Stress-Induced (Not Diabetic) Hyperglycemia Is Associated With Mortality in Geriatric Trauma Patients.

INTRODUCTION: Stress-induced hyperglycemia (SIH) is associated with worse outcomes among trauma patients. It is also known that injured geriatric patients have higher mortality when compared to younger patients. We sought to investigate the association of all levels of SIH with mortality among geriatric trauma patients at a level 1 academic trauma center. We hypothesized that SIH in the geriatric trauma population would be associated with increased mortality. METHODS: A retrospective review of all geriatric patients admitted to our level 1 trauma center over a 3-year period (January 2018-December 2020) was performed using the institutional trauma database. Data collected included demographics, injury severity score (ISS), emergency department (ED) blood glucose level, ED systolic blood pressure (SBP), and mortality. Patients were divided into 4 groups based on emergency room blood glucose level, as follows: normoglycemic (<120 mg/dL), mild hyperglycemia (120-150 mg/dL), moderate hyperglycemia (151-199 mg/dL), and severe hyperglycemia (≥200 mg/dL). Multivariable logistic regression analysis was performed to evaluate the association of SIH and in-hospital mortality adjusting for ISS, age, comorbidities, and ED SBP. RESULTS: A total of 4432 geriatric trauma patients were admitted during the study period, of which 3358 patients (75.8%) were not diabetic. There were 2206 females (65.7%), 2993 were White (89.2%), with a mean age of 81.5 y. There were 114 deaths (3.4%). Univariate results showed that there was a statistically significant association between mortality and glucose groups (P < 0.01). The number of deaths in the four glucose groups were, as follows: 30 (2.0%), 32 (3.8%), 20 (6.2%), and 10 (12.2%), respectively. Multivariable logistic regression analysis results showed that compared to the normoglycemic group, the risk of death was higher in the mild, moderate, and severe glucose groups, as follows: mild group (OR 1.80, 95% confidence interval [CI] 1.04-3.13, P 0.04), moderate group (OR 2.53, 95% CI 1.34-4.80, P < 0.01), and severe group (OR 5.04, 95% CI 2.18-11.67, P < 0.01). CONCLUSIONS: Mild, moderate, and severe SIH are statistically significant predictors of death among geriatric trauma patients independently of ISS, age, comorbidities, and SBP.

Emergency department visits and hospitalizations for pediatric vaso-occlusive pain events during the COVID-19 pandemic.

The coronavirus SARS-CoV-2 (COVID-19) pandemic altered all aspects of life, including healthcare. During the pandemic, social distancing led to decreased transmission of typical viral illnesses, leading to a decrease in these pediatric admissions. Studies have shown that pediatric emergency department (ED) visits and hospitalizations decreased during the pandemic, which may have led to some unmet healthcare needs and delays in treatment. Little is known about the effect of the COVID-19 pandemic on ED visits and hospitalizations specifically for pediatric sickle cell pain. A retrospective review across hospitals in the Northwell Health system was conducted to compare the ED visits and hospitalizations for pediatric patients with sickle cell pain during 2020 (the year of the pandemic), the following year (2021), and the 2 years prior to the pandemic (2018, 2019). The average length of stay for patients hospitalized with vaso-occlusive events was also compared between these years. Total 511 patient encounters for patients seen and discharged home from the ED and 985 hospitalization encounters were included over the 4-year timespan. ED visits per year decreased significantly in 2020 compared with the 2 years prior (p < .001): 91 visits in 2020, 162 visits in 2019, and 143 visits in 2018. The number of ED visits for pediatric vaso-occlusive events trended upward in 2021 to 115. Hospitalizations also decreased in 2020 compared to the 2 years prior (n = 202 vs 196; p < .001), compared with 298 in 2019 and 289 in 2018. The number of patients hospitalized remained stable in 2021 (n = 202 vs 196). There was a statistically significant increase in the median length of stay in 2020 compared to years prior (p = .002): median (interquartile range [IQR]): 4.0 days (2-6 days) in 2020 compared to 3.0 days (2-5 days) in 2018 and 2019. ED encounters and hospitalizations for pediatric patients with sickle cell disease pain decreased during the pandemic; however, admitted patients had a longer median length of stay.

The impact of asthma on COVID-19 disease severity in children and adolescents.

