Diverticulitis evaluation and management among United States emergency departments over an eight-year period.

INTRODUCTION: Diverticulitis is a common reason for presentation to the Emergency Department (ED). However, as imaging options, risk stratification tools, and antibiotic options have expanded, there is a need for current data on the changes in incidence, computed tomography (CT) performance, antibiotic usage, and disposition over time. METHODS: This was a cross-sectional study of ED patients with a diagnosis of diverticulitis from 1/1/2016 to 12/31/2023. Using the Epic Cosmos database, all ED visits for acute diverticulitis were identified using ICD-10 codes. Outcomes included total ED presentations for diverticulitis, admission rates, CTs performed, outpatient antibiotic prescriptions, and antibiotics administered in the ED for admitted patients. RESULTS: There were 186,138,130 total ED encounters, with diverticulitis representing 927,326 (0.50 %). The rate of diverticulitis diagnosis increased from 0.40 % to 0.56 % over time. The admission rate declined over time from 33.6 % to 27.7 %, while the CT rate rose from 83.0 % to 92.6 %. Among those discharged, 90.4 % received an antibiotic, which remained consistent over time. Metronidazole (55.1 %) and ciprofloxacin (40.8 %) were the most commonly prescribed antibiotics, followed by amoxicillin-clavulanate (36.1 %). Among those admitted, most received either metronidazole (62.0 %), a fluoroquinolone (40.4 %), a third-generation cephalosporin (18.9 %), or a penicillin-based agent (38.1 %). Among both discharged and admitted patients, there was a marked shift to penicillin-based agents as the primary antibiotic regimen. CONCLUSION: Diverticulitis remains a common ED presentation, with a gradually rising incidence over time. Admission rates have decreased, while CT imaging has become more common. Most patients receive antibiotics, though the specific antibiotic has shifted in favor of penicillin-based agents. These findings can provide key benchmarking data and inform future initiatives to guide imaging and antibiotic use.

Epidemiology of Deep Venous Thrombosis Among United States Emergency Departments Over an Eight-Year Period.

Introduction: Deep vein thrombosis (DVT) is a significant cause of morbidity and mortality worldwide, accounting for substantial healthcare utilization. However, as management strategies have evolved, there is a critical need for current data on incidence, admission rates, and medical management of DVT in the ED setting. Methods: This cross-sectional study analyzed ED presentations for DVT from 2016-2023 using the Cosmos database. Inclusion criteria comprised patients aged ≥18 years with an ICD-10 code for acute extremity DVT. Outcomes included incidence rates, admission rates, and anticoagulant prescriptions. Data were analyzed using descriptive statistics, and subgroup analyses were performed for upper and lower extremity DVTs. Results: Out of 190,144,463 total ED encounters, DVT represented 368,044 cases (0.2%). Among these cases, 119,986 (32.6%) were admitted, with admission rates stable over the study period. Apixaban was the most prescribed anticoagulant (40.3%), followed by rivaroxaban (28.3%), enoxaparin (7.9%), warfarin (3.6%), and dabigatran (0.3%). Use of apixaban increased from 12.4% in 2016 to 56.2% in 2023. Lower extremity DVTs comprised 88.5% of cases, with a 32.1% admission rate, while upper extremity DVTs accounted for 11.7% of cases, with a 37.0% admission rate. Conclusion: This study provides a summary of DVT presentations and management in United States EDs over an eight52 year period. The findings highlight stable incidence rates, reduced admission rates compared to historical data, and a significant shift towards the use of DOACs, particularly apixaban, for outpatient management. These trends underscore the importance of evidence-based practices 54 and ongoing research to optimize DVT management and improve patient outcomes.

Long COVID Among Undocumented Latino Immigrant Populations in the Emergency Department.

This cross-sectional study assesses the understanding of and access to care for long COVID symptoms among undocumented Latino immigrants in US emergency departments (EDs).

Epidemiology of heart failure presentations to United States emergency departments from 2016 to 2023.

