Balanced crystalloids (RInger's lactate) versus normal Saline in adults with diabetic Ketoacidosis in the Emergency Department (BRISK-ED): a pilot randomised controlled trial.

BACKGROUND: Current diabetic ketoacidosis (DKA) treatment guidelines recommend using normal saline (NS); however, NS may delay DKA resolution by causing more hyperchloremic metabolic acidosis compared with balanced crystalloids. This study's objective was to determine the feasibility of a future multicentred randomised controlled trial (RCT) comparing intravenous Ringer's lactate (RL) with NS in managing ED patients with DKA. METHODS: We conducted a parallel-arm, triple-blind, pilot RCT of adults (≥18 years) with DKA at a Canadian academic tertiary care ED. The primary feasibility outcome was recruitment rate (target ≥41.3% of eligible participants over the 1-year study period); the primary efficacy outcome was time elapsed from ED presentation to DKA resolution. The superiority margin for a clinically significant difference was chosen to be a 40% time reduction to DKA resolution. We also assessed the need to break allocation concealment and loss to follow-up. Patients with clinical suspicion for DKA were screened for inclusion and enrolled patients were randomised 1:1 to receive RL or NS. Patients, clinicians and outcome assessors were blinded to allocation. RESULTS: We enrolled 52 (25 RL, 27 NS) of 60 eligible patients (86.7%), exceeding our target recruitment rate. There were more patients in the NS group with type 1 diabetes, and more patients in the RL group had an admission co-diagnosis in addition to DKA. For the 44 participants with confirmed laboratory evidence of resolution, median (IQR) time to DKA resolution for RL versus NS was 15.7 (10.4-18.8) and 12.7 (7.9-19.2) hours, respectively. There were no cases where blinding was broken, and there was no loss to follow-up. CONCLUSIONS: This pilot trial demonstrated our protocol's feasibility by exceeding our target recruitment rate. Our results may be used to inform future multicentre trials to compare the safety and efficacy of RL and NS in managing DKA in the ED. TRIAL REGISTRATION NUMBER: NCT04926740.

Characteristics and outcomes of patients with COVID-19 who return to the emergency department: a multicentre observational study by the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN).

OBJECTIVE: Unplanned return emergency department (ED) visits can reflect clinical deterioration or unmet need from the original visit. We determined the characteristics and outcomes of patients with COVID-19 who return to the ED for COVID-19-related revisits. METHODS: This retrospective observational study used data for all adult patients visiting 47 Canadian EDs with COVID-19 between 1 March 2020 and 31 March 2022. Multivariable logistic regression assessed the characteristics associated with having a no return visit (SV=single visit group) versus at least one return visit (MV=return visit group) after being discharged alive at the first ED visit. RESULTS: 39 809 patients with COVID-19 had 44 862 COVID-19-related ED visits: 35 468 patients (89%) had one visit (SV group) and 4341 (11%) returned to the ED (MV group) within 30 days (mean 2.2, SD=0.5 ED visit). 40% of SV patients and 16% of MV patients were admitted at their first visit, and 41% of MV patients not admitted at their first ED visit were admitted on their second visit. In the MV group, the median time to return was 4 days, 49% returned within 72 hours. In multivariable modelling, a repeat visit was associated with a variety of factors including older age (OR=1.25 per 10 years, 95% CI (1.22 to 1.28)), pregnancy (1.86 (1.46 to 2.36)) and presence of comorbidities (eg, 1.72 (1.40 to 2.10) for cancer, 2.01 (1.52 to 2.66) for obesity, 2.18 (1.42 to 3.36) for organ transplant), current/prior substance use, higher temperature or WHO severe disease (1.41 (1.29 to 1.54)). Return was less likely for females (0.82 (0.77 to 0.88)) and those boosted or fully vaccinated (0.48 (0.34 to 0.70)). CONCLUSIONS: Return ED visits by patients with COVID-19 within 30 days were common during the first two pandemic years and were associated with multiple factors, many of which reflect known risk for worse outcomes. Future studies should assess reasons for revisit and opportunities to improve ED care and reduce resource use. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov, NCT04702945.

Association between fentanyl treatment for acute pain in the emergency department and opioid use two weeks after discharge.

