Analysis of absolute lymphocyte count in patients with COVID-19.

INTRODUCTION: Symptoms of COVID-19 vary in severity and presentation. When admitting patients to the hospital, it is desirable to isolate patients with COVID-19 from those without the disease. However, reliably identifying patients with COVID-19 in the emergency department before hospital admission is often limited by the speed and availability of testing. Previous studies determined a low lymphocyte count is commonly found in patients with COVID-19. We sought to explore the sensitivity of absolute lymphocyte count in patients presenting to the emergency department requiring subsequent hospitalization who were found to have COVID-19. METHODS: A retrospective chart review was performed on 312 patients with laboratory-confirmed COVID-19 who were admitted to the hospital from the emergency department. The absolute lymphocyte count for these patients was used to calculate sensitivities at various cut-off values. The relationships between absolute lymphocyte count and variables, including age, sex, need for intubation, and mortality, were also explored. RESULTS: Cut-off values for absolute lymphocyte count ranged from 1.1 K/uL to 2.0 K/uL, with sensitivities of 72% and 94%, respectively. Additionally, lower mean absolute lymphocyte counts were identified in males, patients who required intubation, and patients who died. CONCLUSION: Knowing the sensitivity of absolute lymphocyte count in patients with COVID-19 may help identify patients who are unlikely to have the disease. Additionally, absolute lymphocyte count can be used as a marker of disease severity in patients with COVID-19.

Sources of nonmedically used prescription psychotherapeutic drugs using real-world data from adolescents and adults assessed for substance use treatment--2014-2022.

BACKGROUND: Nonmedical use (NMU) of prescription psychotherapeutic drugs (PPD) may increase risk for significant morbidity and mortality in the overdose crisis. OBJECTIVE: This study examines sources of PPD using real-world data from adolescents and adults reporting past 30-day NMU of PPDs. METHODS: A convenience sample of individuals aged ≥10 years assessed for substance use disorders (SUD) treatment was analyzed using the 2014-2022 National Addictions Vigilance Intervention and Prevention Program datasets. PPD include prescription opioids, prescription tranquilizers/sedatives, and prescription stimulants. RESULTS: Overall, among assessments of adolescents aged 10-18 years (N = 1991) and young adults aged 19-24 years (N = 15,166), "family/friend" (46.08-47.41 %) and "dealer" (33.82-42.71 %) were the most common sources. Among assessments of adults aged ≥25 years (N = 89,225), "own prescription" was the most common source and increased in frequency as age increased. Across all age groups, "family/friend" was the most frequent source for all drug classes (41.96-48.76 %) except for nonmedically used buprenorphine/methadone, for which "own prescription" was the most common source (51.85 %) among adults. CONCLUSIONS: Our study demonstrates heterogeneity in sources of nonmedically used PPD across age groups. Tailored prevention strategies for different age groups and improving timely access to medical care to ensure proper treatment of chronic medical conditions including SUD are needed.

Public Health Interventions and Overdose-Related Outcomes Among Persons With Opioid Use Disorder.

Importance: Given the high number of opioid overdose deaths in the US and the complex epidemiology of opioid use disorder (OUD), systems models can serve as a tool to identify opportunities for public health interventions. Objective: To estimate the projected 3-year association between public health interventions and opioid overdose-related outcomes among persons with OUD. Design, Setting, and Participants: This decision analytical model used a simulation model of the estimated US population aged 12 years and older with OUD that was developed and analyzed between January 2019 and December 2023. The model was parameterized and calibrated using 2019 to 2020 data and used to estimate the relative change in outcomes associated with simulated public health interventions implemented between 2021 and 2023. Main Outcomes and Measures: Projected OUD and medications for OUD (MOUD) prevalence in 2023 and number of nonfatal and fatal opioid-involved overdoses among persons with OUD between 2021 and 2023. Results: In a baseline scenario assuming parameters calibrated using 2019 to 2020 data remained constant, the model projected more than 16 million persons with OUD not receiving MOUD treatment and nearly 1.7 million persons receiving MOUD treatment in 2023. Additionally, the model projected over 5 million nonfatal and over 145 000 fatal opioid-involved overdoses among persons with OUD between 2021 and 2023. When simulating combinations of interventions that involved reducing overdose rates by 50%, the model projected decreases of up to 35.2% in nonfatal and 36.6% in fatal opioid-involved overdoses among persons with OUD. Interventions specific to persons with OUD not currently receiving MOUD treatment demonstrated the greatest reduction in numbers of nonfatal and fatal overdoses. Combinations of interventions that increased MOUD initiation and decreased OUD recurrence were projected to reduce OUD prevalence by up to 23.4%, increase MOUD prevalence by up to 137.1%, and reduce nonfatal and fatal opioid-involved overdoses among persons with OUD by 6.7% and 3.5%, respectively. Conclusions and Relevance: In this decision analytical model study of persons with OUD, findings suggested that expansion of evidence-based interventions that directly reduce the risk of overdose fatality among persons with OUD, such as through harm reduction efforts, could engender the highest reductions in fatal overdoses in the short-term. Interventions aimed at increasing MOUD initiation and retention of persons in treatment projected considerable improvement in MOUD and OUD prevalence but could require a longer time horizon for substantial reductions in opioid-involved overdoses.

Hydrofluoric acid ingestions: Retrospective evaluations from cases reported to the National Poison Data System 2007-2017.