INTRODUCTION: Heart failure (HF) is a common condition prompting presentation to the Emergency Department (ED) and is associated with significant morbidity and mortality. However, there is limited recent large-scale, robust data available on the admission rates, evaluation, and treatment of HF in the ED setting. METHODS: This was a cross-sectional study of ED presentations for HF from 1/1/2016 to 12/31/2023 using the Epic Cosmos database. All ED visits with ICD-10 codes corresponding to acute HF were included. We excluded congenital heart disease and isolated right-sided HF. Outcomes included percentage of total ED visits, admission rates, troponin, B-type natriuretic peptide (BNP), chest radiography, and diuretic and nitroglycerin medication administration. Subgroup analyses of medications were performed by medication and route of administration (transdermal, sublingual/oral, and intravenous). RESULTS: Out of 190,694,752 ED encounters, 2,626,011 (1.4 %) visits were due to acute HF. Of these, 1,897,369 (72.3 %) were admitted to the hospital. The majority of patients had a troponin (90.3 %), BNP (91.1 %), and chest radiograph (89.5 %) ordered. 82.5 % received intravenous diuresis, while 46.2 % received oral diuresis. The most common diuretic was furosemide (78.4 % intravenous, 32.5 % oral), followed by bumetanide (9.5 % intravenous, 7.1 % oral), and torsemide (0 % intravenous, 8.1 % oral). Nitroglycerin was given in 26.0 %, with the most common route being sublingual/oral (16.6 %), followed by transdermal (9.2 %) and intravenous (3.5 %). CONCLUSION: HF represents a common reason for ED presentation, with the majority of patients being admitted. All patients received diuresis in the ED, with the majority receiving intravenous diuresis with furosemide. Approximately one-quarter received nitroglycerin with the sublingual/oral route being most common. These findings can help inform health policy initiatives, including admission decisions and evidence-based medication administration.

Diagnostic accuracy of artificial intelligence for identifying systolic and diastolic cardiac dysfunction in the emergency department.

INTRODUCTION: Cardiac point-of-care ultrasound (POCUS) can evaluate for systolic and diastolic dysfunction to inform care in the Emergency Department (ED). However, accurate assessment can be limited by user experience. Artificial intelligence (AI) has been proposed as a model to increase the accuracy of cardiac POCUS. However, there is limited evidence of the accuracy of AI in the clinical environment. The objective of this study was to determine the diagnostic accuracy of AI for identifying systolic and diastolic dysfunction compared with expert reviewers. METHODS: This was a prospective, observational study of adult ED patients aged ≥45 years with risk factors for systolic and diastolic dysfunction. Ultrasound fellowship-trained physicians used an ultrasound machine with existing AI software and obtained parasternal long axis, parasternal short axis, and apical 4-chamber views of the heart. Systolic dysfunction was defined as ejection fraction (EF) < 50 % in at least two views using visual assessment or E-point septal separation >10 mm. Diastolic dysfunction was defined as an E:A < 0.8, or ≥ 2 of the following: septal e' < 7 cm/s or lateral e' < 10 cm/s, E:e' > 14, or left atrial volume > 34 mL/m2. AI was subsequently used to measure EF, E, A, septal e', and lateral e' velocities. The gold standard was systolic or diastolic dysfunction as assessed by two independent physicians with discordance resolved via consensus. We performed descriptive statistics (mean ± standard deviation) and calculated the sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) of the AI in determining systolic and diastolic dysfunction with 95 % confidence interval (CI). Subgroup analyses were performed by body mass index (BMI). RESULTS: We enrolled 220 patients, with 11 being excluded due to inadequate images, resulting in 209 patients being included in the study. Mean age was 60 ± 9 years, 51.7 % were women, and the mean BMI was 31 ± 8.1 mg/kg2. For assessing systolic dysfunction, AI was 85.7 % (95 %CI 57.2 % to 98.2 %) sensitive and 94.8 % (95 %CI 90.6 % to 97.5 %) specific with a LR+ of 16.4 (95 %CI 8.6 to 31.1) and LR- of 0.15 (95 % CI 0.04 to 0.54). For assessing diastolic dysfunction, AI was 91.9 % (95 %CI 85.6 % to 96.0 %) sensitive and 94.2 % (95 %CI 87.0 % to 98.1 %) specific with a LR+ of 15.8 (95 %CI 6.7 to 37.1) and a LR- of 0.09 (0.05 to 0.16). When analyzed by BMI, results were similar except for lower sensitivity in the BMI ≥ 30 vs BMI < 30 (100 % vs 80 %). CONCLUSION: When compared with expert assessment, AI had high sensitivity and specificity for diagnosing both systolic and diastolic dysfunction.

Educator's blueprint: Key considerations for using social media in survey-based medical education research.