BACKGROUND: Analgesia with fentanyl can be associated with hyperalgesia (higher sensitivity to pain) and can contribute to escalating opioid use. Our objective was to assess the relationship between emergency department (ED) acute pain management with fentanyl compared to other opioids, and the quantity of opioids consumed two-week after discharge. We hypothesized that the quantity of opioids consumed would be higher for patients treated with fentanyl compared to those treated with other opioids. METHODS: Patients were selected from two prospective cohorts assessing opioids consumed after ED discharge. Patients ≥18 years treated with an opioid in the ED for an acute pain condition (≤2 weeks) and discharged with an opioid prescription were included. Patients completed a 14-day paper or electronic diary of pain medication use. Quantity of 5 mg morphine equivalent tablets consumed during a 14-day follow-up by patients treated with fentanyl compared to those treated with other opioids during their ED stay were analyzed using a multiple linear regression and propensity scores. RESULTS: We included 707 patients (mean age ± SD: 50 ± 15 years, 47% women) in this study. During follow-up, patients treated with fentanyl (N = 91) during their ED stay consumed a median (IQR) of 5.8 (14) 5 mg morphine equivalent pills compared to 7.0 (14) for those treated with other opioids (p = 0.05). Results were similar using propensity score sensitivity analysis. However, after adjusting for confounding variables, ED fentanyl treatment showed a trend, but not a statistically significant association with a decreased opioid consumption during the 14-day follow-up (B = -2.4; 95%CI = -5.3 to 0.4; p = 0.09). CONCLUSIONS: Patients treated with fentanyl during ED stay did not consume more opioids after ED discharge, compared to those treated with other opioids. If fentanyl does cause more hyperalgesia compared to other opioids, it does not seem to have a significant impact on opioid consumption after ED discharge.

The Feasibility of Utilizing Malunion Criteria to Limit Radiographs After Spica Casting for Pediatric Femur Fractures.

BACKGROUND: There are no existing guidelines regarding the timing or frequency of postoperative radiographs following spica casting for pediatric femur fractures. The purpose of this study was to evaluate established femoral malunion criteria as a potential screening tool to limit postoperative radiographs by identifying patients at risk for unacceptable alignment in the early treatment period. METHODS: A retrospective chart review was conducted for pediatric femoral shaft fractures presenting to a tertiary pediatric referral hospital from 2012 to 2017. Pediatric femur malunion criteria were applied to radiographs at initial presentation, first follow-up visit, and final follow-up visit. The primary outcome was a change in management based on radiographic findings in the early postoperative period. Secondary outcomes included radiographic measures, number of follow-up visits, and complications. RESULTS: Of 449 consecutive pediatric femur fractures treated at our center, 149 patients aged 1 to 4 years (mean age: 2.5±1.6 y) met inclusion criteria. At initial presentation, 36.9% (55/149) of patients met malunion criteria. Only 4.0% (6/149) of patients had a change in management following initial closed reduction and spica cast application due to radiographic findings at subsequent follow-up. Of these patients, 67% (4/6) were identified on preoperative imaging, and 83.3% (5/6) were identified by their first clinic appointment. Four of the 149 patients were converted to definitive surgical fixation, and 2 patients required cast wedging due to either unacceptable fracture shortening or coronal/sagittal angulation. CONCLUSIONS: Routine early postoperative radiographs may not be necessary for all pediatric femur fractures managed with closed reduction and spica casting. The value of this study is that it is the first to demonstrate the feasibility of limiting postoperative radiographs using a preoperative screening tool. However, the established femoral malunion criteria utilized in this study were limited in their predictive value, and further work is necessary to improve the sensitivity and specificity before widespread clinical application. LEVEL OF EVIDENCE: Level IV.

Experience of emergency department patients after a visit for hyperglycaemia: implications for communication and factors affecting adherence postdischarge.

BACKGROUND: While studies have reported factors affecting adherence to diabetic care plans from a chronic disease perspective, no studies have addressed issues with post-discharge adherence facing patients with diabetes after an emergency department (ED) presentation for hyperglycaemia. This study's objectives were to describe patient perspectives on their experience during and after an ED visit for hyperglycaemia and to identify factors that influence postdischarge adherence. METHODS: We conducted a qualitative description (QD) study of adult patients who had visited a Canadian ED for hyperglycaemia. Consistent with QD, purposive sampling was utilised, seeking diversity across age, gender and diabetes type. Participants took part in semistructured interviews and thematic analysis was used to identify and describe core themes. Frequent team meetings were held to review the analysis and to develop the final list of themes used to recode the data set. Analytic insights were tracked using reflective memos and an audit trail documented all steps and decisions. RESULTS: 22 patients with type 1 and 2 diabetes were interviewed from June to October 2019. Participants identified several factors that impacted their ability to adhere to discharge plans: communication of instructions, psychosocial factors (financial considerations, shame and guilt, stigma and mental health), access to follow-up care and paediatric to adult care transitions. CONCLUSIONS: This study describes the patient experience with the communication of discharge instructions, as well as factors affecting adherence post-ED discharge for hyperglycaemia. Our findings suggest four strategies that could improve the patient experience, improve adherence to discharge plans and potentially decrease the frequency of recurrent ED visits for hyperglycaemia.

