Rapid Acute Coronary Syndrome Evaluation Over One Hour With High-Sensitivity Cardiac Troponin I: A United States-Based Stepped-Wedge, Randomized Trial.

STUDY OBJECTIVE: The real-world effectiveness and safety of a 0/1-hour accelerated protocol using high-sensitivity cardiac troponin (hs-cTn) to exclude myocardial infarction (MI) compared to routine care in the United States is uncertain. The objective was to compare a 0/1-hour accelerated protocol for evaluation of MI to a 0/3-hour standard care protocol. METHODS: The RACE-IT trial was a stepped-wedge, randomized trial across 9 emergency departments (EDs) that enrolled 32,609 patients evaluated for possible MI from July 2020 through April 2021. Patients undergoing high-sensitivity cardiac troponin I testing with concentrations less than or equal to 99th percentile were included. Patients who had MI excluded by the 0/1-hour protocol could be discharged from the ED. Patients in the standard care protocol had 0- and 3-hour troponin testing and application of a modified HEART score to be eligible for discharge. The primary endpoint was the proportion of patients discharged from the ED without 30-day death or MI. RESULTS: There were 13,505 and 19,104 patients evaluated in the standard care and accelerated protocol groups, respectively, of whom 19,152 (58.7%) were discharged directly from the ED. There was no significant difference in safe discharges between standard care and the accelerated protocol (59.5% vs 57.8%; adjusted odds ratio (aOR)=1.05, 95% confidence interval [CI] 0.95 to 1.16). At 30 days, there were 90 deaths or MIs with 38 (0.4%) in the standard care group and 52 (0.4%) in the accelerated protocol group (aOR=0.84, 95% CI 0.43 to 1.68). CONCLUSION: A 0/1-hour accelerated protocol using high-sensitivity cardiac troponin I did not lead to more safe ED discharges compared with standard care.

Headpulse measurement can reliably identify large-vessel occlusion stroke in prehospital suspected stroke patients: Results from the EPISODE-PS-COVID study.

BACKGROUND: Large-vessel occlusion (LVO) stroke represents one-third of acute ischemic stroke (AIS) in the United States but causes two-thirds of poststroke dependence and >90% of poststroke mortality. Prehospital LVO stroke detection permits efficient emergency medical systems (EMS) transport to an endovascular thrombectomy (EVT)-capable center. Our primary objective was to determine the feasibility of using a cranial accelerometry (CA) headset device for prehospital LVO stroke detection. Our secondary objective was development of an algorithm capable of distinguishing LVO stroke from other conditions. METHODS: We prospectively enrolled consecutive adult patients suspected of acute stroke from 11 study hospitals in four different U.S. geographical regions over a 21-month period. Patients received device placement by prehospital EMS personnel. Headset data were matched with clinical data following informed consent. LVO stroke diagnosis was determined by medical chart review. The device was trained using device data and Los Angeles Motor Scale (LAMS) examination components. A binary threshold was selected for comparison of device performance to LAMS scores. RESULTS: A total of 594 subjects were enrolled, including 183 subjects who received the second-generation device. Usable data were captured in 158 patients (86.3%). Study subjects were 53% female and 56% Black/African American, with median age 69 years. Twenty-six (16.4%) patients had LVO and 132 (83.6%) were not LVO (not-LVO AIS, 33; intracerebral hemorrhage, nine; stroke mimics, 90). COVID-19 testing and positivity rates (10.6%) were not different between groups. We found a sensitivity of 38.5% and specificity of 82.7% for LAMS ≥ 4 in detecting LVO stroke versus a sensitivity of 84.6% (p < 0.0015 for superiority) and specificity of 82.6% (p = 0.81 for superiority) for the device algorithm (CA + LAMS). CONCLUSIONS: Obtaining adequate recordings with a CA headset is highly feasible in the prehospital environment. Use of the device algorithm incorporating both CA and LAMS data for LVO detection resulted in significantly higher sensitivity without reduced specificity when compared to the use of LAMS alone.

Is rapid acute coronary syndrome evaluation with high-sensitivity cardiac troponin less costly? An economic evaluation.

