Comparison of a Novel Rapid Lateral Flow Assay to Enzyme Immunoassay Results for Early Diagnosis of Coccidioidomycosis.

BACKGROUND: Coccidioidomycosis (CM) is a common cause of community-acquired pneumonia where CM is endemic. Manifestations include self-limited pulmonary infection, chronic fibrocavitary pulmonary disease, and disseminated coccidioidomycosis. Most infections are identified by serological assays including enzyme-linked immunoassay (EIA), complement fixation, and immunodiffusion. These are time-consuming and take days to result, impeding early diagnosis. A new lateral flow assay (LFA; Sona; IMMY, Norman, OK) improves time-to-result to 1 hour. METHODS: We prospectively enrolled 392 patients with suspected CM, compared the LFA with standard EIA and included procalcitonin evaluation. RESULTS: Compared with standard EIA, LFA demonstrates 31% sensitivity (95% confidence interval [CI], 20-44%) and 92% specificity (95% CI, 88-95%). Acute pulmonary disease (74%) was the most common clinical syndrome. Hospitalized patients constituted 75% of subjects, and compared with outpatients, they more frequently had ≥3 previous healthcare facility visits (P = .05), received antibacterials (P < .01), and had >3 antibacterial courses (P < .01). Procalcitonin (PCT) was <0.25 ng/mL in 52 (83%) EIA-positive patients, suggesting infection was not bacterial. CONCLUSIONS: When CM is a possible diagnosis, LFA identified nearly one-third of EIA-positive infections. Combined with PCT <0.25 ng/mL, LFA could reduce unnecessary antibacterial use by 77%.

Medical student perceptions on the instruction of the emergency medicine oral case presentation.

BACKGROUND: The emergency medicine oral case presentation (EM OCP) is the clinician's communication tool to justify whether urgent intervention is required, to argue for ruling out emergent disease states, and to propose safe disposition plans in the context of triaging patients for medical care and prioritization of resources. The EM OCP provides the representation of the practice of emergency medicine, yet we do not know the current level of effectiveness of its instruction. OBJECTIVES: We aimed to document medical student perceptions and expectations of the instruction of the EM OCP. METHODS: We surveyed medical students from five institutions after their emergency medicine clerkship on their instruction of the EM OCP. Analysis included univariate descriptive statistics and chi-squared analyses for interactions. RESULTS: One hundred fifty-five medical students (82%) completed the survey. Most medical students reported the EM OCP to be unique compared to that of other disciplines (86%), integral to their clerkship evaluation (77%), and felt that additional teaching was required beyond their current medical school instruction (78%). A minority report being specifically taught the EM OCP (37%), that their instruction was consistent (29%), or that expectations of the EM OCP were clear (21%). Respondents felt that brief instruction during their orientation (65%) and reading with a portable summary card (45%) would improve their EM OCP skills, whereas other modalities would be less helpful. CONCLUSION: This study identifies a need for additional specific and consistent teaching of the EM OCP to medical students and their preference on how to receive this instruction.

Massive Upper Gastrointestinal Bleeding.