Personalised risk prediction following emergency department assessment for syncope.

BACKGROUND: Published risk tools do not provide possible management options for syncope in the emergency department (ED). Using the 30-day observed risk estimates based on the Canadian Syncope Risk Score (CSRS), we developed personalised risk prediction to guide management decisions. METHODS: We pooled previously reported data from two large cohort studies, the CSRS derivation and validation cohorts, that prospectively enrolled adults (≥16 years) with syncope at 11 Canadian EDs between 2010 and 2018. Using this larger cohort, we calculated the CSRS calibration and discrimination, and determined with greater precision than in previous studies the 30-day risk of adjudicated serious outcomes not identified during the index ED evaluation depending on the CSRS and the risk category. Based on these findings, we developed an on-line calculator and pictorial decision aids. RESULTS: 8233 patients were included of whom 295 (3.6%, 95% CI 3.2% to 4.0%) experienced 30-day serious outcomes. The calibration slope was 1.0, and the area under the curve was 0.88 (95% CI 0.87 to 0.91). The observed risk increased from 0.3% (95% CI 0.2% to 0.5%) in the very-low-risk group (CSRS -3 to -2) to 42.7% (95% CI 35.0% to 50.7%), in the very-high-risk (CSRS≥+6) group (Cochrane-Armitage trend test p<0.001). Among the very-low and low-risk patients (score -3 to 0), ≤1.0% had any serious outcome, there was one death due to sepsis and none suffered a ventricular arrhythmia. Among the medium-risk patients (score +1 to+3), 7.8% had serious outcomes, with <1% death, and a serious outcome was present in >20% of high/very-high-risk patients (score +4 to+11) including 4%-6% deaths. The online calculator and the pictorial aids can be found at: https://teamvenk.com/csrs CONCLUSIONS: 30-day observed risk estimates from a large cohort of patients can be obtained for management decision-making. Our work suggests very-low-risk and low-risk patients may be discharged, discussion with patients regarding investigations and disposition are needed for medium-risk patients, and high-risk patients should be hospitalised. The online calculator, accompanied by pictorial decision aids for the CSRS, may assist in discussion with patients.

Treatment and Survival Disparities of Colon Cancer in the Texas-Mexico Border Population: Cancer Disparities in Border Population.

BACKGROUND: Previous studies have reported healthcare disparities in the Texas-Mexico border population. Our aim was to evaluate treatment utilization and oncologic outcomes of colon cancer patients in this vulnerable population. METHODS: Patients with localized and regional colon cancer (CC) were identified in the Texas Cancer Registry (1995-2016). Clinicopathological data, hospital factors, receipt of optimal treatment, and overall survival (OS) were compared between Texas-Mexico Border (TMB) and the Non-Texas-Mexico Border (NTMB) cohorts. Multivariable analysis was performed to identify risk factors associated with decreased survival. RESULTS: We identified 43,557 patients with localized/regional CC (9% TMB and 91% NTMB). TMB patients were more likely to be Hispanic (73% versus 13%), less likely to have private insurance (13% versus 21%), were more often treated at safety net hospitals (82% versus 22%) and less likely at ACS-CoC accredited hospitals (32% versus 57%). TMB patients were more likely to receive suboptimal treatment (21% versus 16%) and had a lower median OS for localized (8.58 versus 9.58 y) and regional colon cancer (5.75 versus 6.18 y, all P < 0.001). In multivariable analysis, TMB status was not associated with worse OS. Factors associated with worse survival included receipt of suboptimal treatment, Medicare/insured status, and treatment in safety net and non-accredited ACS-CoC hospitals (all P < 0.001) CONCLUSIONS: While TMB CC patients had worse OS, TMB status itself was not found to be a risk factor for decreased survival. This survival disparity is likely associated with higher rate of suboptimal treatment, Medicare/Uninsured status, and decreased access to ACS-CoC accredited hospitals.

Adverse Events Among Emergency Department Patients With Cardiovascular Conditions: A Multicenter Study.