Objective: Protocols to evaluate for myocardial infarction (MI) using high-sensitivity cardiac troponin (hs-cTn) have the potential to drive costs upward due to the added sensitivity. We performed an economic evaluation of an accelerated protocol (AP) to evaluate for MI using hs-cTn to identify changes in costs of treatment and length of stay compared with conventional testing. Methods: We performed a planned secondary economic analysis of a large, cluster randomized trial across nine emergency departments (EDs) from July 2020 to April 2021. Patients were included if they were 18 years or older with clinical suspicion for MI. In the AP, patients could be discharged without further testing at 0 h if they had a hs-cTnI < 4 ng/L and at 1 h if the initial value were 4 ng/L and the 1-h value ≤7 ng/L. Patients in the standard of care (SC) protocol used conventional cTn testing at 0 and 3 h. The primary outcome was the total cost of treatment, and the secondary outcome was ED length of stay. Results: Among 32,450 included patients, an AP had no significant differences in cost (+$89, CI: -$714, $893 hospital cost, +$362, CI: -$414, $1138 health system cost) or ED length of stay (+46, CI: -28, 120 min) compared with the SC protocol. In lower acuity, free-standing EDs, patients under the AP experienced shorter length of stay (-37 min, CI: -62, 12 min) and reduced health system cost (-$112, CI: -$250, $25). Conclusion: Overall, the implementation of AP using hs-cTn does not result in higher costs.

Treatment and outcome variation in out-of-hospital cardiac arrest among four urban hospitals in Detroit.

AIMS: To determine whether out-of-hospital cardiac arrest (OHCA) post-resuscitation management and outcomes differ between four Detroit hospitals. INTRODUCTION: Significant variation exists in treatment/outcomes from OHCA. Disparities between hospitals serving a similar population is not well known. METHODS: Retrospective OHCA data was collected from the Detroit-Cardiac Arrest Registry (DCAR) between January 2014 to December 2019. Four hospitals were compared on two treatments (angiography, do not resuscitate (DNR)) and two outcomes (cerebral performance category (CPC) ≤ 2, in-hospital death). Models for death and CPC were tested with and without coronary angiography and DNR status. RESULTS: 999 patients at hospitals A - D differed (p < 0.05) before multivariable adjustment by age, race, witnessed arrest, dispatch-emergency department (ED) time, TTM, coronary angiography, DNR order, and in-hospital death. Rates of death and CPC ≤ 2 were worse in Hospital A (82.8%, 10%, respectively) compared to others (69.1%, 14.1%). After multivariable adjustment, Hospital A performed angiography less compared to B (OR = 0.17) and was more likely to initiate new DNR status than B (OR = 2.9), C (OR = 16.1), or D (OR = 3.6). CPC ≤ 2 were worse in Hospital A compared to B (OR = 0.27) and D (OR = 0.35). After sensitivity analysis, CPC ≤ 2 odds did not differ for A versus B (OR = 0.58, adjusted for angiography) or D (OR = 0.65, adjusted for DNR). Odds of death, despite angiography and DNR differences, were worse in Hospital A compared to B (OR = 1.87) and D (OR = 1.81). CONCLUSION: Differing rates of DNR and coronary angiography was associated with observed disparities in favorable neurologic outcome, but not death, between four Detroit hospitals.

The Effect of Missing Data on the Measurement of Cardiac Arrest Outcomes According to Race.

INTRODUCTION: High-quality data are important to understanding racial differences in outcome following out of hospital cardiac arrest (OHCA). Previous studies have shown differences in OHCA outcomes according to both race and socioeconomic status. EMS reporting of data on race is often incomplete. We aim to determine the effect of missing data on the determination of racial differences in outcomes for OHCA patients. METHODS: We performed a secondary analysis of a data set developed by probabilistically linking the Michigan Cardiac Arrest Registry to Enhance Survival (CARES) and the Michigan Inpatient Database (MIDB). Adult OHCA patients (age >18) who survived to hospital admission between 2014 and 2017 were included. Both datasets recorded patient race and ethnicity with CARES using a single race/ethnicity variable. Patients were categorized as White, Black, other, or missing and only a single choice was allowed. Due to the small number of Hispanic patients and the combined race/ethnicity variable, these patients were excluded. The outcomes of interest were survival to hospital discharge and survival to discharge with Cerebral Performance Category 1 or 2 (good outcome). Outcomes were stratified according to EMS- or hospital-documented race. RESULTS: We included 3,756 matched patients, after excluding 34 Hispanic patients from analysis. Documentation of patient race was missing in 892 (22.1%) of CARES and 212 (5.6%) of MIDB patients. When both datasets documented Black or White race, agreement in race documentation was excellent (κ=0.83). White patients were more likely to have good outcomes than Black in both the CARES (27.3% vs 14.8%) and MIDB (26.9% vs 16.1%) databases (both p < 0.001), but were not more likely to survive (30.8% vs 27.3% p = 0.22; 30.3% vs 28.1%, p = 0.07). Moreover, we found no significant difference in outcome measures based on race documentation for White vs Black patients (good outcome [27.3 vs 26.9% (MIDB)] and [16.1% vs 14.8% (CARES)] respectively and survival [30.8% vs 30.3% (MIDB)] and [27.3 vs 28.1% (CARES)] respectively). CONCLUSION: Despite higher rates of missing EMS documentation, we identified statistically similar rates in OHCA outcome measures between databases. Further work is needed to determine the true effect of missing documentation of race on OHCA outcome measures.

