，3例医疗保险。因此，住院人数的减少将防止409360美元的住院总医疗费用和36232美元的医疗系统损失。结论基于ED的流感疫苗接种计划将对患者流感疾病负担和相关医疗支出产生可衡量的影响。

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引用次数: 0

Ingestion of a saw-edge knife in a patient with mental illness: A unique and uncommon presentation 精神疾病患者摄入锯刃刀:一种独特而不常见的表现

JEM reports

Pub Date : 2023-09-01 DOI: 10.1016/j.jemrpt.2023.100044

Bharath Gopinath , Prakash Ranjan Mishra , Nihar Ranjan Dash , Gaurav Kumar , Jayapal Rajendran , Rajesh Panwar

Background

Foreign body ingestion leading to complications is rare, and the need for surgery is even rarer. Foreign body ingestion in patients with mental illness poses challenges in diagnosis due to the varied and often delayed presentation and difficulties in history-taking. Symptom-based management in patients with mental illness may sometimes result in incorrect diagnoses and delayed treatment. Detailed history and investigation may uncover unexpected findings.

Case report

We present the case of a 28-year-old male patient with a history of depression and suicidal tendencies who admitted to ingesting a knife after repeated probing. Although there were no signs of peritonitis, abdominal imaging revealed a 17 cm saw-edge knife traversing from the duodenum to the adjacent right lobe of the liver. The patient successfully underwent exploratory laparotomy with knife removal, duodenotomy repair, and feeding jejunostomy.

Why should an emergency physician be aware of this?

A high index of suspicion is required to diagnose complications of foreign body ingestion, especially in patients with mental illness. In many high-volume emergency departments, these patients receive symptomatic management and are discharged with advice for outpatient follow-up. Emergency physicians should be aware that meticulous history-taking and a detailed examination are necessary in patients with mental illness. This approach facilitates a comprehensive diagnosis, timely management, and improved outcomes.

背景:异物摄入导致并发症是罕见的，需要手术的更是罕见。精神疾病患者的异物摄入，由于各种各样的，往往延迟的表现和困难的历史，提出了诊断的挑战。精神疾病患者基于症状的管理有时可能导致错误的诊断和延迟治疗。详细的历史和调查可能会发现意想不到的结果。病例报告:我们报告一例28岁的男性患者，有抑郁史和自杀倾向，他承认在反复探查后吞下一把刀。虽然没有腹膜炎的迹象，但腹部影像学显示从十二指肠到邻近的肝右叶有一把17厘米的锯刃刀。患者成功行剖腹探查术并刀切除、十二指肠切除修复、空肠喂养吻合术。急诊医生为什么要意识到这一点?诊断异物摄入并发症需要高度的怀疑指数，特别是对精神疾病患者。在许多大容量急诊科，这些患者接受症状管理，出院时建议进行门诊随访。急诊医生应该意识到，对精神疾病患者进行细致的病史记录和详细的检查是必要的。这种方法有助于全面诊断，及时管理和改善结果。

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引用次数: 0

Rare case of SVC perforation secondary to PICC line PICC线路继发SVC穿孔的罕见病例

JEM reports

Pub Date : 2023-09-01 DOI: 10.1016/j.jemrpt.2023.100047

Trung V. Ho , Thomas L. Schumann , Eric J. Schmieler

Background

While relatively rare, complications from peripherally inserted central catheter (PICC) lines can carry serious morbidity and mortality. PICC lines are known to be associated with infection and thromboembolism, though literature discussing vessel perforation from PICC lines is limited, and to our knowledge there are no reports describing specifically the superior vena cava (SVC) being perforated from a PICC line.

Case report

In this report, we describe a case of a 48-year-old female who presented with chest pain in the setting of having a PICC line for chronic medical conditions. A computed tomography with angiography (CTA) was obtained and revealed perforation of the SVC and subsequent mediastinitis from her PICC line. Her PICC line was immediately secured, broad spectrum antibiotics were given, and cardiothoracic surgery was consulted. She subsequently had her PICC removed under ultrasound guidance with plans for immediate operative intervention if that failed. The patient did well and was ultimately discharged with a new PICC line.

Why should an emergency physician be aware of this?

Although large vessel perforation from PICC lines is relatively rare, it can be associated with significant morbidity and needs immediate treatment. It is important for the emergency physician to have knowledge of this complication to make the diagnosis and initiate timely specialist intervention.