STUDY OBJECTIVE: We aim to determine incidence and type of adverse events (adverse outcomes related to emergency care) among emergency department (ED) patients discharged with recent-onset atrial fibrillation, acute heart failure, and syncope. METHODS: This 5-year prospective cohort study included high-acuity adult patients discharged with the 3 sentinel diagnoses from 6 tertiary care Canadian EDs. We screened all ED visits for eligibility and performed telephone interviews 14 days postdischarge to identify flagged outcomes: death, hospital admission, return ED visit, health care provider visit, and new or worsening symptoms. We created case summaries describing index ED visit and flagged outcomes, and trained emergency physicians reviewed case summaries to identify adverse events. We reported adverse event incidence and rates with 95% confidence intervals and contributing factor themes. RESULTS: Among 4,741 subjects (mean age 70.2 years; 51.2% men), we observed 170 adverse events (3.6 per 100 patients; 95% confidence interval 3.1 to 4.2). Patients discharged with acute heart failure were most likely to experience adverse events (5.3%), followed by those with atrial fibrillation (2.0%) and syncope (0.8%). We noted variation in absolute adverse event rates across sites from 0.7 to 6.0 per 100 patients. The most common adverse event types were management issues, diagnostic issues, and unsafe disposition decisions. Frequent contributing factor themes included failure to recognize underlying causes and inappropriate management of dual diagnoses. CONCLUSION: Among adverse events after ED discharge for patients with these 3 sentinel cardiovascular diagnoses, we identified quality improvement opportunities such as strengthening dual diagnosis detection and evidence-based clinical practice guideline adherence.

Seeking Care for Hyperglycemia in the Emergency Department: Through the Eyes of the Patient.

Health care systems often provide a range of options of care for patients with illnesses who do not require hospital admission. For individuals with diabetes, these options may include primary care providers, specialized diabetes clinics, and urgent care and walk-in clinics. We explored the reasons why patients choose the Emergency Department over other health care settings when seeking care for hyperglycemia.

Intraoperative Burden of Flexible Intramedullary Nailing and Spica Casting for Femur Fractures in Young Children.

BACKGROUND: Spica casting (Spica) remains the widely accepted treatment of closed femoral shaft fractures in young children aged 6 months to 5 years. In some centers, there has been a recent trend towards surgical fixation of these fractures with flexible intramedullary nails (FINs). Despite numerous studies evaluating both Spica and FIN treatment of femoral shaft fractures, there remains a paucity of data regarding patient burden during the intraoperative period. The purpose of this study was to compare the intraoperative burden, defined as anesthetic exposure, fluoroscopic duration, and radiation load, between Spica and FIN treatment of femoral shaft fractures in young children. METHODS: A retrospective chart review was conducted for pediatric femoral shaft fractures presenting to a tertiary pediatric referral hospital from 2012 to 2017. Comparison groups included pediatric femur fractures treated with Spica and those treated with FIN. Outcomes included anesthetic exposure, fluoroscopy duration, and radiation exposure. In addition, length of stay, clinic visits, and complications were recorded. RESULTS: Of 449 consecutive pediatric femur fractures treated at our center, 143 patients ages 2 to 6 years (mean age 3.8±1.4 y) met inclusion criteria. The Spica group contained 91 patients; FIN contained 52 patients. Mean anesthetic exposure was less for Spica compared with FIN [45.1 min, 95% confidence interval (CI): 38.0-52.3 vs. 90.7 min, 95% CI: 80.5-100.8 min; P<0.001]. On average, Spica procedures required less fluoroscopy time compared with FIN (15.4 s, 95% CI: 4.8-26.0 vs. 131.6 s, 95% CI: 117.6-145.6 s; P<0.001). Mean radiation load was less for Spica compared with FIN (1.6 mGy, 95% CI: 0.6-2.6 vs. 6.9 mGy, 95% CI: 5.7-8.1 mGy; P<0.001). There was no difference in length of hospital stay (P=0.831), follow-up visits (P=0.248), or complication rate (P=0.645) between Spica and FIN groups. The most common complication was skin irritation for Spica (18.7%) and symptomatic hardware for FIN (17.3%). CONCLUSIONS: The findings of this study suggest that pediatric patients with femoral shaft fractures experience an increased intraoperative burden when treated with FIN compared with Spica. Treatment with FIN was associated with increased exposure to anesthesia, fluoroscopic duration, and radiation load despite similar complication rates when compared with Spica. LEVEL OF EVIDENCE: Level III.

Benefit of hospital admission for detecting serious adverse events among emergency department patients with syncope: a propensity-score-matched analysis of a multicentre prospective cohort.

