Emergency Department Management of Hypertension in the Context of COVID-19.

PURPOSE OF REVIEW: This review describes the relationship between COVID-19 and hypertension (HTN), and considerations for emergency medicine providers in the management of hypertensive patients during the COVID-19 pandemic. RECENT FINDINGS: Hypertensive patients with COVID-19 have a higher risk of severe disease/complications, hospitalizations, intensive care unit (ICU) admissions, and mortality than non-hypertensive patients. Studies have also shown the importance of consideration of various demographic factors (such as older age) and socioeconomic factors that may confound these relationships. Despite concerns at the start of the pandemic that RAAS inhibiting antihypertension medications may contribute to worsened outcomes in COVID-19 patients, subsequent research has shown that use of ACEi/ARBs is associated with neutral or even improved COVID-19 outcomes. Socioeconomic factors must also be considered including patients' potential delay of health care due to fear of contracting COVID-19, loss of health insurance, and barriers to accessing primary care appointments for post-ED follow-up care. While there is mixed evidence on biological considerations for HTN care during the COVID-19 pandemic, the pandemic has undoubtedly been a major stressor and barrier to effective chronic disease management. Emergency medicine and other providers should consider this when evaluating acute care patients with a history of HTN or newly elevated blood pressure.

Babesiosis in the Emergency Department: A Case Report.

BACKGROUND: Babesiosis, a tick-borne illness spread by Ixodes scapularis, is an emerging infectious disease in the Northeastern and upper Midwestern United States. Infection can present as a flu-like illness with anemia, thrombocytopenia, and jaundice. This disease can even be fatal in the immunocompromised or highly infected patient. Co-infection with other tick-borne illnesses is common, and prompt treatment with antiprotozoal agents and antibiotics is indicated to prevent adverse outcomes. CASE REPORT: We describe a patient who presented to the emergency department with flu-like symptoms, but had history concerning for environmental exposure to babesiosis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Early detection is important to prevent severe sequalae of the disease. This is a disease that can imitate a viral syndrome but should be considered in the differential for a patient with a concerning history.

Care plans reduce ED visits in those with drug-seeking behavior.

UNLABELLED: Patients with drug-seeking behavior can be both labor and resource intensive to the emergency department (ED). OBJECTIVE: To determine the effectiveness of ED care plans for individuals at high risk for drug-seeking behavior on ED visits. METHODS: A retrospective, cohort observational study. LOCATION: A suburban teaching hospital with an annual census of 80,000 patients. The number of ED visits was determined 1 year before and 2 subsequent years following care plan initiation. EXCLUSION CRITERIA: Unclaimed letter, incomplete data, and/or non-drug-seeking care plan. STATISTICS: Two-tailed Wilcoxon signed-rank test with significance of P < .05. RESULTS: Sixty patients were enrolled and 7 were excluded, leaving 53 patients for analysis. Mean annual visits before care plan initiation were 7.6 (95% confidence interval [CI], 6.3-9.1). One year following implementation, mean visits decreased to 2.3 (95% CI, 1.5-3.1) (P ≤ .0001). Two years following implementation, mean visits continued to decline to 1.5 (95% CI, 0.9-2.1) (P ≤ .0001). A significant reduction in visits occurred 1 and 2 years following care plan implementation. CONCLUSIONS: Emergency department care plans are an effective method to reduce ED visits in those with drug-seeking behavior.

More Accessible COVID-19 Treatment Through Monoclonal Antibody Infusion in the Emergency Department.

