CJEM最新文献

Introduction: As point-of-care ultrasound (POCUS) applications expand in the emergency department (ED), its utilization within the management of patients presenting with rapid atrial fibrillation (AF) or flutter (AFL) is unclear. The co-morbidity of heart failure and AF/AFL complicates the rate/rhythm control and disposition of this population. ED physicians diagnose heart failure by integrating POCUS left ventricular function assessment, but studies have not focused on the rapid AF/AFL population.

Methods: Our survey aimed to explore the use, integration, and perceived barriers of POCUS left ventricular function assessment in AF/AFL patients. Canadian ED physicians and residents who are members of the Canadian Association of Emergency Physicians (CAEP) completed an online survey through email between February and March 2024.

Results: We received 91 responses. For patients presenting with rapid AF/AFL with no prior imaging in the last 12 months, 51% of respondents indicated using cardiac POCUS for left ventricular function assessment. Half of respondents indicated that distinguishing between normal and severely reduced left ventricular function with POCUS would help guide management in rapid AF/AFL patients, and 77% responded that it would help guide disposition. A majority, 63% of respondents, agreed the assessment of left ventricular function would assist in determining if they will use calcium channel blockers. Perceived barriers included confidence in interpretation, skill level, machine accessibility, and accuracy of left ventricular function assessment in rapid AF/AFL patients.

Conclusion: Our survey demonstrated that half of ED physicians and residents are currently integrating POCUS left ventricular function assessment in rapid AF/AFL patients and most adapt their clinical decision making based on their findings, notably in whether or not to use calcium channel blockers. Among the perceived barriers, ED physicians most commonly reported low POCUS expertise level and the accuracy of left ventricular assessment in rapid AF/AFL.

Objective: Urolithiasis is a common urological condition accounting for more than 1.3 million emergency department visits annually with costs exceeding $2.8 billion (Scales et al. in Eur Urol. 62:160-5, 2012;Eaton et al. in J Endourol 27:1535-1538, 2013;Antonelli et al. in Eur Urol 66:724-729, 2014;). Non-contrast computed tomography of the abdomen and pelvis remains the diagnostic gold standard. Studies assessing urinalysis and renal point-of-care ultrasound (PoCUS), individually, to diagnose symptomatic ureterolithiasis demonstrate inadequate sensitivities (Mefford et al. in West J Emerg Med 18:775, 2017;Eray et al. in Am J Emerg Med 21:152-4, 2003;Luchs et al. in Urology 59:839-842, 2002;Smith-Bindman et al. in N Engl J Med 371:1100-1110, 2014;Riddell et al. in West J Emerg Med 15:96-100, 2014;Rosen et al. in J Emerg Med 16:865-870, 1998;Gaspari and Horst in Acad Emerg Med 12:1180-1184, 2005;Watkins et al. in Emerg Med Australas 19:188-195, 2007;). The primary objective of this study was to assess the test characteristics of the U-PoCUS (urinalysis with renal point-of-care ultrasound) protocol.

Methods: This was an Institutional Review Board approved, multi-center, retrospective chart review at a university-based healthcare system. Study investigators included all patients who presented from January 1, 2016 through June 30, 2020, and underwent computed tomography of the abdomen and pelvis and had a urinalysis and PoCUS for suspected ureterolithiasis. Investigators utilized MedCalc (Version 19.1.6) and standard 2 × 2 tables to calculate test characteristics with 95% confidence intervals (CI).

Results: Study investigators enrolled 183 patients, including 122 patients diagnosed with computed tomography confirmed ureterolithiasis and 61 patients without it. The combination of hematuria and/or hydronephrosis on PoCUS had a sensitivity of 99.2% (95.6-100) and a specificity of 14.8% (7-26.2) for the presence of urolithiasis. Positive predictive value and negative predictive value were 69.9% (67.7-72.1) and 90% (53.9-98.6), respectively.

Conclusion: The presence of hematuria and/or hydronephrosis was 99.2% sensitive for the presence of ureterolithiasis diagnosed on computed tomography of the abdomen and pelvis. The U-PoCUS protocol missed only one symptomatic ureterolithiasis.

Background: Recent advancements in artificial intelligence have shown promise in enhancing diagnostic precision within healthcare sectors. In emergency departments, artificial intelligence has demonstrated potential for improving triage, guiding the choice of radiologic imaging and crafting individualized medical notes and discharge summaries, including tailored care plans. Advances in generative artificial intelligence have led to the development of sophisticated models such as OpenAI's GPT-4. This study assessed the ability of generative artificial intelligence in diagnosis and management in emergency medicine. Specifically, we compared GPT-4 with the performance of emergency medicine trainees in Canada, as gauged by the Canadian In-Training Examination.

Methods: We compared the performance of emergency medicine residents to GPT-4 on the Canadian in-training exams for the years 2021 and 2022. Each question was entered into a fresh GPT-4 chat and the first response was recorded without any prompting. GPT-4's responses were then assessed using the same marking grid that is employed for evaluating medical trainees. We then compared GPT-4'sscores to the average scores of each post-graduate year (PGY) level of residents across all FRCPC training programs. Ethical approval was obtained, then Canadian In-Training Examination committee provided exam questions and anonymized national results.