BACKGROUND: The benefit of hospital admission after emergency department evaluation for syncope is unclear. We sought to determine the association between hospital admission and detection of serious adverse events, and whether this varied according to the Canadian Syncope Risk Score (CSRS). METHODS: We conducted a secondary analysis of a multicentre prospective cohort of patients assessed in the emergency department for syncope. We compared patients admitted to hospital and discharged patients, using propensity scores to match 1:1 for risk of a serious adverse event. The primary outcome was detection of a serious adverse event in hospital for admitted patients or within 30 days after emergency department disposition for discharged patients. RESULTS: We included 8183 patients, of whom 743 (9.1%) were admitted; 658/743 (88.6%) were matched. Admitted patients had higher odds of detection of a serious adverse event (odds ratio [OR] 5.0, 95% confidence interval [CI] 3.3-7.4), nonfatal arrhythmia (OR 5.1, 95% CI 2.9-8.8) and nonarrhythmic serious adverse event (OR 6.3, 95% CI 2.9-13.5). There were no significant differences between the 2 groups in death (OR 1.0, 95% CI 0.4-2.7) or detection of ventricular arrhythmia (OR 2.0, 95% CI 0.7-6.0). Differences between admitted and discharged patients in detection of serious adverse events were greater for those with a CSRS indicating medium to high risk (p = 0.04). INTERPRETATION: Patients with syncope were more likely to have serious adverse events identified within 30 days if they were admitted to hospital rather than discharged from the emergency department. However, the benefit of hospital admission is low for patients at low risk of a serious adverse event.

The Reverse Oblique Supracondylar Humerus Fracture: Description of a Novel Fracture Pattern.

BACKGROUND: Sagittal profile descriptions of supracondylar humerus fractures are limited. We describe a reverse oblique (RO) pattern in which the distal fragment has a prominent anterior spike that is displaced posterior to the proximal fragment. This pattern presents a challenge during closed manipulation utilizing traditional reduction maneuvers. The purpose of this study is to compare the clinical and radiographic characteristics of the RO and non-RO patterns of supracondylar humerus fractures. We hypothesized that the RO pattern would be associated with greater soft tissue trauma. METHODS: Retrospective evaluation of operative supracondylar humerus fractures treated at a tertiary pediatric hospital from 2014 to 2016. Patients were categorized into RO and non-RO groups for analysis. Associated neurovascular injuries were compared between groups. RESULTS: Two hundred ninety-nine consecutive patients were reviewed. The RO fracture pattern was seen in 12 patients. All displaced RO fractures were able to be closed reduced with a modification to the traditional reduction sequence. Overall cohort rates of preoperative soft tissue injury included antecubital ecchymosis 16.8%, nerve palsies 15%, and vascular compromise 6.4%. Compared with non-RO fractures, the RO fracture group had significantly higher rates of anterior interosseous nerve (AIN) palsies (P=0.013), antecubital ecchymosis (P=0.018), and compartment syndrome (P=0.043). When comparing RO with non-RO type II fractures, there were no differences in soft tissue injury (P=0.439). Compared with non-RO type III fractures, RO type III fractures had higher rates of AIN injury (P=0.047), antecubital ecchymosis (P=0.007), and overall soft tissue injury (P=0.009). CONCLUSIONS: This study introduces a previously undescribed supracondylar humerus fracture subtype: the RO fracture. We found increased rates of soft tissue compromise including antecubital ecchymosis and AIN palsy in this fracture type. Further, traditional reduction methods proved to be ineffectual for this fracture pattern. We utilized a simple modification that allowed for closed reduction and percutaneous pinning of displaced RO fractures. LEVEL OF EVIDENCE: Level III-prognostic.

Characteristics and outcomes for acute heart failure in elderly patients presenting to the ED.

INTRODUCTION: The first aim of this study was to investigate the characteristics for elderly patients with acute heart failure presenting to the emergency department (ED). The second aim was to determine the characteristics of these elderly patients associated with serious adverse events. METHODS: The population was divided into 2 age groups, <80 and ≥80 years. The primary outcome was the occurrence of a serious adverse event, defined as either death from any cause within 30 days of the index ED visit or any of the following events within 14 days of the index ED visit: admission to a monitored unit, intubation, need for noninvasive ventilation, myocardial infarction, major procedure, or, for patients who were discharged after the initial visit, return to the ED resulting in admission to hospital. RESULTS: This prospective cohort study included 1658 visits. Older patients had a lower heart rate and higher diastolic blood pressure. The older patients were more likely to experience hospital admission (56% vs 46%, P < .001). For patients 80 years or older, 109 (14%) experienced a serious adverse event. In this ≥80-year group, history of heart failure, current medication with antiarrhythmic, acute infarction on the arrival electrocardiography, chest x-ray with pleural effusion, and urea greater than 12 mmol/L were independently associated with short-term serious adverse events. CONCLUSIONS: Elderly patients with heart failure are a high-risk group. Careful assessment of these factors could help physicians identify those patients most at risk for adverse outcomes and, therefore, most in need of hospital admission.

The impact of emergency department segmentation and nursing staffing increase on inpatient mortality and management times.