BACKGROUND: Atopy and allergic asthma have been found to be protective against coronavirus disease (COVID-19) in adults but have not been studied in children. OBJECTIVE: To identify whether children and adolescents with asthma had less severe disease and lower morbidity from COVID-19 than their counterparts without asthma. METHODS: This was a retrospective chart review from March 1, 2020, through January 31, 2021. Charts were eligible for inclusion if patients were over 6 years of age and below 20 years of age and tested positive for COVID-19 by PCR or antigen testing or were COVID-19 antibody positive when they presented to the emergency department (ED). Patients were grouped according to disease severity and divided into two groups, those with asthma and those without. A total of 1,585 patients were included-1,492 without asthma and 93 with asthma. RESULTS: Children and adolescents with asthma are less likely to be seen in the ED for COVID-19-related disease (p value< 0.0001, but if they presented to the ED, they were significantly more likely to be hospitalized, require oxygen, and have more severe forms of COVID-19 than children and adolescents without asthma (p value< 0.0001). CONCLUSIONS: Children and adolescents with asthma, though less likely to be seen in ED with COVID-19, were more likely to have severe disease than patients without asthma, once they presented to the ED.

Hemodynamic instability in the immediate postoperative setting after transcarotid artery revascularization.

OBJECTIVE: Transcarotid artery revascularization (TCAR) is a relatively recent development in the management of carotid artery occlusive disease, the utilization of which is becoming more prevalent. This study aims to evaluate the timing, prevalence, and types of hemodynamic instability after TCAR. METHODS: We performed a retrospective review of all TCAR procedures performed at two tertiary care academic medical centers within a single hospital system from 2017 through 2019. Demographics, comorbidities, preoperative patient factors, procedural details, and postoperative data were collected. Patients were assessed over 24 hours postoperatively for stroke, death, myocardial infarction (MI), and hemodynamic instability at 3, 6, 9, 12, and 24 hour intervals. Hemodynamic instability was defined as any vital sign abnormality which required pharmacological intervention with antihypertensive, vasopressor, and/or anti-arrhythmic agents. The incidence and timing of postoperative complications and hemodynamic instability were recorded. RESULTS: During the study period, 76 patients 80 TCAR procedures. Out of 80 procedures, 64 (80.0%) were receiving home antihypertensive medication and 28 (35.0%) were symptomatic lesions preoperatively. Intraoperatively, one patient (1.3%) received atropine, 26 (32.5%) received glycopyrrolate, 76 (95%) underwent predilatation, and 16 (20.0%) underwent postdilatation. Postoperatively, a total of 22 cases (27.5%) required medication for acute control of blood pressure or heart rate, which reached a peak of 19 patients (23.8%) within the first 3 hours, and tapered to nine patients (11.3%) by the 24 hour mark. A total of three patients (3.75%) required initiation of pharmacological management after the three-hour mark. Six patients (7.5%) underwent stroke code workup, 4 (5.0%) of whom were confirmed to have stroke on CT. Average time to neurologic event was 3.9 hours. No patients experienced MI or death. Median ICU and hospital days for unstable patients were two and three, respectively, compared to one and one for stable patients. CONCLUSIONS: Hemodynamic instability is common after TCAR and reliably presents at or before postoperative hour 3. Hypo- followed by hyper-tension were the most common manifestations of hemodynamic instability. Regardless, unstable patients and stroke patients were more likely to require longer periods of time in the ICU and in the hospital overall. This may have implications for postoperative ICU resource management when deciding to transfer patients out of a monitored setting. Further study is required to establish relationships between pre- and intra-operative risk factors and outcomes such as hemodynamic instability and/or stroke. At present, one should proceed with careful evaluation of preoperative medications, strict management of postoperative hemodynamics, and clear communication among team members should all be employed to optimize outcomes.

Urinary Tract Infections in Low Birth Weight Neonates.