Results: The participants in this study included 389 residents in 2021 and 333 residents in the 2022 exams. In 2021, mean trainee scores increased progressively across the levels, with PGY1 trainees scoring 48.0% (SD 15.6), PGY2 at 56.2% (SD 14.7), PGY3 at 59.8% (SD 16.7), PGY4 at 67.2% (12.3), and PGY5 at 70.1% (SD 12.5), whereas GPT-4 scored 88.7%. In 2022, a similar pattern, with PGY1 scoring 46.3% (SD 14.7), PGY2 at 51.8% (SD 14.7), PGY3 at 58.2% (SD 14.3), PGY4 at 66.2% (SD 15.3), and PGY5 at 64.3% (SD 8.5), while GPT-4 scored 82.0%.

Conclusions: GPT-4 has shown impressive capabilities, surpassing the performance of medical trainees at different postgraduate levels in the clinical written exam. These findings highlight the potential of artificial intelligence to serve as a valuable support tool in medical practice. However, it should be used with caution and must not substitute for established, evidence-based medical resources.

Objectives: Alberta's Virtual MD program was established to enhance nurse tele-triage and divert low-acuity patients from the emergency department (ED). This study describes the use of Virtual MD and its impact on healthcare utilization.

Methods: Demographic and clinical characteristics of Virtual MD patients were compared with Health Link 811 callers and the overall Alberta population between April 1, 2022, and March 31, 2023. Virtual MD recommendations included seeing a primary care provider, going to ED/urgent care, and self-management at home. Concordance with recommendations was determined using linked health administrative data.

Results: Virtual MD patients (n = 19,312) had a mean age of 34.8 years and were mostly female (62.3%). Compared to Health Link 811 callers, Virtual MD patients were slightly older (≥ 55 years) (20.8% vs. 25.0%). Of patients called within 4 h, 55.7% visited primary care within 14 days as advised, 60.0% visited ED within 2 days as advised and 52.5% of those advised to self-manage care at home did not use any healthcare within 14 days. Those advised to seek primary care had a higher odds [OR = 1.65 (95%CI: 1.24-2.21)] of family practice-sensitive conditions when they presented at ED compared to those advised to seek ED care. Hospitalization within 2 weeks was lower for patients advised to see primary care compared to those advised to see ED [4 h callback: OR = 0.33 (95%CI: 0.26 - 0.43), 24 h callback: OR = 0.15 (95%CI 0.08 - 0.28)].

Conclusion: Virtual MD effectively triaged patients, with over half following through on recommendations to see primary care, see ED, or self-manage care at home. Patients referred to primary care, but instead choosing to visit ED, were more likely to present with family practice-sensitive conditions, demonstrating appropriateness of the initial primary care advice. Overall, the Virtual MD service enables patients to access more appropriate levels of care for their healthcare needs.

Objectives: D-dimer testing can reduce imaging utilization in the workup of pulmonary embolism, but the optimal cutoff remains unclear. The conventional D-dimer cutoff is < 500 µg/L Fibrinogen Equivalent Units, while the age-adjusted cutoff in patients over 50 is age × 10. Newer probability-adjusted strategies-the YEARS criteria and PEGeD algorithm-allow a higher threshold (D-dimer < 1000 µg/L) for select low-risk patients. We aimed to retrospectively compare the diagnostic accuracy of four evidence-based pathways to exclude pulmonary embolism without imaging among our emergency department patients who were imaged.

Methods: A historical patient cohort was generated including all adults who received computed tomography pulmonary angiography or ventilation-perfusion scans after D-dimer testing in three emergency departments in a large urban Canadian center. Electronic medical records were reviewed to retrospectively compare the test performance of four D-dimer pathways: (i) conventional, (ii) age-adjusted, (iii) YEARS, and (iv) PEGeD.

Results: Of 1092 patients, 129 had pulmonary embolism. Conventional and age-adjusted cutoffs were both 100% sensitive (95% CI, 97.1-100.0), with specificities of 3.5% (2.5-4.9) and 6.4% (5.1-8.2). YEARS was 93.8% sensitive (88.2-96.8) and 30.4% specific (27.6-33.4), with PPV of 15.3% (13.0-18.0) and NPV of 97.3% (94.8-98.6). PEGeD was the least sensitive (92.2%, 86.3-95.7), but most specific (39.1%, 36.1-42.3), with PPV of 16.9% (14.3-19.8) and NPV of 97.4% (95.3-98.6). PEGeD would have resulted in the most patients managed without imaging (35.4%), followed by YEARS (27.6%), age-adjusted (5.7%), and the conventional cutoff (3.1%).

Conclusion: While implementation of a probability-adjusted D-dimer pathway, such as YEARS or PEGeD, would have substantially reduced imaging utilization, these strategies may miss some cases of pulmonary embolism detectable by both age-adjusted and conventional cutoffs. We add to the heterogeneity of safety data, suggesting that adjustment of D-dimer to clinical probability represents a trade-off between sensitivity and imaging utilization.