Intervention during wait time: identification and referral of individuals non-adherent for colorectal cancer screening.

Background: Despite unanimous recommendations from numerous specialty societies on regular colorectal cancer screening, a substantial proportion of eligible adults are non-adherent with screening. The current study investigated whether research associates (RAs) in the emergency department (ED) can adequately assess patients' adherence with colorectal cancer screening recommendations, outlined by the US Preventive Services Task Force (USPSTF), and provide referrals to individuals who are found to be non-adherent. Methods: RAs at seven heterogeneous hospitals in the USA queried non-emergent adult patients and visitors between the ages of 50 and 75. After obtaining verbal consent, the participant's adherence with USPSTF guidelines for colorectal cancer screening was assessed. Participants found due for screening were provided with referrals to obtain these recommended screenings. Results: A total of 8258 participants were surveyed on their colorectal cancer screening status, with RAs identifying 2063 participants who were not adherent with USPSTF guidelines for colorectal cancer screening and 67 for whom adherence could not be determined (total 27%). Conclusions: Our study demonstrates that RAs can identify a large volume of eligible adults who would benefit from colorectal cancer screening across a variety of emergency department settings.

Hepatitis C Virus Reflex Testing Protocol in an Emergency Department.

INTRODUCTION: Our aim was to measure hepatitis C virus (HCV) screening and linkage-to-care rates in an urban emergency department (ED) before and after implementing an HCV viral RNA (vRNA) reflex testing protocol within a HCV screening program for at-risk patients. Our hypothesis was that using a reflex testing protocol would increase HCV testing rates of at-risk patients in the ED, which would increase the linkage-to-care rate. METHODS: In August 2018, our institution implemented an automated, electronic health record-based HCV screening protocol in the ED for at-risk patients. In January 2019, we implemented an HCV vRNA reflex testing protocol (reflex testing) for all positive HCV antibody (Ab) tests that were initiated through the screening protocol. We compared completion rates of HCV vRNA testing and the rate of linkage to care for patients with positive HCV Ab test results before and after implementation of reflex testing (five months per study period). RESULTS: Prior to reflex testing implementation, 233/425 (55%) patients with a positive HCV Ab test had an HCV vRNA test performed, whereas 270/323 (84%) patients with a positive HCV Ab test result had vRNA testing after reflex testing implementation (odds ratio [OR], 4.2; 95% confidence interval (CI): 3.0-6.0; P < 0.001). Of the eligible patients with positive HCV Ab test results who could be linked to care, 45 (10.6%) were linked to care before HCV reflex implementation and 46 (14.2%) were linked to care with reflex testing (OR, 1.4; 95% CI: 0.9-2.2; P = 0.13). CONCLUSION: Implementing a reflex testing initiative into an HCV screening program in the ED can result in an increase of the percentage of patients who receive an HCV vRNA test after having had a positive HCV Ab. Hepatitis C virus vRNA reflex testing was not associated with a statistically significant increase in linkage-to-care rates for HCV Ab-positive patients; however, further studies are required.

Prehospital Tibial Intraosseous Drug Administration is Associated with Reduced Survival Following Out of Hospital Cardiac Arrest: A study for the CARES Surveillance Group.