Audience: This case is targeted to emergency medicine residents of all levels. Introduction: Upper gastrointestinal bleeding (UGIB) is a common chief complaint encountered in the emergency department, resulting in over 500,000 hospitalizations and 20,000 deaths annually in the United States.1 The diagnosis and management of UGIB in stable patients is typically fairly straightforward. However, there are a number of circumstances where the treatment of UGIB is much more challenging, and emergency medicine (EM) physicians should be familiar with, and have experience managing, these difficult presentations. Massive UGIB can necessitate the need for management of a difficult airway in the setting of airway contamination, as well as placement of a gastroesophageal balloon tamponade device. The appropriate use and indications for performing this high-risk/low-frequency procedure requires dedicated practice. Furthermore, the management of gastrointestinal hemorrhage in a patient with a religious objection to the administration of blood products, including Jehovah's Witnesses, can be especially challenging and requires knowledge of alternative therapies to support blood pressure, oxygen carrying capacity, and decrease coagulopathy.2,3. Educational Objectives: By the end of this simulation, learners will be able to: 1) manage a hypotensive patient with syncope and hematemesis, 2) pharmacologically manage an acute UGIB addressing the various causes, 3) recognize worsening clinical status and intervene by performing difficult airway management, 4) place a gastroesophageal balloon tamponade device. Educational Methods: This simulation was conducted with a high-fidelity mannequin with a separate medium-fidelity intubating mannequin that was modified to allow rapid filling of the oropharynx with simulated blood. Due to the COVID-19 pandemic, a total of six EM residents in various levels of training participated in the simulated patient encounter while the rest of the learners watched the simulation and participated in the debrief via video conference. Research Methods: Following the simulation and debrief session, all the residents, including those who participated in-person and via video conference, were sent a survey via surveymonkey.com to assess the educational quality of the simulation. Results: Overall residents expressed positive feedback on the scenario, noting that the case was realistic, appropriately complex, and improved their medical knowledge and procedural skills. Discussion: This case has a mixture of high-fidelity and medium-fidelity components which can be easily reproduced. The case was extremely useful in teaching EM residents of all levels not only how to manage large volume UGIB in a patient who is also a Jehovah's Witness, but also how to manage the airway and place a gastroesophageal balloon tamponade device. The case starts with a patient presenting with syncope and as the case unfolds, the patient's clinical status deteriorates, requiring learners to resuscitate, intubate, and obtain a gastroesophageal balloon tamponade.Residents commented that managing this case of an UGIB was extremely challenging because it exposed and filled important gaps in both their knowledge and procedural skills. Residents struggled most with identifying alternative therapies to blood products in patients with religious objections, and the step-by-step process of placing a Blakemore tube. Topics: Upper gastrointestinal bleed, hemorrhagic shock, Jehovah's Witness, difficult airway.

A randomized, double-blind, placebo-controlled clinical trial of fluconazole as early empiric treatment of coccidioidomycosis pneumonia (Valley Fever) in adults presenting with community-acquired pneumonia in endemic areas (FLEET-Valley Fever).

INTRODUCTION: Coccidioidomycosis is a fungal infection endemic in the southwestern United States (US). Primary pulmonary coccidioidomycosis (PPC) is a leading cause of community-acquired pneumonia (CAP) in this region, although its diagnosis is often delayed, leading to lag in antifungal treatment and subsequent morbidity. The impact of early empiric antifungal therapy as part of treatment for CAP in endemic areas on clinical outcomes is unknown. METHODS: Phase IV randomized, double-blind, placebo-controlled trial in individuals aged 18 years or older with CAP who met all eligibility criteria in Coccidioides endemic regions in the US. Eligible participants with CAP were randomized to receive either fluconazole (400 mg daily) or matching placebo for 42 days and were subsequently monitored for clinical resolution of their illness. OBJECTIVES: The primary objective was to assess the clinical response of early empiric antifungal therapy with fluconazole through Day 22 in subjects with PPC who were adherent to the study intervention. Secondary objectives included: assessments of the impact of early empiric antifungal therapy with fluconazole through Day 22 and 43 in subjects with PPC regardless of adherence, comparisons of the clinical response and its individual components over time by treatment group in subjects with PPC, assessments of days lost from work or school, hospitalization, and all-cause mortality. DISCUSSION: This trial was halted early due to slow enrollment (72 participants in one year, 33 received fluconazole and 39 received placebo). Of those enrolled, eight (11%) met the study definition of PPC. The study design and challenges are discussed.

Diagnosis and management of the acute red eye.

The red eye is one of the most frequent presenting complaints in the emergency department setting. A wide spectrum of disease processes may present as a red eye, ranging from benign self-limiting etiologies to serious vision-threatening ones. The emergency physician must be adept at recognizing "red flags" from the history and physical examination that necessitate immediate treatment and referral. In addition, it is imperative for the emergency physician to recognize the need for immediate versus elective ophthalmologist consultation for the various conditions. This article includes a discussion of the key historical features, clinical presentations, physical examination findings, and management of the more common causes of the red eye.

Non-aneurysmal infectious aortitis: a case report.