BACKGROUND: The aim of our study was to investigate the impact of a new organization of our emergency department (ED) on patients' mortality and management delays. METHODS: The ED segmentation consisted of the development of a new patient care geographical layout on a pre-existing site and changing the organization of patient flow. It took place on May 10, 2012. We did a before-after study in the ED of a university hospital, "before" (winter 2012) and "after" (summer 2012) reorganization by segmentation into sectors. All ED patients were included. RESULTS: Eighty-three thousand three hundred twenty-two patient visits were analyzed, 61,118 in phase "before", 22,204 during the phase "after". The overall inpatient mortality was 1.5 % during summer 2011 ("before" period), 1.8 % during winter 2012 ("before" period), 1.3 % during summer 2012 ("after" period) period (summer 2012 vs. winter 2012, OR = 0.72; 95 % CIs [0.61, 0.85], and summer 2012 vs. summer 2011, OR = 0.85; 95 % CIs [0.72, 0.99]). The mean (SD) time to first medical contact was 129 min (±133) during winter 2012 and 104 min (± 95) during summer 2012 (p < .05). CONCLUSIONS: Our study showed a decrease in mortality and improvement in time to first medical contact after the segmentation of our ED and nursing staffing increase, without an increase in medical personnel. Improving patient care through optimizing ED segmentation may be an effective strategy.

Risk Factors Associated with Urologic Intervention in Emergency Department Patients with Suspected Renal Colic.

BACKGROUND: Whereas most patients with urolithiasis pass their stones spontaneously and require only symptomatic management, a minority will require urologic intervention. OBJECTIVE: Our primary objective was to confirm previously reported risk factors and to identify additional predictors of urologic intervention within 90 days, for emergency department (ED) patients with suspected renal colic. METHODS: We conducted a prospective cohort study of adult patients presenting to one of two tertiary care EDs with suspected renal colic over a 20-month period. Multivariate logistic regression models determined predictor variables independently associated with urologic intervention. RESULTS: Of the 565 patients included in the analysis, 220 (38.9%) patients had a ureteric stone visualized on diagnostic imaging. Eighty-four patients (14.9%) had urologic intervention within 90 days of their initial ED visit. Urinary nitrites (odds ratio [OR] 4.2, 95% confidence interval [CI] 1.3-13.6), stone size ≥ 5 mm (OR 4.2, 95% CI 2.4-7.4), proximal ureteric stone (OR 3.1, 95% CI 1.5-6.4), age ≥ 50 years (OR 2.8, 95% CI 1.5-5.0), tachycardia at triage (OR 2.5, 95% CI 1.1-5.4), urinary leukocyte esterase (OR 2.3, 95% CI 1.2-4.5), abnormal serum white blood cells (OR 2.0, 95% CI 1.2-3.3), and history of renal colic (OR 1.8, 95% CI 1.1-3.1) were factors independently associated with urologic intervention within 90 days. CONCLUSIONS: Our study reports eight risk factors associated with urologic intervention within 90 days in patients presenting to the ED with renal colic. These risk factors should be considered when making management, prognostic, and disposition decisions for patients with suspected urolithiasis.

Predictors of 30-day recurrent emergency department visits for hyperglycemia in patients with types 1 and 2 diabetes: a population-based cohort study.

OBJECTIVES: This study's aims were to describe the outcomes of patients with diabetes presenting with their first ED visit for hyperglycemia, and to identify predictors of recurrent ED visits for hyperglycemia. METHODS: Using linked databases, we conducted a population-based cohort study of adult and pediatric patients with types 1 and 2 diabetes presenting with a first ED visit for hyperglycemia from April 2010 to March 2020 in Ontario, Canada. We determined the proportion of patients with a recurrent ED visit for hyperglycemia within 30 days of the index visit. Using multivariable regression analysis, we examined clinical and socioeconomic predictors for recurrent visits. RESULTS: There were 779,632 patients with a first ED visit for hyperglycemia. Mean (SD) age was 64.3 (15.2) years; 47.7% were female. 11.0% had a recurrent visit for hyperglycemia within 30 days. Statistically significant predictors of a recurrent visit included: male sex, type 1 diabetes, regions with fewer visible minority groups and with less education or employment, higher hemoglobin A1C, more family physician or internist visits within the past year, being rostered to a family physician, previous ED visits in the past year, ED or hospitalization within the previous 14 days, access to homecare services, and previous hyperglycemia encounters in the past 5 years. Alcoholism and depression or anxiety were positive predictors for the 18-65 age group. CONCLUSIONS: This population-level study identifies predictors of recurrent ED visits for hyperglycemia, including male sex, type 1 diabetes, regions with fewer visible minority groups and with less education or employment, higher hemoglobin A1C, higher previous healthcare system utilization (ED visits and hospitalization) for hyperglycemia, being rostered to a family physician, and access to homecare services. Knowledge of these predictors may be used to develop targeted interventions to improve patient outcomes and reduce healthcare system costs.