Background: Hydrofluoric acid (HF) is associated with systemic toxicity, particularly with high-concentration formulations. However, most existing data describe dermal exposures; there is a paucity of data related to outcomes after ingestions. Objective: To determine the morbidity and mortality associated with HF ingestions as reported to the National Poison Data System (NPDS). A secondary objective is to assess for clinical criteria that are associated with serious outcomes after HF ingestion. Methods: We performed a retrospective review of HF ingestions reported to the NPDS from 2007 to 2017. Data including patient demographics, exposure and caller sites, electrolyte abnormalities, treatments, and serious (moderate or major effect or death as documented in NPDS) and non-serious outcomes were abstracted from case narratives. Cases meeting the criteria for a qualifiable HF ingestion were included in the study. Results: During the study period, there were 653 HF ingestions reported to NPDS, of which 142 were included in the final data analysis. Most HF exposures occurred in men (68.3%), and the most common exposure site was at the exposed individual's own residence (78.2%). Nearly half of all exposures (46.5%) were due to transfer into a non-labeled secondary storage container. Total of 45.8% of the cases resulted in a serious outcome. Electrolyte disturbances were associated with an increased risk of a serious outcome. Hypocalcemia was the most frequently reported electrolyte abnormality, occurring in 24.6% of cases. Nine (6.3%) individuals died. Conclusions: Mortality after HF ingestion is low. However, a large cohort of exposures occurred after the transfer of HF to secondary containers. Targeted interventions to reduce this practice are necessary to decrease hazardous chemical exposures.

Quality Improvement Intervention associated with Improved Lung Protective Ventilation Settings in an Emergency Department.

INTRODUCTION: Patients requiring endotracheal intubation and mechanical ventilation in the emergency department (ED) are critically ill, and their ventilator management is crucial for their subsequent clinical outcomes. Lung-protective ventilation (LPV) setting strategies are key considerations for this care. The objectives of this 2019-2020 community-based quality improvement project were to: a) identify patients at greater risk of not receiving LPV, and b) evaluate the effectiveness of a series of brief quality improvement educational sessions to improve LPV setting protocol adherence rates. METHODS: A 15-month retrospective chart review of ventilator settings and subject characteristics (N = 200) was conducted before and after a series of 10-15-minute educational sessions were delivered to improve LPV adherence. This information was presented at a series of four educational sessions for 25 attending physicians (n = two sessions) and 27 residents at conferences (n = two sessions). Two additional materials (e.g., LPV reference charts, tape measures to gauge patients' heights) were also posted in three ED resuscitation rooms and on cabinets containing emergency airway equipment. The pre and post-intervention occurrence rates of LPV setting orders were inferentially compared before and after educational sessions. RESULTS: Patients ventilated using LPV increased from 70% to 82% after the educational sessions (p = 0.04). All patients who were 67 inches or greater in height were ventilated appropriately before and after sessions. For patients under 65 inches in height, post-session LPV adherence increased from 13% to 53% (p = 0.01). CONCLUSIONS: Based on these results, a brief ED provider educational intervention can significantly improve the utilization of LPV guideline-based settings. Patients under 65 inches in height may also be especially at risk of receiving non-LPV ventilator setting orders.

Maternity Experiences and Perceptions of Emergency Medicine Physicians.

INTRODUCTION: Postpartum employment has been recognized as a significant obstacle to breastfeeding continuation rates in the general population. Multiple additional factors can influence emergency medicine (EM) physician mothers' ability to continue breastfeeding upon return to work. These include the unpredictable nature of emergency room volumes and acuity, absence of protected lactation time or facilities, and varying levels of support from colleagues. This study investigated a sample of female EM physicians' current perceptions and experiences regarding breastfeeding practices and identified modifiable work-place factors affecting their decision to wean. The authors hypothesized that EM physician mothers would have excellent breastfeeding initiation rates but be largely unable to maintain breastfeeding practices upon returning to work. METHODS: A 34-item survey questionnaire evaluated demographics, perceptions, and experiences with breastfeeding with a convenience sample of EM attending and resident physicians from two Michigan academic community hospitals. RESULTS: Thirty-nine surveys were completed, representing a participant response rate of 88.6%. Breastfeeding had been initiated by all respondent mothers, all of whom returned to full-time employment after delivery. Upon return to work, 15 (75%) respondents continued to exclusively breastfeed. The goal of participants was to breastfeed for an average of 7.1 months (± 4.1 months), although the average duration children were exclusively breastfed was 5.8 months (± 4.0 months). CONCLUSIONS: Based on these results, the reasons for decreased breastfeeding after return to work in an EM residency program setting are multifactorial and include some modifiable interpersonal and institutional influences. These findings support the implementation of work-place strategies and policies to promote successful breastfeeding practices among EM resident and attending physician mothers returning to work.

Neurogenic Stunned Myocardium Following an Attempt to Pass a Drug Test.

Ingestion of a large volume of free water or other hypotonic solution can cause acute hyponatremia, leading to multiorgan dysfunction. Individuals may attempt to generate a false-negative urine drug screen through increased free water consumption leading to acute hyponatremia requiring emergency medical care. We present the case of a 19-year-old male who presented to a community emergency department for altered mental status after an attempt to generate a false-negative urine drug screen. He ingested a large volume of free water and multiple detoxification solutions, causing acute hyponatremia with resultant cerebral edema and neurogenic stunned myocardium. He required extracorporeal membrane oxygenation therapy with complete recovery of neurologic and cardiac function. Acute hyponatremia from excess free water consumption is a well-documented phenomenon that all emergency providers should be aware of. Prompt identification and management of acute hyponatremia are essential to prevent potentially severe, devastating sequelae, including cerebral edema and cardiopulmonary failure.In addition, extracorporeal membrane oxygenation may be considered in patients with cardiopulmonary failure in the setting of reversible cardiomyopathy, as evidenced in our case.