INTRODUCTION: Monoclonal antibody (MAB) infusion is the first treatment to manage coronavirus 2019 (COVID-19) in an outpatient setting. Yet increased risk of severe COVID-19 illness may occur from inequities in social determinants of health including access to quality healthcare. Given the safety-net nature of emergency departments (ED), a model that puts them at the center of MAB infusion may better reach underserved patients than models that require physician referral and distribute MAB at outpatient infusion centers. We examined characteristics of two groups of patients who received MAB infusion in the Robert Wood Johnson University Hospital (RWJUH) ED in New Brunswick, New Jersey: 1) patients who tested positive for COVID-19 in the ED and received ED infusion; and 2) patients who tested positive elsewhere and were referred to the ED for infusion. The process for the latter group was similar to the more common national model of patients testing COVID-19 positive in the community and then being referred to an infusion center for MAB therapy. METHODS: We performed a cross-sectional retrospective health record review of all adult patients presenting to the ED from November 20, 2020-March 15, 2021 who received MAB infusion at RWJUH ED (N = 486). Patients were identified through the electronic health record system by an administrative query, with manual chart review for any additional characteristics not available through the query. We compared the two groups using chi-squared tests for categorical variables and t-tests for continuous variables. RESULTS: We found higher proportions of Black (18% vs 6% P < 0.001, statistically significant), Hispanic (19% vs 11% P = 0.02), Medicaid (12% vs 9% P = 0.01), and uninsured (17% vs 8% P = 0.01) patients who tested positive for COVID-19 in their ED visit and then received MAB therapy during their visit than patients tested elsewhere in the community and referred to the ED for MAB therapy. CONCLUSION: These findings suggest that providing MAB infusion in the ED allows increased access for patients traditionally marginalized from the healthcare system, who may be at risk of longer disease duration and complications from COVID-19.

Steroids for migraine headaches: a randomized double-blind, two-armed, placebo-controlled trial.

BACKGROUND: Recurrence of migraine headache after treatment in the emergency department (ED) is common. Conflicting evidence exists regarding the utility of steroids in preventing migraine headache recurrence at 24-48 h. OBJECTIVE: To determine if steroids decrease the headache recurrence in patients treated for migraine headaches in the ED. METHODS: Double-blind placebo-controlled, two-tailed randomized trial. Patients aged >17 years with a moderately severe migraine headache diagnosed by treating Emergency Physician were approached for participation. Enrollees received either dexamethasone (10 mg i.v.) if intravenous access was utilized or prednisone (40 mg by mouth × 2 days) if no intravenous access was obtained. Each medication was matched with an identical-appearing placebo. Patients were contacted 24-72 h after the ED visit to assess headache recurrence. RESULTS: A total of 181 patients were enrolled. Eight were lost to follow-up, 6 in the dexamethasone group and 2 in the prednisone arm. Participants had a mean age of 37 years (±10 years), with 86% female. Eighty-six percent met the International Headache Society Criteria for migraine headache. Of the 173 patients with completed follow-up, 20/91 (22%) (95% confidence interval [CI] 13.5-30.5) in the steroid arm and 26/82 (32%) (95% CI 21.9-42.1) in the placebo arm had recurrent headaches (p = 0.21). CONCLUSION: We did not find a statistically significant decrease in headache recurrence in patients treated with steroids for migraine headaches.

Monthly variations in the diagnosis of carbon monoxide exposures in the emergency department.

INTRODUCTION: Carbon monoxide (CO) poisoning is the leading cause of toxicological deaths worldwide. Symptoms may be subtle, contributing to its frequent delay in diagnosis. If a seasonal variation occurs, a heightened awareness during peak time may lead to improved recognition and diagnosis. STUDY OBJECTIVES: To determine whether monthly variations in CO poisoning occur in emergency departments. DESIGN: A multicenter retrospective emergency department (ED) cohort. STUDY SETTING: 23 New Jersey and New York emergency departments. SUBJECTS: Consecutive patients with the ICD-9 primary diagnosis of"toxic effects CO" from January 1, 2000 to October 31, 2006. STATISTICS: We tested for significant differences using chi-square and Student's t-test with alpha set at 0.5. RESULTS: There were 1,006 patients who were diagnosed in the ED with CO toxicity (0.024% of all ED patients). Mean age was 30 years (SD +/- 20), 54% were female, and Caucasians compromised 54% of participants. Thirty-nine percent of documented patients arrived via ambulance and 90% were subsequently discharged. Incidence of CO visits peaked in December (0.036%) and were least likely in May (0.011%). Mean monthly CO visits were statistically increased during October (p = < 0.0001), November (p = 0.008), December (< 0.0001), January (p = 0.01), and March (p = 0.04). Statistically fewer case of CO exposure were diagnosed in May (p = 0.0003), June (p = 0.005), August (p = < 0.0001), and September (p = 0.002).