ABSTRAIT: OBJECTIFS: Les objectifs de cette étude étaient de décrire les résultats des patients diabétiques présentant leur première visite aux urgences pour hyperglycémie, et d'identifier les prédicteurs des visites récurrentes aux urgences pour hyperglycémie. MéTHODES: À l'aide de bases de données couplées, nous avons mené une étude de cohorte basée sur la population de patients adultes et pédiatriques atteints de diabète de type 1 et 2 présentant une première visite aux urgences pour l'hyperglycémie d'avril 2010 à mars 2020 en Ontario, au Canada. Nous avons déterminé la proportion de patients présentant une visite récurrente à l'urgence pour hyperglycémie dans les 30 jours suivant la visite d'index. À l'aide d'une analyse de régression multivariée, nous avons examiné les prédicteurs cliniques et socioéconomiques des visites récurrentes. RéSULTATS: Il y avait 779 632 patients avec une première visite à l'urgence pour hyperglycémie. L'âge moyen (ET) était de 64,3 (15,2) ans; 47,7% étaient des femmes. 11,0 % avaient une visite récurrente pour hyperglycémie dans les 30 jours. Les prédicteurs statistiquement significatifs d'une visite récurrente comprenaient le sexe masculin, le diabète de type 1, les régions comptant moins de groupes de minorités visibles et ayant moins d'études ou d'emploi, une hémoglobine A1C plus élevée, plus de visites chez un médecin de famille ou un interniste au cours de la dernière année, être inscrit auprès d'un médecin de famille, consulter le service d'urgence au cours de la dernière année, être hospitalisé au cours des 14 derniers jours, avoir accès à des services de soins à domicile et avoir été confronté à une hyperglycémie au cours des 5 dernières années. L'alcoolisme et la dépression ou l'anxiété étaient des prédicteurs positifs pour le groupe des 18-65 ans. CONCLUSIONS: Cette étude au niveau de la population identifie des prédicteurs de visites récurrentes aux urgences pour l'hyperglycémie, y compris le sexe masculin, le diabète de type 1, les régions avec moins de groupes de minorités visibles et avec moins d'études ou d'emploi, plus d'hémoglobine A1C, l'utilisation antérieure plus élevée du système de soins de santé (visites aux urgences et hospitalisation) pour l'hyperglycémie, le fait d'être inscrit auprès d'un médecin de famille et l'accès aux services de soins à domicile. La connaissance de ces prédicteurs peut être utilisée pour élaborer des interventions ciblées afin d'améliorer les résultats pour les patients et de réduire les coûts du système de santé.

Factors associated with frequent buprenorphine / naloxone initiation in a national survey of Canadian emergency physicians.

OBJECTIVE: To identify individual and site-related factors associated with frequent emergency department (ED) buprenorphine/naloxone (BUP) initiation. BUP initiation, an effective opioid use disorder (OUD) intervention, varies widely across Canadian EDs. METHODS: We surveyed emergency physicians in 6 Canadian provinces from 2018 to 2019 using bilingual paper and web-based questionnaires. Survey domains included BUP-related practice, demographics, attitudes toward BUP, and site characteristics. We defined frequent BUP initiation (the primary outcome) as at least once per month, high OUD prevalence as at least one OUD patient per shift, and high OUD resources as at least 3 out of the following 5 resources: BUP initiation pathways, BUP in ED, peer navigators, accessible addiction specialists, and accessible follow-up clinics. We excluded responses from sites with <50% participation (to minimize non-responder bias) and those missing the primary outcome. We used univariate analysis to identify associations between frequent BUP initiation and factors of interest, stratifying by OUD prevalence. RESULTS: We excluded 3 responses for missing BUP initiation frequency and 9 for low response rate at one ED. Of the remaining 649 respondents from 34 EDs, 374 (58%) practiced in metropolitan areas, 384 (59%) reported high OUD prevalence, 312 (48%) had high OUD resources, and 161 (25%) initiated BUP frequently. Age, gender, board certification and years in practice were not associated with frequent BUP initiation. Site-specific factors were associated with frequent BUP initiation (high OUD resources [OR 6.91], high OUD prevalence [OR 4.45], and metropolitan location [OR 2.39],) as were individual attitudinal factors (willingness, confidence, and responsibility to initiate BUP.) Similar associations persisted in the high OUD prevalence subgroup. CONCLUSIONS: Individual attitudinal and site-specific factors were associated with frequent BUP initiation. Training to increase physician confidence and increasing OUD resources could increase BUP initiation and benefit ED patients with OUD.

