Are We Overusing Coagulation Studies in the Emergency Department?

Methods: This retrospective observational study, conducted in the ED of King Saud University Medical City (KSUMC) in Riyadh, Saudi Arabia, during July and August of 2021(2 months) examined coagulation profile requests. Patients' demographic data (age and gender), medical and clinical history (presenting complaint, comorbidities, and diagnosis), the use of antiplatelets or anticoagulant agents and laboratory values for PT, APTT, and INR were collected. We calculated the total cost of unnecessary coagulation profile testing based on the independent assessment of two ED consultants. Results: Of 1,754 patients included in the study, 811 (46.2%) were males and 943 (53.8%) were females, with a mean age of 42.1 ± 18.5 years. There were 29 (1.7%) patients with liver disease and 21 (1.2%) patients had thromboembolic disease. The majority of the patients' results were within normal levels of PT (n = 1,409, 80.3%), APTT (n = 1,262, 71.9%), and INR (n = 1,711, 97.4%). Evidence of active bleeding was detected in 29 patients (1.7%). Among patients with bleeding only one had an abnormal INR (3.01) and was on warfarin. Forty-six (2.6%) patients had elevated INR level. Cohen's kappa between the two consultants was recorded at 0.681 (substantial agreement) in their assessment of the appropriateness of coagulation tests requests and both consultants believed that 1,051 tests (59.9%) were not indicated and were unnecessary. The expected annual cost saving if the unnecessary tests were removed would be around SAR 1,897,200 (approximately US$ 503,232) which is about SAR 180000 (US$ 48000)/1000 patients. Conclusion: This study showed that coagulation tests are overused in the ED. More than half of coagulation profile tests in our study population were deemed unnecessary and associated with significant cost. Targeted testing based on specific patient presentation and medical history can guide physicians in wisely choosing who needs coagulation studies.

Accuracy of Brain Computed Tomography Diagnosis by Emergency Medicine Physicians.

Objectives: The objective of this study is to prospectively analyze emergency physicians' (EP's) abilities to interpret noncontrast computed tomography (NCCT) brain images in a blinded fashion and assess whether they can make medical decisions solely based on their interpretations. Methods: A cross-sectional study was conducted at the emergency department (ED), King Saud University Medical City (KSU-MC), Saudi Arabia, over a period of one year, from May 2014 to May 2015. Any patient who underwent plain brain NCCT during the study period in our ED was included in this study. An independent attending neuroradiologist compared the EP's interpretations with the official final reports dictated by an on-call radiologist. Results: A brain NCCT prospective chart audit of 1,524 patients was interpreted by ED physicians (EP) at KSU-MC from 2014-2015. The ages of patients were between 14 and 107 years, and the mean ± SD age was 45.6 ± 22.1 years. Radiological brain lesions were confirmed by EPs and radiology physicians in 230 (15.09) and 239 (15.68) patients, respectively, out of which concordance was observed in 170 (71.13) cases, with a kappa value of r = 0.675. Normal, chronic, and nil acute reports were made by EPs and radiology physicians for 1,295 (84.97) patients and 1,285 (84.32) patients, respectively, out of which concordance was observed in 1,225 (95.33) cases, with a kappa value of r = 0.672. The study results demonstrated that the overall agreement between EPs and radiologist specialists was 91.6, with a kappa value of .675 (p < 0.001). Conclusion: Emergency physicians are moderately accurate at interpreting brain NCCT compared to radiologists. More research is needed to discover the most cost-effective technique for reducing the number of significant misinterpretations.

Shotgun whole genome sequencing of drug-resistance Streptococcus anginosus strain 47S1 isolated from a patient with pharyngitis in Saudi Arabia.

BACKGROUND: Streptococcus anginosus is an emergence opportunistic pathogen that colonize the human upper respiratory tract (URT), S. anginosus alongside with S. intermedius and S. constellatus, members of S. anginosus group, are implicated in several human infections. However, our understanding this bacterium to the genotype level with determining the genes associated with pathogenicity and antimicrobial resistance (AMR) is scarce. S. anginosus 47S1 strain was isolated from sore throat infection, the whole genome was characterized and the virulence & AMR genes contributing in pathogenicity were investigated. METHODOLOGY: The whole genome of 47S1 was sequenced by Illumina sequencing technology. Strain 47S1 genome was de novo assembled with different strategies and annotated via PGAP, PROKKA and RAST pipelines. Identifying the CRISPR-Cass system and prophages sequences was performed using CRISPRloci and PhiSpy tools respectively. Prediction the virulence genes were performed with the VFDB database. AMR genes were detected in silico using NCBI AMRFinderPlus pipeline and CARD database and compared with in vitro AST findings. RESULTS: ß-hemolytic strain 47S1 was identified with conventional microbiology techniques and confirmed by the sequences of 16S rRNA gene. Genome of 47S1 comprised of 1981512 bp. Type I-C CRISPR-Cas system and 4 prophages were detected among the genome of 47S1. Several virulence genes were predicted, most of these genes are found in other pathogenic streptococci, mainly lmb, pavA, htrA/degP, eno, sagA, psaA and cpsI which play a significant role in colonizing, invading host tissues and evade form immune system. In silico AMR findings showed that 47S1 gnome harbors (tetA, tetB &tet32), (aac(6')-I, aadK &aph(3')-IVa), fusC, and PmrA genes that mediated-resistance to tetracyclines, aminoglycosides, fusidic acid, and fluoroquinolone respectively which corresponds with in vitro AST obtained results. In conclusion, WGS is a key approach to predict the virulence and AMR genes, results obtained in this study may contribute for a better understanding of the opportunistic S. anginosus pathogenicity.