背景:虽然相对罕见，但外周插入中心导管(PICC)线的并发症可导致严重的发病率和死亡率。已知PICC线与感染和血栓栓塞有关，尽管讨论PICC线血管穿孔的文献有限，而且据我们所知，没有报道专门描述上腔静脉(SVC)从PICC线穿孔。病例报告在本报告中，我们描述了一例48岁的女性，她在PICC线诊断慢性疾病时出现胸痛。计算机断层扫描血管造影(CTA)显示SVC穿孔和随后的纵隔炎从她的PICC线。她的PICC线立即固定，给予广谱抗生素，并咨询了心胸外科手术。随后，她在超声指导下切除了PICC，如果手术失败，她计划立即进行手术干预。患者情况良好，最终通过新的PICC导管出院。急诊医生为什么要意识到这一点?虽然PICC系的大血管穿孔相对罕见，但它可能与显著的发病率相关，需要立即治疗。对急诊医生来说，了解这种并发症对诊断和及时进行专科干预是很重要的。

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引用次数: 0

A mimicker of serious neck pain - Acute calcific tendinitis of the longus colli 严重颈部疼痛的模仿者——急性钙化性颈长肌腱炎

JEM reports

Pub Date : 2023-09-01 DOI: 10.1016/j.jemrpt.2023.100040

David Peng , Christina Seow , Alison Toczek , Ian Ferguson , David Massasso

引用次数: 0

Re-presentations to the emergency department post COVID-19 admission in Australia 在澳大利亚，COVID-19入院后急诊部门的重新介绍

JEM reports

Pub Date : 2023-07-01 DOI: 10.1016/j.jemrpt.2023.100049

Zahra Al Haloob, G. Braitberg, Anthony Tu Tran, J. Rotella, Anselm Wong

引用次数: 0

Obstructive pyelonephritis caused by the accidental malpositioning of a urethral catheter into the ureter: A case report 导尿管误插输尿管致梗阻性肾盂肾炎1例

JEM reports

Pub Date : 2023-06-01 DOI: 10.1016/j.jemrpt.2023.100041

Hiroshi Ito, Toshiya Nakashima, Jura Oshida, Taisuke Kodama, Sayato Fukui, Daiki Kobayashi

Background

Indwelling urethral catheters can sometimes be accidently inserted into the ureter, which impedes urine flow.

Case report

We report a 74-year-old Japanese woman with neurogenic bladder who visited to our hospital due to fever. She was diagnosed as pyelonephritis based on her symptoms and laboratory findings, including pyuria. Abdominal computed tomographic scan showed an indwelling urethral catheter accidently malpositioned into a right ureter, caused ureteral dilatation, and hydronephrosis. Her urethral catheter was replaced, and she was successfully treated with piperacillin-tazobactam and cefotiam.

Why should an emergency physician be aware of this?

Urethral catheter malpositioning into the ureter may be asymptomatic and overlooked in patients with neurogenic bladder, which can result in obstructive pyelonephritis. Prompt urethral catheter replacement is essential in treating such conditions.

留置导尿管有时会意外插入输尿管，从而阻碍尿液流动。病例报告我们报告一名74岁的日本妇女，因发烧到我们医院就诊。根据她的症状和化验室检查结果，包括脓尿，诊断为肾盂肾炎。腹部计算机断层扫描显示留置导尿管意外错位进入右输尿管，导致输尿管扩张及肾积水。她的导尿管被更换，她成功地用哌拉西林-他唑巴坦和头孢替安治疗。急诊医生为什么要意识到这一点?在神经源性膀胱患者中，导尿管错位进入输尿管可能是无症状和被忽视的，这可能导致梗阻性肾盂肾炎。及时更换导尿管是治疗此类疾病的必要条件。

引用次数: 0

Chewing gum bezoar in a pediatric patient 儿科病人嚼牛黄口香糖

JEM reports

Pub Date : 2023-06-01 DOI: 10.1016/j.jemrpt.2023.100036

Chizite Iheonunekwu , Calvin Jackson , Kara Weichler , Oscar N. Emihe , Erin L. Simon

Background

A bezoar is a collection of indigestible material found in the gastrointestinal (GI) tract that has become large enough not to progress through the rest of the intestinal system. Bezoars are caused by both food and non-food materials. Symptoms resemble other forms of GI obstructions with post-prandial fullness, abdominal pain, nausea, vomiting, and weight loss.

Case report

A five-year-old male presented to the emergency department (ED) complaining of abdominal pain and diarrhea. He reportedly swallowed a large quantity of chewing gum a day before his presentation. A computed tomography (CT) of the abdomen and pelvis revealed a gastric bezoar due to chewing gum. The patient was successfully treated with several passes of an esophagoduodenoscopy (EGD) to remove the chewing gum mass.