OBJECTIVE: Our objective was to evaluate the incidence of urinary tract infections (UTIs) in low birth weight (LBW) neonates and to evaluate the compliance of neonatal intensive care unit (NICU) providers in performing urine cultures as a part of late-onset sepsis (LOS) evaluations following an educational intervention. STUDY DESIGN: A retrospective chart review for all LBW infants undergoing LOS evaluations was performed. An educational intervention was conducted to encourage NICU providers to perform urine cultures in LOS evaluations. Prospective chart reviews were conducted following the intervention to assess compliance with the urine culture directive and the incidence of UTIs before and after the intervention. RESULTS: Rate of UTIs among LBW neonates was 1.3% for the entire study period and typical uropathogens were the cause. UTIs were found concurrently with bacteremia in only 33.3% of cases and showed a predilection for male infants when analyzing based on the number of infections. Urine cultures were performed in 20% of LOS evaluations prior to our educational intervention and increased to 57% (p < 0.0001) postintervention. CONCLUSION: An educational intervention is effective at increasing the rate of obtaining urine cultures with LOS evaluations. Performing these cultures reveals that UTIs in LBW neonates are common without bacteremia and can be missed if they are omitted from LOS evaluations. KEY POINTS: · UTIs occur often in preterm infants, especially boys.. · Education increases the performance of urine cultures.. · UTIs in preterm infants occur often without bacteremia..

Meta-Analysis of the Effect of Vascular Complications on Mortality in Patients Undergoing Femoral Venoarterial Extracorporeal Membrane Oxygenation.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) has become an accepted treatment modality in the management of select patients with cardiopulmonary failure. As a result, its use has increased significantly over the past decade. However, the effect of complications on mortality is not clearly established. We performed a comprehensive, up-to-date meta-analysis of peer-reviewed literature focusing on the effect of vascular complications (VCs) on the survival of patients receiving venoarterial ECMO (VA-ECMO) with femoral cannulation. METHODS: A systematic search of 4 different databases (PubMed, Embase, Scopus, and Web of Science) was conducted from their inception to mid-September of 2019. To keep the pooled analysis current, only studies published within the past 5 years were included. Mortality was analyzed based on presence or absence of VCs. Studies with less then 10 patients, with incomplete mortality data, and not accessible in the English language were excluded. RESULTS: Ten studies were included in the analysis encompassing 1,643 patients over a 5-year period. There were 369 patients with a cumulative VC rate of 22.5% (range 9.4 to 43.9%). The pooled mortality rate for patients with and without VCs was 69.6% and 56.8%, respectively. Meta-analysis demonstrated a significant correlation between VCs and mortality with a relative risk (RR) of 1.36 (95% confidence interval (CI), 1.15-1.60; P = 0.0004). Covariate-adjusted meta-regression analysis revealed an inverse relationship between age and mortality for VCs, with an RR of 1.33 (95% CI, 1.15-1.54; P = 0.0184), and direct relationship between female gender and mortality from VCs, RR 1.39 (95% CI, 1.21-1.59; P = 0.0165). CONCLUSIONS: The most recently available data published in the literature demonstrate a significant correlation of VCs with mortality. Therefore, aggressive attempts should be made to minimize VCs in patients with femoral VA-ECMO cannulation.

Can obstructive urolithiasis be safely excluded on contrast CT? A retrospective analysis of contrast-enhanced and noncontrast CT.

PURPOSE: The aim of this study was to determine if contrast-enhanced CT can safely exclude obstructive urolithiasis in patients with flank plain. We performed a retrospective cohort analysis to compare the negative predictive values of contrast-enhanced and non-contrast CTs for the detection of obstructing urolithiasis. METHODS: Through report analysis, we identified all non-contrast and contrast-enhanced CT examinations of the abdomen and pelvis performed on adult patients in the emergency department at a single, multi-site academic medical institution in 2017 with an indication of flank pain. The prevalence of obstructive urolithiasis in each group was calculated. We subsequently analyzed 200 consecutive studies from each of these groups (reported negative for obstructive urolithiasis) for negative predictive value calculation. Follow up abdominal imaging within 7 days from original presentation was used as a reference standard for analysis. RESULTS: In the noncontrast group, 1 study out of 200 was false negative (negative predictive value = 99.5%). In the contrast-enhanced group, there were no false negatives (negative predictive value = 100%). The prevalence of obstructive urolithiasis was 44.0% (351/797) in the noncontrast group and 18.7% (86/459) in the contrast-enhanced group. CONCLUSION: Our results suggest that contrast-enhanced CT can safely exclude obstructing ureteral calculi in the setting of acute flank pain. This finding is of clinical relevance given the inherent benefit of IV contrast in diagnosing abdominopelvic pathology.