BACKGROUND: Recent reports have questioned the efficacy of intraosseous (IO) drug administration for out-of-hospital cardiac arrest (OHCA) resuscitation. Our aim was to determine whether prehospital administration of resuscitative medications via the IO route was associated with lower rates of return of spontaneous circulation (ROSC) and survival to hospital discharge than peripheral intravenous (IV) infusion in the setting of OHCA. METHODS: We obtained data on all OHCA patients receiving prehospital IV or IO drug administration from the three most populous counties in Michigan over three years. Data was from the Michigan Cardiac Arrest Registry to Enhance Survival (CARES) database. The association between route of drug administration and outcomes was tested using a matched propensity score analysis. RESULTS: From a total of 10,626 OHCA patients, 6869 received parenteral drugs during their prehospital resuscitation (37.8% by IO) and were included in analysis. Unadjusted outcomes were lower in patients with IO vs. IV access: 18.3% vs. 23.8% for ROSC (p < 0.001), 3.2% vs. 7.6% for survival to hospital discharge (p < 0.001), and 2.0% vs. 5.8% for favorable neurological function (p < 0.001). After adjustment, IO route remained associated with lower odds of sustained ROSC (OR 0.72, 95% CI 0.63-0.81, p < 0.001), hospital survival (OR 0.48, 95% CI 0.37-0.62, p < 0.001), and favorable neurological outcomes (OR 0.42, 95% CI 0.30-0.57, p < 0.001). CONCLUSION: In this cohort of OHCA patients, the use of prehospital IO drug administration was associated with unfavorable clinical outcomes.

Intravenous Cetirizine Versus Intravenous Diphenhydramine for the Treatment of Acute Urticaria: A Phase III Randomized Controlled Noninferiority Trial.

STUDY OBJECTIVE: Acute urticaria is a frequent presentation in emergency departments (EDs), urgent care centers, and other clinical arenas. Treatment options are limited if diphenhydramine is the only intravenous antihistamine offered because of its short duration of action and well-known adverse effects. We evaluate cetirizine injection, the first second-generation injectable antihistamine, for acute urticaria in this multicenter, randomized, noninferiority, phase 3 clinical trial. METHODS: Adult patients presenting to EDs and urgent care centers with acute urticaria requiring an intravenous antihistamine were randomized to either intravenous cetirizine 10 mg or intravenous diphenhydramine 50 mg. The primary endpoint was the 2-hour pruritus score change from baseline, with time spent in treatment center and rate of return to treatment centers as key secondary endpoints. Frequency of sedation and anticholinergic adverse effects were also recorded. RESULTS: Among 262 enrolled patients, the 2-hour pruritus score change from baseline for intravenous cetirizine was statistically noninferior to that for intravenous diphenhydramine (-1.6 versus -1.5; 95% confidence interval -0.1 to 0.3), and in favor of cetirizine. Treatment differences also favored cetirizine for mean time spent in treatment center (1.7 versus 2.1 hours; P=.005), return to treatment center (5.5% versus 14.1%; P=.02), lower change from baseline sedation score at 2 hours (0.1 versus 0.5; P=.03), and adverse event rate (3.9% versus 13.3%). CONCLUSION: Intravenous cetirizine is an effective alternative to intravenous diphenhydramine for treating acute urticaria, with benefits of less sedation, fewer adverse events, shorter time spent in treatment center, and lower rates of revisit to treatment center.

Situs Inversus: Inferior-Lateral ST-Elevation Myocardial Infarction on Right-Sided Electrocardiogram.

Dextrocardia is a rare anatomical anomaly in which the heart is located in the patient's right hemithorax with its apex directed to the right. Although it usually does not pose any serious health risks, patients with undiagnosed dextrocardia present a diagnostic challenge especially in those presenting with chest pain. Traditional left-sided electrocardiograms (ECG) inadequately capture the electrical activity of a heart positioned in the right hemithorax, which if unnoticed could delay or even miss an acute coronary syndrome diagnosis. Here, we present a case of a patient with dextrocardia presenting with chest pain and diagnosed with ST-elevation myocardial infarction using a right-sided ECG.

Survey of Emergency Department Chemical Hazard Preparedness in Michigan, USA: A Seven Year Comparison.