Procedure rates performed by emergency medicine residents: a retrospective review.

BACKGROUND: The purpose of our study is to investigate rates of individual procedures performed by residents in our emergency medicine (EM) residency program. Different programs expose residents to different training environments. Our hypothesis is that ultrasound examinations are the most commonly performed procedure in our residency. METHODS: The study took place in an academic level I trauma center with multiple residency and fellowship programs including surgery, surgical critical care, trauma, medicine, pulmonary/critical care, anesthesiology and others. Also, the hospital provides a large emergency medical services program providing basic and advanced life support and critical care transport, which is capable of performing rapid sequence intubation. Each EM residency class, except for the first 2 months of the inaugural class, used New Innovations to log procedures. New Innovations is an online database for tracking residency requirements, such as procedures and hours. For the first 3 months, procedures were logged by hand on a log sheet. In addition, our department has a wireless electronic system (Qpath) for recording and logging ultrasound images. These logs were reviewed retrospectively without any patient identifiers. Actual procedures and simulation procedures were combined for analysis as they were only logged separately halfway through the study period. Procedures were summed and the average procedure rate per resident per year was calculated. RESULTS: In total, 66 full resident years were analyzed. Overall, ultrasound was the most commonly performed procedure, with each resident performing 125 ultrasounds per year. Removing "resuscitations," the second most common was endotracheal intubation, performed 28.91 times per year, and third most was laceration repair, which was performed 17.39 times per year. Our lowest performed procedure was thoracentesis, which was performed on average 0.11 times per resident per year. CONCLUSIONS: Residents performed a variety of procedures each year. Ultrasound examinations were the most frequent procedure performed. The number of ultrasound procedures performed may reflect the changing training landscape and influence future Accreditation Council of Graduate Medical Education requirements.

Do patients with recurrent headaches attempt abortive therapy before their emergency department visit?

Headache is one of the most frequent symptoms prompting an emergency department (ED) visit. For many patients this is an exacerbation of a recurrent or chronic headache pattern. Our objective in this study was to determine if ED patients with recurrent headaches attempt abortive analgesics before seeking ED care. Patients with five or greater similar headache episodes presenting to the ED with the chief complaint of headache were included. There were 150 patients enrolled into the study group. Fourteen percent (95% confidence interval 1-41) of patients did not attempt abortive medication before an ED visit. Males were significantly less likely to utilize pain medication than females before their ED visit (69% vs. 91%; p = 0.003). Of those patients previously seen by a neurologist, 5% did not attempt analgesia before ED arrival, compared to 22% of those who did see a neurologist (p = 0.004). A small, but significant percentage of patients with recurrent headaches do not attempt abortive analgesic therapy before ED encounter. In particular, males and those patients not previously evaluated by a neurologist were significantly less likely to utilize such medications. Further education and selective neurology referral by practitioners may reduce ED utilization in this subset of patients.

Phase I study utilizing a novel antigen-presenting cell-targeted vaccine with Toll-like receptor stimulation to induce immunity to self-antigens in cancer patients.