Are Health-Care Providers Well Prepared in Providing Optimal End-of-Life Care to Critically Ill Patients? A Cross-Sectional Study at a Tertiary Care Hospital in the United States.

It is important for health-care providers to be comfortable in providing end-of-life (EOL) care to critically ill patients and realizing when continuing aggressive measures would be futile. Therefore, there is a need to understand health-care providers' self-perceived skills and barriers to providing optimum EOL care. A total of 660 health-care providers from medicine and surgery departments were asked via e-mail to complete an anonymous survey assessing their self-reported EOL care competencies, of which 238 responses were received. Our study identified several deficiencies in the self-reported EOL care competencies among health-care providers. Around 34% of the participants either disagreed (strongly disagree or disagree) or were neutral when asked whether they feel well prepared for delivering EOL care. Around 30% of the participants did not agree (agree and strongly agree) that they were well prepared to determine when to refer patients to hospice. 51% of the participants, did not agree (agree and strongly agree) that clear and accurate information is delivered by team members to patients/family. The most common barrier to providing EOL care in the intensive care unit was family not accepting the patient's poor prognosis. Nursing staff (registered nurse) had higher knowledge and attitudes mean competency scores than the medical staff. Attending physicians reported stronger knowledge competencies when compared to residents and fellows. More than half of the participants denied having received any previous training in EOL care. 82% of the participants agreed that training should be mandatory in this field. Most of the participants reported that the palliative care team is involved in EOL care when the patient is believed to be terminally ill. Apart from a need for a stronger training in the field of EOL care for health-care providers, the overall policies surrounding EOL and palliative care delivery require further evaluation and improvement to promote better outcomes in caring patients at the EOL.

An insight into Clostridium difficile infection: a single-center retrospective case-control study.

BACKGROUND: Clostridium difficile infection (CDI) has become a worldwide health problem in view of its significant incidence and medical and economic impact on the health system. Prior studies have been undergone about risk factors and disease characteristics. We wanted to study the characteristics, prognostic factors associated with CDI at our institute, as well as a new prognostic factor. METHODS: Our study aimed at describing the risk factors, patient characteristics, and outcomes associated with healthcare facility-acquired CDI (HCFA-CDI) and community-acquired CDI (CA-CDI). We intended to identify the factors associated with worse outcomes. We evaluated the characteristics associated with CDI over 3 years. We also evaluated a simple neutrophil-lymphocyte ratio (NLR) and its predictive value for worse outcomes. RESULTS: Six hundred patients were enrolled (333 in a control group; 171 in the HCFA-CDI group and 96 in the CA-CDI group). NLR > 5 predicted increased mortality and intensive care unit transfer in all CDI if done as early as day 2 after CDI diagnosis. In HCFA-CDI, NLR > 5 predicted a higher ICU transfer if done as early as day 1 post-diagnosis and with increased mortality as early as day 2 post-diagnosis. In CA-CDI, NLR > 5 predicted a higher mortality and ICU transfer if done at least 4 days after diagnosis. Moreover, every 10-unit increase in NLR was associated with a significant increase in mortality and ICU transfer in patients with CDI. CONCLUSION: A timely use of NLR can be used as a mean to predict worse outcomes, namely ICU transfer and mortality, in patients with CDI.

The relationship between emergency department volume and patient complexity.

INTRODUCTION: Forecasting emergency department (ED) visits is a well-studied topic. The importance of understanding the complexity of patients along with the days and times of varying patient volumes is critical for planning medical and ancillary staffing. Though multiple studies stratify their results based on severity of disease, severity was determined by triage status. The goal of this study was to utilize a novel method to evaluate the correlation between daily emergency department patient complexity, based on Current Procedure Terminology (CPT) code, and day of the week. METHODS: This was a retrospective study of subjects presenting to the ED between January 1, 2010 and December 31, 2015. We identified the correlation between subjects with each CPT code who were evaluated on a specific day of the week and evaluated the day before, the day of and the day after a legal holiday. RESULTS: During the study period 312,550 (48%) male and 336,348 (52%) female subjects were identified. No correlation between daily ED patient complexity, based on CPT code, and day of the week (p=0.75) or any legal holidays were identified. Individual significant differences were noted among day of the week and particular CPT code as well as legal holiday and particular CPT code with no appreciable trend or pattern. CONCLUSIONS: There was no correlation between daily ED patient complexity based on CPT code and day of the week or daily ED patient acuity and legal holiday. In light of these data, emergency department staffing and resource allocation patterns may need to be revisited.