OBJECTIVE: To compare the state of chemical hazard preparedness in emergency departments (EDs) in Michigan, USA between 2005 and 2012. METHODS: This was a longitudinal study involving a 30 question survey sent to ED directors at each hospital listed in the Michigan College of Emergency Physician (MCEP) Directory in 2005 and in 2012. The surveys contained questions relating to chemical, biological, radiological, nuclear, and explosive events with a focus on hazardous material capabilities. RESULTS: One hundred twelve of 139 EDs responded to the 2005 survey compared to 99/136 in 2012. Ten of 27 responses were statistically significant, all favoring an enhancement in disaster preparedness in 2012 when compared to 2005. Questions with improvement included: EDs with employees participating in the Michigan voluntary registry; EDs with decontamination rooms; MARK 1 and cyanide kits available; those planning to use dry decontamination, powered air purifiers, surgical masks, chemical gloves, and surgical gowns; and those wishing for better coordination with local and regional resources. Forty-two percent of EDs in 2012 had greater than one-half of their staff trained in decontamination and 81% of respondents wished for more training opportunities in disaster preparedness. Eighty-four percent of respondents believed that they were more prepared in disaster preparedness in 2012 versus seven years prior. CONCLUSIONS: Emergency departments in Michigan have made significant advances in chemical hazard preparedness between 2005 and 2012 based on survey responses. Despite these improvements, staff training in decontamination and hazardous material events remains a weakness among EDs in the state of Michigan.

Ecallantide for the acute treatment of angiotensin-converting enzyme inhibitor-induced angioedema: a multicenter, randomized, controlled trial.

STUDY OBJECTIVE: We compare the safety and efficacy of ecallantide with placebo in subjects undergoing assessment for acute angiotensin-converting enzyme inhibitor-induced angioedema (ACEIA) in an emergency department (ED). METHODS: This was a multicenter, phase 2, double-blind study with subjects randomized to receive a single subcutaneous dose of ecallantide (10, 30, or 60 mg) or placebo plus physician-directed conventional therapy. The primary endpoint was defined as meeting predetermined discharge eligibility criteria within 6 hours of study drug administration. Discharge criteria included improvement of edema, stable vital signs, absence of stridor, absence of dyspnea or use of accessory muscles during respiration, absence of drooling, and ability to drink without difficulty. RESULTS: An interim analysis showed that a high percentage of subjects met the primary endpoint, and the study was halted. Overall, 79 subjects were randomized and 76 had data for analysis. Most had mild (45%) or moderate (42%) ACEIA. The discharge eligibility endpoint was met by 72% of the placebo group and 85%, 89%, and 89% of the ecallantide 10-, 30-, and 60-mg groups, respectively. This difference in meeting discharge eligibility endpoint criteria between treatment groups was not statistically significant. The incidence of treatment-emergent adverse events was similar between placebo and active-treatment groups. CONCLUSION: The addition of ecallantide to standard therapy does not appear to improve angioedema compared with placebo in ED patients with ACEIA. Our data suggest that most ED patients presenting with mild to moderate ACEIA are likely to meet our discharge eligibility criteria within 6 hours of treatment, regardless of intervention. Further studies to assess the utility of ecallantide in patients with more severe angioedema may be useful. No new safety signals related to ecallantide administration were identified.

Early biomarker activity in severe sepsis and septic shock and a contemporary review of immunotherapy trials: not a time to give up, but to give it earlier.

Improving time to diagnosis and intervention has positively impacted outcomes in acute myocardial infarction, stroke, and trauma through elucidating the early pathogenesis of those diseases. This insight may partly explain the futility of time-insensitive immunotherapy trials for severe sepsis and septic shock. The aim of this study was to examine the early natural history of circulatory biomarker activity in sepsis, relative to previous animal and human outcome trials. We conducted a literature search using PubMed, MEDLINE, and Google Scholar to identify outcome trials targeting biomarkers with emphasis on the timing of therapy. These findings were compared with the biomarker activity observed over the first 72 h of hospital presentation in a cohort of severe sepsis and septic shock patients. Biomarker levels in animal and human research models are elevated within 30 min after exposure to an inflammatory septic stimulus. Consistent with these findings, the biomarker cascade is activated at the most proximal point of hospital presentation in our patient cohort. These circulatory biomarkers overlap; some have bimodal patterns and generally peak between 3 and 36 h while diminishing over the subsequent 72 h of observation. When this is taken into account, prior outcome immunotherapy trials have generally enrolled patients after peak circulatory biomarker concentrations. In previous immunotherapy sepsis trials, intervention was delayed after the optimal window of peak biomarker activity. As a result, future studies need to recalibrate the timing of enrollment and administration of immunotherapy agents that still may hold great promise for this deadly disease.