Culinary Medicine as Innovative Nutrition Education for Medical Students: A Scoping Review.

PURPOSE: Lifestyle-related disease substantially impacts health, but physicians lack adequate nutrition education to discuss behavioral change with patients. Many medical schools have developed culinary medicine programs as a nutrition education strategy, but common elements of success have not been defined. METHOD: The authors conducted a scoping review of the literature on culinary medicine programs for medical students. They searched PubMed, Ovid MEDLINE, and MedEdPORTAL databases to identify English-language studies published between January 1, 2012, and October 15, 2021. Multiple search terms were used to identify medical student-focused culinary medicine programs. The authors focused inclusion criteria on medical student learners, curricular description, hands-on cooking components, reflection or application to patient care, and assessment. Additionally, the authors reviewed 2 online databases which list programs delivering culinary medicine education for U.S. medical students. RESULTS: Authors identified 251 studies, of which 12 met inclusion criteria. These studies described programs that used a kitchen or similar space adaptable for food preparation to enable hands-on learning, and some programs provided opportunities for practical application. Most programs administered surveys to assess course impact, but the type of survey and cohort size varied. Culinary medicine programs for medical students varied in learner level, number of participants, course length and structure, and instructor background but consistently improved student knowledge in key areas of nutrition application and changed knowledge and attitudes about food and nutrition. Funding was often noted as a barrier to program sustainability. When funding source was provided, it derived from philanthropic or academic sources. When the authors reviewed the 2 online databases, they identified 34 programs offering medical student-focused culinary medicine courses. CONCLUSIONS: As culinary education programs emerge across academic centers, standardizing programmatic and curricular elements, best practices, and assessment strategies will be vital for quality control, sustainability, and optimal population health impact.

Performance Benchmark Metrics and Clinicopathologic Outcomes of MRI-Guided Breast Biopsies: A Systematic Review and Meta-Analysis.

Objective: To determine key performance metrics of magnetic resonance imaging (MRI)-guided breast biopsies (MRGB) to help identify reference benchmarks. Materials and Methods: We identified studies reporting MRGB results up to 04.01.2021 in the Embase database, Ovid Medline (R) Process, Other Non-Indexed Citations, Ovid Medline (R) and completed a PRISMA checklist and sources of bias (QUADAS-2). The inclusion criteria were English language, available histopathological outcomes, or at least one imaging follow-up after biopsy. A random intercept logistic regression model was used to pool rates. Between-study heterogeneity was quantified by the I2 statistic. Results: A total of 11,215 lesions in 50 articles were analyzed. The technical success rate was 99.10% [95% confidence interval (CI): 97.89-99.62%]. The MRI indications were staging in 1,496 (28.05%, 95% CI: 26.85-29.28%), screening in 1,427 (26.76%, 95% CI: 25.57-27.97%), surveillance in 1,027 (19.26%, 95% CI: 18.21-20.34%), diagnostic in 1,038 (19.46%, 95% CI: 18.41-20.55%), unknown primary in 74 (1.39%, 95% CI: 1.09-1.74%), and other in 271 (5.08%, 95% CI: 4.51-5.71%). Histopathology was benign in 65.06% (95% CI: 59.15-70.54%), malignant in 29.64% (95% CI: 23.58-36.52%) and high risk in 16.69% (95% CI: 9.96-26.64%). Detection of malignancy was significantly lower in those patients who underwent MRI for screening purposes (odds ratio 0.47, 95% CI: 0.25-0.87; p = 0.02), while mass lesions were more likely to yield malignancy compared to non-mass and foci [27.39% vs 11.36% (non-mass),18.03% (foci); p<0.001]. Surgical upgrade to invasive cancer occurred in 12.24% of ductal carcinoma in situ (95% CI: 7.76-18.77%) and malignancy in 15.14% of high-risk lesions (95% CI: 10.69-21.17%). MRI follow-up was performed in 1,651 (20.92%) patients after benign results [median=25 months (range: 0.4-117)]. Radiology-pathology discordance (2.48%, 95% CI: 1.62-3.77%), false negative after a benign-concordant biopsy (0.75%, 95% CI: 0.34-1.62%) and biopsy complications (2.36%, 95% CI: 2.03-2.72%) were rare. Conclusion: MRGB is a highly accurate minimally-invasive diagnostic technique with low false-negative and complication rates. MRI indication and lesion type should be considered when evaluating the performance of institutional MRGB programs.