In this paper, we present a set of recommendations for using social media as a tool for participant recruitment in survey-based medical education research. Drawing from a limited but growing body of literature, we discuss the opportunities and challenges inherent to social media recruitment. This article builds on the authors' previous educator's blueprints about survey design and administration. We highlight the advantages of social media, including its wide reach, cost-effectiveness, and capability to access diverse and geographically dispersed populations, which can significantly enhance the representativeness of research samples. However, we also caution against potential pitfalls, such as ethical concerns, sampling bias, and the fluid nature of social media platforms. Our recommendations are informed by both empirical evidence and best practices, aiming to provide researchers with practical advice for effectively leveraging social media in survey-based medical education research. We emphasize the importance of selecting suitable platforms and engaging with targeted demographics thoughtfully. By sharing our insights, we hope to assist fellow medical education researchers in navigating the complexities of social media recruitment, thereby enriching the quality and impact of survey-based research in this field.

Skin, Soft Tissue, and Musculoskeletal Ultrasound.

Point-of-care ultrasound may be used to assist in the diagnosis of skin, soft tissue, and musculoskeletal concerns in the emergency department. Frequently, linear or curvilinear probes are used to perform these studies and ultrasound may be used to assist in common emergency department procedures related to these conditions.

Is Phenobarbital an Effective Treatment for Alcohol Withdrawal Syndrome?

BACKGROUND: Alcohol use disorder is associated with a variety of complications, including alcohol withdrawal syndrome (AWS), which may occur in those who decrease or stop alcohol consumption suddenly. AWS is associated with a range of signs and symptoms, which are most commonly treated with GABAergic medications. CLINICAL QUESTION: Is phenobarbital an effective treatment for AWS? EVIDENCE REVIEW: Studies retrieved included two prospective, randomized, double-blind studies and three systematic reviews. These studies provided estimates of the effectiveness and safety of phenobarbital for treatment of AWS. CONCLUSIONS: Based on the available literature, phenobarbital is reasonable to consider for treatment of AWS. Clinicians must consider the individual patient, clinical situation, and comorbidities when selecting a medication for treatment of AWS.

Can I Discharge This Adult Patient with Abnormal Vital Signs From the Emergency Department?

BACKGROUND: Vital signs are an essential component of the emergency department (ED) assessment. Vital sign abnormalities are associated with adverse events in the ED setting and may indicate a risk of poor outcomes after ED discharge. CLINICAL QUESTION: What is the risk of adverse events among adult patients with abnormal vital signs at the time of ED discharge? EVIDENCE REVIEW: Studies retrieved included 6 retrospective studies with adult patients discharged from the ED. These studies evaluated adverse outcomes in adult patients discharged from the ED with abnormal vital signs. Hypotension at discharge was associated with the highest odds of adverse events after discharge. Tachycardia was also a key predictor of adverse events after discharge and may be easily missed by ED clinicians. CONCLUSION: Based on the available evidence, the specific vital sign abnormality and the number of total abnormalities influence the risk of adverse outcomes after discharge. Vital sign abnormalities at the time of discharge also increase the risk of ED revisit. The most common abnormal vital sign at the time of discharge is tachycardia.

Long COVID Illness: Disparities in Understanding and Receipt of Care in Emergency Department Populations.

STUDY OBJECTIVE: Most long coronavirus disease (long COVID) studies rely on traditional surveillance methods that miss underserved populations who use emergency departments (EDs) as their primary health care source. In medically underserved ED populations, we sought to determine (1) whether there are gaps in awareness and self-declared understanding about long COVID illness, and (2) the prevalence, impact on school/work attendance, and receipt of care for long COVID symptoms. METHODS: This study was a cross-sectional, convenience sample survey study of adult patients at 11 geographically representative US EDs from December 2022 to October 2023. Awareness and self-declared understanding about long COVID illness were measured. Prevalence, impact on school/work attendance, and receipt of care for long COVID symptoms were also assessed. RESULTS: Of 1,618 eligible patients, 1455 (89.9%) agreed to participate, including 33.4% African Americans and 30.9% Latino/a. Of the patients, 17.1% lacked primary care. In total, 33.2% had persistent COVID-19 symptoms lasting >1 month, and 20.3% had symptoms >3 months. Moreover, 49.8% with long COVID symptoms missed work/school because of symptoms; 30.3% of all participants and 33.5% of participants who had long COVID symptoms had prior awareness and self-declared understanding of long COVID. Characteristics associated with poor understanding of long COVID were African American race (adjusted odds ratio [aOR] 3.68, 95% confidence interval [CI] 2.66 to 5.09) and Latino/a ethnicity (aOR 3.16, 95% CI 2.15 to 4.64). Participants lacking primary care were less likely to have received long COVID care (24.6% versus 51.2%; difference 26.6%; 95% CI 13.7% to 36.9%). CONCLUSIONS: Despite high prevalence and impact on school/work attendance of long COVID symptoms, most of this ED population had limited awareness and self-declared understanding of long COVID, and many had not received care. EDs should consider the development of protocols for diagnosis, education, and treatment of long COVID illness.