Use of Concomitant FSH with hCG at the Time of Trigger May Improve Success Rates of Couples with Poor Ovarian Response Undergoing Gonadotropin Therapy with IUI.

OBJECTIVE: To investigate if administration of an additional dose of gonadotropins concomitantly to human chorionic gonadotropin (hCG) trigger increases pregnancy rates in patients undergoing intrauterine insemination (IUI) with controlled ovarian hyperstimulation (COH). STUDY DESIGN: This is a retrospective cohort study of all gonadotropin-IUI cycles performed by a single physician in a private practice between January 2012 and September 2013. Control cycles were those in which follicle-stimulating hormone (FSH) was discontinued prior to the day of hCG trigger shot, and study cycles received continuous FSH including the day of hCG trigger shot. A total of 423 cycles from 239 patients were included; 275 (65.5%) were control cycles (137 patients), and 146 (34.7%) were study cycles (102 patients). RESULTS: Pregnancy rates were comparable in both control and study groups (15.27% vs. 15.07%, respectively, p=0.956). There was a 42% increase in multiple gestations in the study group; however, the difference was not statistically significant (p=0.155). Upon multivariate logistic regression, male factor infertility was the only variable that was associated with pregnancy outcomes. CONCLUSION: Continuous administration of FSH including the day of hCG trigger in patients undergoing COH with IUI does not seem to increase pregnancy rates. Our suggested protocol might be beneficial in patients with poor ovarian response.

The clinical impact of early detection of ESBL-producing Enterobacterales with PCR-based blood culture assays.

BACKGROUND: Starting January 4, 2021, our health system core microbiology laboratory changed blood culture identification (BCID) platforms to ePlex BCID from BioFire BCID1 with the additional capability to detect the blaCTX-M-Type gene of ESBL-producing organisms. Clinical outcomes of ESBL bloodstream infections (BSI) after implementing ePlex BCID were unknown. METHODS: Patients with ESBL BSI were compared pre and postimplementation of ePlex BCID in this 11-hospital retrospective analysis (BioFire BCID1 in 2019 vs ePlex BCID in 2021). The primary outcome was time from the Gram stain result to escalation to a carbapenem. Secondary outcomes included in-hospital mortality, 30-day readmission rate, length of stay (LOS), and the duration of antimicrobial therapy. RESULTS: A total of 275 patients were analyzed. The median time of Gram stain result to escalation to carbapenem was reduced from 44.5 hours with BioFire BCID1 to 7.9 hours with ePlex BCID (P < .001). There were no significant differences in mortality, 30-day readmission, or LOS. The duration of antimicrobial therapy for ESBL BSI was lower in the ePlex BCID group (from 14.4 days to 12.7 days, P = .014). CONCLUSIONS: Timely detection of the blaCTX-M-Type gene by BCID provides valuable information for the early initiation of appropriate and effective antimicrobial therapy. Although it was not associated with lower mortality, 30-day readmission, or LOS, it may have benefits such as decreasing antimicrobial exposure to patients.

Acute ischemic stroke outcomes in patients with COVID-19: a systematic review and meta-analysis.