Why should an emergency physician be aware of this?

Gastric bezoars are rare and can vary in their presentations. ED physicians must consider bezoars in their differential diagnosis for pediatric patients presenting with postprandial fullness, abdominal pain, nausea, vomiting, or weight loss. Complications of bezoars include ischemia and perforation. A thorough history can help delineate the material causing the bezoar. Treatment of bezoars varies and can include treatment with carbonated beverages, endoscopy, and surgery.

牛黄是一种在胃肠道(GI)中发现的不易消化的物质的集合，这些物质已经变得足够大，无法通过肠道系统的其他部分。牛粪是由食物和非食物材料引起的。症状类似于其他形式的胃肠道阻塞，伴有餐后饱腹感、腹痛、恶心、呕吐和体重减轻。病例报告一名五岁男性到急诊科(ED)主诉腹痛和腹泻。据报道，他在演讲前一天吞下了大量口香糖。腹部和骨盆的计算机断层扫描(CT)显示咀嚼口香糖引起的胃牛黄。患者通过多次食管十二指肠镜检查(EGD)成功切除了口香糖团块。急诊医生为什么要意识到这一点?胃牛黄很少见，其表现形式也各不相同。对于出现餐后饱腹、腹痛、恶心、呕吐或体重减轻的儿科患者，急诊科医生必须在鉴别诊断时考虑牛粪。牛黄的并发症包括缺血和穿孔。详细的病史可以帮助描述引起牛黄的物质。牛黄的治疗方法多种多样，包括碳酸饮料、内窥镜检查和手术治疗。

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引用次数: 0

Emergent pharmacological management of ulnar artery thrombosis 尺动脉血栓形成的紧急药物治疗

JEM reports

Pub Date : 2023-06-01 DOI: 10.1016/j.jemrpt.2023.100019

Henry Zou , Bethany Beard MD

Background

Ulnar artery thrombosis (UAT) refers to occlusion of the ulnar artery due to a blood clot and is a subcategory of hypothenar hammer syndrome (HHS). We present a case of right ulnar artery thrombosis that was pharmacologically managed in the Emergency Department (ED) and inpatient ward.

Case report

A 52-year-old male with a history of anemia and elevated ferritin presented to the ED with a 5-day history of skin discoloration, numbness, and tingling of his right 5th finger. CT angiogram showed a focal 1.5 cm-long thrombotic ulnar artery occlusion at the palmar bifurcation and embolic occlusion of the 5th digital arteries in the finger. Following consultation with vascular surgery, he was given intravenous heparin, transitioned to apixaban for lifelong anticoagulation therapy, and discharged following the placement of a Zio^Ⓡ patch.

Why should an emergency physician be aware of this?

The patient's career involving manual labor, elevated ferritin, and smoking history may have been risk factors for UAT development. Our case illustrates the value of interdisciplinary collaboration and conservative management in low-acuity cases of UAT.

背景尺骨动脉血栓形成（UAT）是指由于血栓导致的尺骨动脉闭塞，是小鱼际锤综合征（HHS）的一个子类。我们报告了一例在急诊科（ED）和住院病房进行药物治疗的右尺动脉血栓形成病例。病例报告：一名52岁男性，有贫血和铁蛋白升高病史，向急诊科就诊，有5天的皮肤变色、麻木和右五指刺痛病史。CT血管造影显示手掌分叉处有1.5厘米长的局灶性血栓性尺动脉闭塞，手指第5指动脉栓塞闭塞。在咨询了血管手术后，他接受了静脉注射肝素，转为阿哌沙班进行终身抗凝治疗，并在放置ZioⓇ贴片后出院。为什么急诊医生应该意识到这一点？患者的体力劳动、铁蛋白升高和吸烟史可能是UAT发展的危险因素。我们的案例说明了跨学科合作和保守管理在UAT低敏锐度病例中的价值。

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引用次数: 0

Traumatic hypopharyngeal perforation and pneumomediastinum from a toothbrush 外伤性下咽穿孔和纵隔气由牙刷引起

JEM reports

Pub Date : 2023-06-01 DOI: 10.1016/j.jemrpt.2023.100017

Rahul V. Nene , Mena Said , Philip A. Weissbrod , Christanne H. Coffey , Peter J. Witucki

Background

Hypopharyngeal injuries are infrequently described, and management is extrapolated from the literature on esophageal perforations. Cases may present with associated pneumomediastinum and are associated with high morbidity and mortality, particularly if there is a delay in diagnosis.