Infectious aortitis is a rare clinical entity that is most often associated with an abdominal aortic aneurysm. There have been very few documented cases of aortitis in the setting of a normal-sized caliber aorta. We present a 67-year-old patient who presented to our Emergency Department with a history of recent fevers, fatigue, and abdominal pain. Based on an abdominal computed tomography scan, the patient was initially thought to have ruptured an abdominal aortic aneurysm of infectious etiology with extension into the left psoas muscle. Explorative laparotomy, however, revealed an infected abdominal aorta secondary to a retroperitoneal abscess with no evidence of aneurysm or pseudoaneurysm. The pathophysiology of the disease suggests that infectious aortitis and mycotic aneurysm represent extremes along a spectrum of the same disease. Establishing a diagnosis of aortic infection before the formation of an aneurysm or rupture is very difficult, but essential in preventing the devastating complications.

Resuscitation of the elderly.

The changing demographics of America's population over the past couple of decades have propelled geriatric medicine into the fore-front. Due to this, emergency medicine physicians will face numerous challenges managing an increasing number of critically ill elderly patients. This article will focus on success of resuscitation in this population, important pathophysiologic changes that occur with aging, as well as ethical considerations in end-of-life care.

Clinicopathological conference: A 71-year-old female with neurological deficits, chest pain, and electrocardiographic changes.

The authors present a case of a 71-year-old female who presented to the emergency department with slurred speech, left sided facial droop, and right arm and leg weakness. During her ED stay, she developed left sided chest pain and right arm numbness in the setting of EKG changes. The patient's clinical course is outlined and a discussion of the potential etiologies as well as the clinical management is provided.

Comparison of intubation success of video laryngoscopy versus direct laryngoscopy in the difficult airway using high-fidelity simulation.

INTRODUCTION: A number of devices, including video laryngoscopy, are used to aid in managing difficult airways. The goal of this study was to compare timing and success of video laryngoscopy to standard laryngoscopic intubation using a simulation mannequin in normal and difficult airway scenarios. METHODS: Residents and attending physicians of a PGY 2-4 emergency medicine residency program participated. A single, high-fidelity simulation mannequin was used. Each participant received an in-service on the video laryngoscope (GlideScope). Three airway settings were used: standard, decreased neck mobility, and tongue edema. Participants intubated with a Macintosh blade and video laryngoscope in each scenario, and graded the best view achieved using the Cormack-Lehane classification. Outcome measures included time to view the vocal cords, time to intubation, grading of view, and intubation success or failure. Institutional Review Board approval was obtained. RESULTS: Fifty-two participants were enrolled. Participants successfully intubated the mannequin faster using the Macintosh blade in both the normal and neck immobility settings (9.4 seconds faster, 95% CI 3.2-15.7, P = 0.004, 16.1 seconds faster, 95% CI 3.6-28.7, P = 0.01). In the tongue edema setting, however, video laryngoscopy provided a better grade view of the cords, a higher success rate of viewing the cords at time of intubation (50% vs. 12%), and a higher rate of successful intubations (83% vs. 23%). The GlideScope also significantly reduced the time needed to view the cords (89 seconds reduction, 95% CI 54.4-123.7, P < 0.0001) and intubate (131.3 seconds reduction, 95% CI 99.1-163.6, P< 0.0001) for the tongue edema setting. CONCLUSIONS: In the most difficult airway case, tongue edema, the video laryngoscope provided an enhanced view of the cords using less time, increased intubation success, and decreased the time to intubation.

Teaching and assessing procedural skills using simulation: metrics and methodology.

Simulation allows educators to develop learner-focused training and outcomes-based assessments. However, the effectiveness and validity of simulation-based training in emergency medicine (EM) requires further investigation. Teaching and testing technical skills require methods and assessment instruments that are somewhat different than those used for cognitive or team skills. Drawing from work published by other medical disciplines as well as educational, behavioral, and human factors research, the authors developed six research themes: measurement of procedural skills; development of performance standards; assessment and validation of training methods, simulator models, and assessment tools; optimization of training methods; transfer of skills learned on simulator models to patients; and prevention of skill decay over time. The article reviews relevant and established educational research methodologies and identifies gaps in our knowledge of how physicians learn procedures. The authors present questions requiring further research that, once answered, will advance understanding of simulation-based procedural training and assessment in EM.