BACKGROUND: Although patients with COVID-19 have a higher risk of acute ischemic stroke (AIS), the impact on stroke outcomes remains uncertain. AIMS: To determine the clinical outcomes of patients with AIS and COVID-19 (AIS-COVID+). METHODS: We performed a systematic review and meta-analysis following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Our protocol was registered with the International Prospective Register of Systematic Reviews (CRD42020211977). Systematic searches were last performed on June 3, 2021 in EMBASE, PubMed, Web-of-Science, Scopus, and CINAHL Databases. INCLUSION CRITERIA: (1) studies reporting outcomes on AIS-COVID+; (2) original articles published in 2020 or later; (3) study participants aged ≥18 years. EXCLUSION CRITERIA: (1) case reports with <5 patients, abstracts, review articles; (2) studies analyzing novel interventions. Risk of bias was assessed using the Mixed Methods Appraisal Tool. Random-effects models estimated the pooled OR and 95% confidence intervals (95% CI) for mortality, modified Rankin Scale (mRS) score, length of stay (LOS), and discharge disposition. RESULTS: Of the 43 selected studies, 46.5% (20/43) reported patients with AIS without COVID-19 (AIS-COVID-) for comparison. Random-effects model included 7294 AIS-COVID+ and 158 401 AIS-COVID-. Compared with AIS-COVID-, AIS-COVID+ patients had higher in-hospital mortality (OR=3.87 (95% CI 2.75 to 5.45), P<0.001), less mRS scores 0-2 (OR=0.53 (95% CI 0.46 to 0.62), P<0.001), longer LOS (mean difference=4.21 days (95% CI 1.96 to 6.47), P<0.001), and less home discharge (OR=0.31 (95% CI 0.21 to 0.47), P<0.001). CONCLUSIONS: Patients with AIS-COVID had worse outcomes, with almost fourfold increased mortality, half the odds of mRS scores 0-2, and one-third the odds of home discharge. These findings confirm the significant impact of COVID-19 on early stroke outcomes.

Pediatric and emergency medicine resident comfort assessing and treating pediatric pain across pediatric age groups.

Aim: Assess pediatric and emergency medicine (EM) resident comfort treating and assessing pediatric pain. Materials & methods: Pediatric and EM residents at a single institution (SIUH Northwell Health in New York) completed an anonymous survey 6 months into the academic year regarding comfort assessing and treating pediatric pain. Results: A total of 40 (16/24 EM and 24/24 pediatric) residents completed this survey: 20% (8/24) pediatric first year residents, 40% (16/40) pediatric second year and above, 20% (8/40) EM first year and 20% (8/40) EM second year and above. A 46% (11/24) pediatric and 12% (2/16) EM residents were comfortable assessing neonatal pain (p < 0.05). A 38% (9/24) pediatric residents were comfortable treating neonatal pain compared with 12% (2/16) EM residents (p < 0.05). Both resident groups reported increasing comfort assessing and treating pain with increasing patient age. Conclusion: Both residents groups reported limitations in comfort assessing and treating pediatric pain, especially in younger patients. Education for both groups is important to optimize pediatric pain management.

Pediatric pain is common, and often underassessed and undertreated. Pediatric and emergency medicine (EM) residents care for pediatric patients with pain and must be able to appropriately assess and treat this pain. For this study, pediatric and EM residents at a single institution (SIUH Northwell Health in New York) completed an anonymous survey 6 months into the academic year regarding comfort assessing and treating pain and comfort prescribing pain medications across pediatric age ranges. In this study, 40 (16/24 EM and 24/24 pediatric) residents completed this anonymous survey. Of the 40 residents, 20% (8/24) were pediatric first year residents, 40% (16/40) were second or third year pediatric residents, 20% (8/40) were EM first year residents and 20% (8/40) were second, third or fourth year residents. About 46% (11/24) of pediatric residents and 12% (2/16) of EM residents were comfortable assessing neonatal pain. With increasing patient age, pediatric residents and EM residents comfort in assessing pediatric pain trended up (93.3% EM residents comfortable assessing pain in teenage patients). About 38% (9/24) of pediatric residents were comfortable treating neonatal pain as compared with 12% (2/16) of EM residents. While pediatric residents were significantly more comfortable treating pain in age categories from neonate to adolescents as compared with EM residents, both pediatric and EM residents reported increasing comfort in treating pediatric pain with increasing patient age. Limitations in comfort assessing and treating pediatric pain exist for both specialties. Education for both groups is important to optimize pediatric pain management.

Characteristics of Suspected COVID-19 Discharged Emergency Department Patients Who Returned During the First Wave.