Educator's blueprint: A how-to guide for creating high-quality slides.

Didactics are the primary modality in which educators disseminate knowledge. The accompanying slides are a critical element, which can enhance or distract from the corresponding presentation. This Educator's Blueprint provides 10 strategies for creating high-quality presentation slides. These strategies include keeping the slides simple, ensuring consistency, making text easy to read, using images wisely, optimizing video integration, presenting data effectively, embedding active learning, avoiding long reference lists, ensuring cultural humility, and optimizing slide design via artificial intelligence. By incorporating these strategies, educators can enhance their slides and improve knowledge translation and retention for learners.

Measuring Burnout and Professional Fulfillment Among Emergency Medicine Residency Program Leaders in the United States: A Cross-Sectional Survey Study.

Objective: Emergency medicine (EM) physicians face high burnout rates, even in academic settings. Research on burnout among EM residency program leaders is limited, despite their role in shaping the training environment and influencing resident well-being. This study aims to measure burnout and professional fulfillment among EM residency program leaders and identify contributing factors. Methods: A cross-sectional survey using the adapted Stanford Professional Fulfillment Index (SPFI) was conducted in 2023 to assess burnout and professional fulfillment among EM residency program leaders at US programs. The survey, tailored to EM leaders, was distributed to all current EM Program Directors (PDs) and Assistant or Associate Program Directors (APDs) from accredited US programs. Descriptive statistics and odds ratios were used to compare burnout and professional fulfillment across various groups. Results: A total of 112 of 281 PDs (39.9% response rate) and 130 of 577 APDs (22.5% response rate) participated. Professional fulfillment was reported by 59.8% of PDs and 58.5% of APDs. Burnout was experienced by 42.0% of PDs and 26.9% of APDs. Higher professional fulfillment correlated with alignment with expectations, positive work environments, and perceived appreciation, while burnout was strongly associated with negative impacts on personal health and relationships. About 27.7% of PDs and 23.8% of APDs expressed intentions to leave their current positions within 18 months. Conclusion: A significant portion of US EM residency program leaders experience burnout and low professional fulfillment. Addressing well-being in this population has important implications for education and mentorship provided to future physicians in the field.

Holistic Review in Applicant Selection: A Scoping Review.

PURPOSE: To avoid overreliance on metrics and better identify candidates who add value to the learning environment, some medical schools and residency programs have begun using holistic review for screening and selection, but limited data support or refute this use. This scoping review examines holistic review definitions and practice in medical education, summarizes research findings, and identifies gaps for future research. METHOD: The authors searched 7 databases using the keywords holistic, attributes, mission-based, mission-centric , and socially accountable for articles on holistic review within undergraduate medical education (UME) and graduate medical education (GME) published from database inception through July 5, 2024. Author pairs independently screened articles for inclusion and extracted data. Discrepancies were resolved via discussion. Quantitative and qualitative synthesis was performed. RESULTS: A total of 6,511 articles were identified, with 33 included in this review. Twenty-five studies (76%) focused exclusively on GME, with only a few assessing holistic review in UME. Holistic review was implemented at 3 main stages: screening, interviewing, and ranking. Common rationales included service patterns, patient-physician identity concordance, enhancing patient trust, professional advocacy, and educational benefits. Holistic review elements varied, with most falling within the Association of American Medical Colleges experiences, attributes, and metrics framework. Nearly all studies reported an increase in the percentage of underrepresented in medicine trainees interviewed or selected. Several studies also demonstrated increases in other groups (e.g., women, lower socioeconomic status). Many studies included additional interventions to promote diversity, limiting the ability to assess holistic review in isolation. CONCLUSIONS: This scoping review summarizes the literature on rationale, development and implementation process, structure and components, outcomes assessed, barriers, and strategies for success for holistic review. This work can inform institutions and departments seeking to develop or refine their own holistic review systems and serve as a nidus for future research.