The association between money and opinion in academic emergency medicine.

OBJECTIVES: Financial conflicts of interest have come under increasing scrutiny in medicine, but their impact has not been quantified. Our objective was to use the results of a national survey of academic emergency medicine (EM) faculty to determine if an association between money and personal opinion exists. METHODS: We conducted a web-based survey of EM faculty. Opinion questions were analyzed with regard to whether the respondent had either 1) received research grant money or 2) received money from industry as a speaker, consultant, or advisor. Responses were unweighted, and tests of differences in proportions were made using Chi-squared tests, with p<0.05 set for significance. RESULTS: We received responses from 430 members; 98 (23%) received research grants from industry, while 145 (34%) reported fee-for-service money. Respondents with research money were more likely to be comfortable accepting gifts (40% vs. 29%) and acting as paid consultants (50% vs. 37%). They had a more favorable attitude with regard to societal interactions with industry and felt that industry-sponsored lectures could be fair and unbiased (52% vs. 29%). Faculty with fee-for-service money mirrored those with research money. They were also more likely to believe that industry-sponsored research produces fair and unbiased results (61% vs. 45%) and less likely to believe that honoraria biased speakers (49% vs. 69%). CONCLUSION: Accepting money for either service or research identified a distinct population defined by their opinions. Faculty engaged in industry-sponsored research benefitted socially (collaborations), academically (publications), and financially from the relationship.

Proximal humerus intraosseous infusion: a preferred emergency venous access.

PURPOSE: To assess the proximal humerus intraosseous (PHIO) catheter placement as a preferred method for venous access over conventional methods, including peripheral intravenous (PIV) and central venous catheters (CVCs), during emergency room resuscitation. METHODS: In phase 1, conventional methods for venous access (PIV and CVC) were assessed for all patients presenting to the emergency department resuscitation bay. Outcome measures in both phases were speed, immediate complications, and pain. CVC placement was performed when PIV access was deemed impossible or when rapid volume resuscitation was needed. In phase 2, resuscitations requiring venous access or complicated by failed PIV access attempts underwent PHIO catheter placement. RESULTS: Sixty-two patients received either PIV (57) or CVC (5) catheterization, and 29 patients received 30 PHIO catheters. PHIO catheter placement was significantly faster than conventional methods (1.5 [SD 1.1] versus 3.6 minutes [SD 3.7; p < 0.001 for PIV, and 15.6 minutes [SD 6.7; p < 0.0056] for CVC). No major complications were identified in either phase. Minor complications for PIV access included extravasation and placement failure. Minor complications for CVC placement included inability to thread the guidewire. Minor complications with PHIO catheter placement included placement failure, poor flow, and catheter dislodgement. Pain scores associated with PHIO insertion and infusion were higher than those associated with PIV and CVC catheter placement. CONCLUSION: PHIO catheter placement is significantly faster than PIV and CVC placement with increased minor complication profile and perceived pain. PHIO venous access is absolutely life saving when PIV or CVC placement is difficult or impossible.

Academic emergency medicine faculty and industry relationships.

OBJECTIVES: The authors surveyed the membership of the Society for Academic Emergency Medicine (SAEM) about their associations with industry and predictors of those associations. METHODS: A national Web-based survey inviting faculty from the active member list of SAEM was conducted. Follow-up requests for participation were sent weekly for 3 weeks. Information was collected on respondents' personal and practice characteristics, industry interactions, and personal opinions regarding these interactions. Raw response rates were reported and a logistic regression was used to generate descriptive statistics. RESULTS: Responses were received from 430 members, representing 14% of the 3,183 active members. Respondents were 83% male and 86% white, with 96% holding an MD degree (24% with an additional postdoctoral degree). Most were at the assistant (37%) or associate (25%) professor rank, with 51% holding at least one leadership position. Most respondents (82%) reported some type of industry interaction, most commonly the acceptance of food or beverages (67%). Respondents at the associate professor rank or higher were more likely to receive payments from industry (51% vs. 22%, odds ratio [OR] = 3.7). CONCLUSIONS: This survey suggests that interactions between industry and academic EM faculty are common and increase with academic rank, but not with years in practice or leadership influence. The number and type of interactions are consistent with those reported by a national sampling of other physician specialties.