INTRODUCTION: Limited information exists on patients with suspected coronavirus disease 2019 (COVID-19) who return to the emergency department (ED) during the first wave. In this study we aimed to identify predictors of ED return within 72 hours for patients with suspected COVID-19. METHODS: Incorporating data from 14 EDs within an integrated healthcare network in the New York metropolitan region from March 2-April 27, 2020, we analyzed this data on predictors for a return ED visit-including demographics, comorbidities, vital signs, and laboratory results. RESULTS: In total, 18,599 patients were included in the study. The median age was 46 years old [interquartile range 34-58]), 50.74% were female, and 49.26% were male. Overall, 532 (2.86%) returned to the ED within 72 hours, and 95.49% were admitted at the return visit. Of those tested for COVID-19, 59.24% (4704/7941) tested positive. Patients with chief complaints of "fever" or "flu" or a history of diabetes or renal disease were more likely to return at 72 hours. Risk of return increased with persistently abnormal temperature (odds ratio [OR] 2.43, 95% CI 1.8-3.2), respiratory rate (2.17, 95% CI 1.6-3.0), and chest radiograph (OR 2.54, 95% CI 2.0-3.2). Abnormally high neutrophil counts, low platelet counts, high bicarbonate values, and high aspartate aminotransferase levels were associated with a higher rate of return. Risk of return decreased when discharged on antibiotics (OR 0.12, 95% CI 0.0-0.3) or corticosteroids (OR 0.12, 95% CI 0.0-0.9). CONCLUSION: The low overall return rate of patients during the first COVID-19 wave indicates that physicians' clinical decision-making successfully identified those acceptable for discharge.

Preexisting anticoagulation is an independent predictor of mortality in geriatric trauma patients - a retrospective cohort study.

Introduction: Preexisting anticoagulation is common among geriatric trauma patients. Geriatric trauma patients have a higher risk of mortality compared to younger patients. We sought to evaluate the association of preexisting anticoagulation with mortality in a group of geriatric trauma patients. Methods: A retrospective review of geriatric trauma patients was conducted for those admitted to a Level 1 trauma center from January 2018 to December 2020. Vital signs, demographics, injury characteristics, laboratory data, and mortality were all collected. Multivariable logistic regression analysis was performed for the association of preexisting anticoagulation and a primary endpoint of all-cause mortality. These groups were controlled for preexisting comorbidities, injury severity scores, and systolic blood pressure in the emergency department. Results: Four thousand four hundred thirty-two geriatric patients were admitted during the study period. This cohort was made up of 36.9% men and 63.1% women. Three thousand eight hundred fifty-nine (87.2%) were white; the average age was 81±8.5 years, and the median injury severity score (ISS) was 5. The mean systolic blood pressure was 150±32 mmHg, mean heart rate was 81±16 bpm, mean lactate was 2.3±1.3, mean hematocrit was 37.3±8.8, and mean international normalized ratio (INR) was 1.7±10.3. One thousand five hundred ninety-two (35.9%) patients were on anticoagulation (AC) upon presentation. One hundred and sixty-five (3.7%) mortalities were recorded. Multivariable logistic regression analysis results show that preexisting anticoagulation [ odds ratio (OR) 1.92, 95% CI 1.36-2.72] was independently predictive of death. The analysis was adjusted for systolic BP in the emergency department less than90 mmHg (OR 5.55, 95% CI 2.83-10.9), having more than 1 comorbidity (OR 2.30, 95% CI 1.57-3.38) and ISS (OR 1.13, 95% CI 1.10-1.15). Conclusion: Our study indicates that preexisting anticoagulation is associated with mortality among geriatric trauma patients.

Low correlation between serum thyroglobulin and 131I radioiodine whole body scintigraphy: implication for postoperative disease surveillance in differentiated thyroid cancer.