Case Report

A 52-year-old man presented with dyspnea and neck swelling after inserting a toothbrush into his throat when he thought he was developing an allergic reaction to sushi. He had extensive neck and chest crepitus, with pneumomediastinum identified on chest x-ray. Flexible laryngoscopy was used to directly identify a posterior pharyngeal perforation. The patient was hemodynamically stable without signs of sepsis, and the otolaryngology consultant deferred surgical intervention. He was successfully treated with conservative medical management and made a full recovery.

Why should an emergency physician be aware of this?

Hypopharyngeal perforation is a rare diagnosis with high morbidity and mortality. Early diagnosis, broad-spectrum antibiotics, and early surgical consultation are essential to minimize complications of this rare presentation.

背景咽部损伤很少被描述，治疗方法是从食管穿孔的文献中推断出来的。病例可能伴有纵隔气肿，并伴有高发病率和死亡率，特别是在诊断延误的情况下。病例报告:一名52岁男子以为自己对寿司过敏，将牙刷插入喉咙后出现呼吸困难和颈部肿胀。他有广泛的颈部和胸部震颤，胸片上发现纵隔气肿。使用柔性喉镜直接识别咽后穿孔。患者血流动力学稳定，无脓毒症症状，耳鼻喉科会诊医生推迟了手术干预。经保守治疗，患者完全康复。急诊医生为什么要意识到这一点?下咽穿孔是一种罕见的诊断，发病率和死亡率都很高。早期诊断，广谱抗生素和早期手术咨询是必要的，以尽量减少并发症这种罕见的表现。

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引用次数: 0

Cotton fever: A case report and review of the literature 棉花热1例报告及文献复习

JEM reports

Pub Date : 2023-06-01 DOI: 10.1016/j.jemrpt.2023.100030

Natasha Tobarran , John Huchison , Emily Kershner , Andrew Chambers , Kirk L. Cumpston , Brandon K. Wills

Background

The term “cotton fever” describes a benign, self-limited febrile response within minutes following cotton filter use with intravenous (IV) drug injection. We present a case of Pantoea species (previously Enterobacter agglomerans) bacteremia related to injection of solubilized oxycodone.

Case report

A 33-year-old male solubilized half of an oxycodone 5 mg tablet in tap water, filtered it with cotton and injected it intravenously. He immediately felt unwell. Initial vital signs included a temperature of 40.5 °C, blood pressure 150/107 mmHg, heart rate 170 bpm, respiratory rate 28 bpm, and SpO2 of 98% on room air. His physical exam was notable only for rigors. Initial laboratory studies demonstrated a serum lactate of 2.7 mmol/L without leukocytosis. He was treated with vancomycin and piperacillin/tazobactam for two days with resolution of fever. Blood cultures were positive for Pantoea species resistant to ampicillin and cefazolin. He continued piperacillin/tazobactam for three additional days then transitioned to oral levofloxacin for seven days upon discharge.

Why should an emergency physician be aware of this?

Cotton fever describes an acute, febrile response following IV injection using cotton as a filter. The initial febrile reaction could be due to pyrogens or preformed endotoxins. Bacteremia from Enterobacter agglomerans (now Pantoea species) is possible and is frequently resistant to amoxicillin and first- and second-generation cephalosporins.

背景:“棉热”一词描述的是在静脉注射药物后使用棉滤网几分钟内出现的良性、自限性发热反应。我们提出一个病例Pantoea种(以前肠杆菌团聚)菌血症与注射溶氧可酮。病例报告:一名33岁男性将一半羟考酮5毫克片剂溶解于自来水中，用棉花过滤后静脉注射。他立刻感到不舒服。最初的生命体征包括体温40.5°C，血压150/107 mmHg，心率170 bpm，呼吸率28 bpm，室内空气SpO2为98%。他的体格检查只因为严格而引人注目。初步实验室研究显示血清乳酸2.7 mmol/L，无白细胞增多。患者给予万古霉素和哌拉西林/他唑巴坦治疗2天，发热消退。血培养对氨苄西林和头孢唑林耐药的泛菌属呈阳性。他继续服用哌拉西林/他唑巴坦3天，出院后改用口服左氧氟沙星7天。急诊医生为什么要意识到这一点?棉花热是指使用棉花作为过滤器进行静脉注射后出现的急性发热反应。最初的发热反应可能是由于热原或预先形成的内毒素。可能出现聚集肠杆菌(现在是Pantoea种)引起的菌血症，并且经常对阿莫西林和第一代和第二代头孢菌素耐药。

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