A trial of levofloxacin 750 mg once daily for 5 days versus ciprofloxacin 400 mg and/or 500 mg twice daily for 10 days in the treatment of acute pyelonephritis.

OBJECTIVE: A double-blind, noninferiority trial was conducted to establish the safety and efficacy of a once-daily, 5-day course of levofloxacin 750 mg compared to a twice-daily, 10-day course of ciprofloxacin in complicated urinary tract infections (cUTI) and acute pyelonephritis (AP). This report focuses on subjects with AP. RESEARCH DESIGN AND METHODS: Adult male and female subjects with clinical signs and symptoms of AP and laboratory confirmation of their diagnosis were randomized to receive one dose of levofloxacin 750 mg once daily intravenously (i.v.) or orally and one dose of placebo for 5 days, followed by placebo; or ciprofloxacin 400 mg i.v. and/or 500 mg orally twice daily for 10 days. MAIN OUTCOME MEASURES: The primary, prospectively defined end point was microbiologic eradication at post-therapy (study days 15-22). Secondary outcomes included clinical response and safety and tolerability. RESULTS: In the modified intent-to-treat (mITT) population (levofloxacin 94, ciprofloxacin 98), 83% of levofloxacin-treated and 79.6% of ciprofloxacin-treated subjects achieved microbiological eradication (difference -3.4, 95% CI -14.4%, 7.6%). In the microbiologically evaluable (ME) population (levofloxacin 80, ciprofloxacin 76), 92.5% of levofloxacin-treated vs. 93.4% of ciprofloxacin-treated subjects (difference -0.9, 95% CI -7.1%, 8.9%) achieved microbiologic eradication. Clinical success was achieved in 86.2% vs. 80.6% (mITT) and in 92.5% vs. 89.5% (ME) of levofloxacin-treated and ciprofloxacin-treated subjects, respectively. Escherichia coli was the most commonly isolated uropathogen. Few (2.1%) of the pathogens were fluoroquinolone-resistant. Adverse events (AEs) were similar to those seen previously with both agents. Potential limitations are that this analysis is based on a subset of subjects from a larger study and, because of different durations of therapy, the results may be biased against levofloxacin. CONCLUSIONS: High-dose, short-course therapy with levofloxacin in subjects with AP is at least as effective as standard 10-day therapy with ciprofloxacin.

Blackout 2003: preparedness and lessons learned from the perspectives of four hospitals.

INTRODUCTION: The blackout in North America of August 2003 was one of the worst on record. It affected eight US states and parts of Canada for >24 hours. Additionally, two large US cities, Detroit, Michigan and Cleveland, Ohio, suffered from a loss of water pressure and a subsequent ban on the use of public supplies of potable water that lasted four days. A literature review revealed a paucity of literature that describes blackouts and how they may affect the medical community. METHODS: This paper includes a review of after-action reports from four inner-city, urban hospitals supplemented accounts from the authors' hospital's emergency operations center (EOC). RESULTS: Some of the problems encountered, included: (1)lighting; (2) elevator operations; (3) supplies of water; (4) communication operations; (5) computer failure; (6) lack of adequate supplies of food; (7) mobility to obtain X-ray studies; (8) heating, air condition, and ventilation; (9) staffing; (10) pharmacy; (11) registration of patients; (12) hospital EOC; (13) loss of isolation facilities; (14) inadequate supplies of paper; (15) impaired ability to provide care for non-emergency patients; (16) sanitation; and (17) inadequate emergency power. DISCUSSION: The blackout of 2003 uncovered problems within the US hospital system, ranging from staffing to generator coverage. This report is a review of the effects that the blackout and water ban of 2003 had on hospitals in a large inner-city area. Also discussed are solutions utilized at the time and recommendations for the future. CONCLUSION: The blackout of 2003 was an excellent test of disaster/emergency planning, and produced many valuable lessons to be used in future events.

Infrequent causes of stroke.

Infrequent causes of stroke are likely to be encountered by emergency physicians. Infrequent causes of stroke can be recalled using the ABC-IT mnemonic. Of the many infrequent causes, the five conditions more likely to be encountered are sickle cell anemia, migrainous stroke, antiphospholipid antibody syndrome, arterial dissection, and cocaine-related stroke. Consideration of the use of thrombolytic therapy in a patient with stroke from any cause lies at the forefront of treatment strategy in the emergency department.