PURPOSE: To evaluate postoperative serum thyroglobulin (Tg) as a reliable tumor marker in low-risk differentiated thyroid cancer (DTC). METHODS: Two hundred and three patients met the selection criteria of >18 years old; who had undergone total or near total thyroidectomy; had a postoperative Tg, and had undergone 131I pre ablation whole body scan (PA-WBS). The primary endpoint was the correlation between Tg level and functional remnant thyroid tissues. Outcomes were categorized as concordant and discordant. Concordant results were positive Tg (>1 ng/ml) with positive PA-WBS or negative Tg (<1 ng/ml) with negative PA-WBS. Discordant results were negative Tg with a positive PA-WBS or positive Tg with a negative PA-WBS. To increase the sensitivity of Tg detection, we evaluated Tg in patients with high thyroid stimulating hormone (TSH) with serum level >30 mU/l on thyroxine withdrawal protocol. RESULTS: One hundred ten patients (54.1%) had discordant results (p < 0.05) with positive PA-WBS and Tg <1 ng/ml, while 93 patients (45.9%) had concordant results. For concordant results, 88 patients had positive PA-WBS and Tg >1 ng/ml, and 5 patients had negative PA-WBS and Tg <1 ng/ml. There was no patient with Tg >1 ng/ml and negative PA-WBS. There were 74 patients with high TSH (>30 mU/l) on abstention (thyroxine withdrawal protocol). Twenty-four (32.5%) had discordant results (p < 0.001) and 50 (67.5%) had concordant results. CONCLUSION: There is low correlation between postoperative Tg and PA-WBS. The sole use of Tg as a serum biomarker for postoperative disease status may not be reliable.

Single shot lymphoscintigraphy in breast cancer: Effective single tracer sentinel node detection protocol with reduction in procedural pain.

PURPOSE: Variation in protocols for axillary sentinel lymph node (SLN) mapping exists. We strive to evaluate the effectiveness of reduction in number of injections on reducing procedural pain, while maintaining nodal detection. METHODS: Over 7 years, the number of periareolar injections performed was reduced stepwise from 4 to 1. This was analyzed for SLN detection and patients' subjective perceived pain. RESULTS: 828 patients with invasive breast cancer who underwent SLN mapping were included. Laterality of breast injection site included 326 (39.4%) in the right breast, 354 (42.8%) in the left breast and 148 (17.9%) in bilateral breasts. In patients who had 4 injection sites in a unilateral breast (n = 143), the reported pain score was 4.3 ± 2.4. Patients with 3 injections (n = 163), 2 injections (n = 163) and 1 injection (n = 211) in a breast reported pain scores of 3.4 ± 2.4, 3.2 ± 2.2, and 2.9 ± 2.6, respectively. In patients who had bilateral sentinel node procedures, those with 4 injections in each breast for a total of 8 injections (n = 37) reported a pain score of 5.7 ± 2.4. Patients with 3 (n = 51), 2 (n = 31) and 1 (n = 39) injection(s) in each breast reported perceived pain of 4.8 ± 2.8, 3.7 ± 2.7 and 3.5 ± 1.9, respectively. Incremental decreased pain scores were achieved with decreasing number of injections (p < 0.001). Nodal detection was maintained. CONCLUSION: A single periareolar subdermal injection site reduces periprocedural pain while maintaining nodal detection.

Substantial interreader agreement for biopsy with reduction in biopsy rate: A multireader diagnostic performance study of ACR TI-RADS.

PURPOSE: To assess diagnostic performance of ACR TI-RADS in thyroid cancer detection and evaluate interobserver agreement among radiologists with lower interpreting experience. METHODS: Four radiologists retrospectively assessed 295 biopsied thyroid nodules from ultrasound studies performed between 2009 and 2019, blinded to histopathology. Diagnostic performance for cancer detection was determined individually, and interobserver agreement among four readers was evaluated with Fleiss kappa coefficient (ⱪ). RESULTS: 245 (83.1%) benign and 50 (16.9%) malignant nodules were evaluated. Diagnostic performance based on final TR level was consistent and without significant difference among four readers, with excellent sensitivity (≥98.0%) and negative predictive value (NPV) [≥94.4%] for TR levels 3 to 5. Diagnostic performance based on recommendation to biopsy has moderate sensitivity (≥62%) and high NPV (≥84.7%). Retrospective scoring with established ACR TI-RADS criteria would have substantially reduced the number of biopsies performed, with 63.2% of malignancy not biopsied meeting criteria for sonographic surveillance. Interobserver agreement on TI-RADS scoring for final TR level was fair (ⱪ = 0.39, 95% CI 0.32, 0.47), with substantial agreement for recommendation to biopsy (ⱪ = 0.64, 95% CI 0.58, 0.70). CONCLUSIONS: Substantial reduction in biopsy rate (up to 48%) would have been achieved using the ACR TI-RADS criteria, with 63% of malignancy not biopsied meeting criteria for sonographic surveillance. Interobserver agreement was fair for TI-RADS level scoring and substantial for recommendation to biopsy.