PURPOSE: The use of tumor-derived proteins as cancer vaccines is complicated by tolerance to these self-antigens. Tolerance may be broken by immunization with activated, autologous, ex vivo generated and antigen-loaded, antigen-presenting cells (APC); however, targeting tumor antigen directly to APC in vivo would be a less complicated strategy. We wished to test whether targeted delivery of an otherwise poorly immunogenic, soluble antigen to APC through their mannose receptors (MR) would induce clinically relevant immunity. EXPERIMENTAL DESIGN: Two phase I studies were conducted with CDX-1307, a vaccine composed of human chorionic gonadotropin beta-chain (hCG-ß) fused to an MR-specific monoclonal antibody, administered either locally (intradermally) or systemically (intravenously) in patients with advanced epithelial malignancies. An initial dose escalation of single-agent CDX-1307 was followed by additional cohorts of CDX-1307 combined with granulocyte-macrophage colony-stimulating factor (GM-CSF) and the Toll-like receptor (TLR) 3 agonist polyinosinic-polycytidylic acid (poly-ICLC) and TLR7/8 agonist resiquimod to activate the APC. RESULTS: CDX-1307 induced consistent humoral and T-cell responses to hCG-ß when coadministered with TLR agonists. Greater immune responses and clinical benefit, including the longest duration of stable disease, were observed with immunization combined with local TLR agonists. Immune responses were induced equally efficiently in patients with elevated and nonelevated levels of serum hCG-ß. Antibodies within the serum of vaccinated participants had tumor suppressive function in vitro. Toxicity consisted chiefly of mild injection site reactions. CONCLUSIONS: APC targeting and activation induce adaptive immunity against poorly immunogenic self-antigens which has implications for enhancing the efficacy of cancer immunotherapy.

Canadian Headache Society criteria for the diagnosis of acute migraine headache in the ED--do our patients meet these criteria?

INTRODUCTION: We previously reported that many patients who present to the ED with "migraine" headache do not meet the International Headache Society criteria (IHSC) for the diagnosis of acute migraine. Objective The aim of the study was to compare the frequency for which ED patients with migraine headache meet the Canadian Headache Society criteria (CHSC) vs the IHSC. METHODS: This was a prospective, observational study, performed at a community ED. Consecutive patients who presented to study authors with a chief complaint of headache were enrolled. Historical/clinical data were collected on a standardized form. Ninety-five percent confidence intervals (95% CIs) were calculated and Fisher exact test was used as appropriate. RESULTS: One hundred eighty-nine patients were enrolled in this study. Mean age was 38 years. Females comprised 69% of patients. Thirty-seven percent of patients had prior ED visits for headaches. A positive family history of migraines was present in 35% of patients. Diagnostic imaging was previously performed in 44 of the enrollees to evaluate the cause of their headaches. A total of 43 (23%) patients had a prior diagnosis of migraine. Overall CHSC was met in 18% of patients, compared with 15% of patients who met IHSC. Discharge diagnosis of migraine was made in 41% of patients. Of these patients, 33% met CHSC and 28% met IHSC (P=.30). For patients with discharge diagnosis of migraine, 33% of females and 36% of males fit CHSC (P=.53), whereas 26% and 36% met IHSC (P=.34), respectively. For patients with a prior diagnosis of migraine, 32% met CHSC and 26% met IHSC (P=.24). Patients with a prior diagnosis of migraine and/or a discharge diagnosis of migraine met CHSC 31% (95% CI, 22%-40%) of the time vs 25% for the IHSC (95% CI, 16%-34%) (P=.26). Four patients without a discharge and/or previous diagnosis of migraine met CHSC; 3 met IHSC. CONCLUSIONS: In our study population, only a minority of patients with headache who have prior diagnosis and/or ED diagnosis of migraine headache met CHSC. The utility of CHSC and/or IHSC to standardize ED patients for headache research may be limited.

Do ED patients with migraine headaches meet internationally accepted criteria?

A recent editorial criticized emergency medicine researchers who study the treatment of acute migraine for failing to standardize patients according to definitions provided by the International Headache Society (IHS). In fact, most emergency medicine-based studies of migraine therapies have not used IHS Criteria (IHSC) for patient inclusion and are not uniform in the definition of acute migraine. The purpose of this study was to determine the percentage of patients with complaint of headache who present to the emergency department with a prior diagnosis of migraine and/or emergency department discharge diagnosis of acute migraine that meet IHSC. The study was a prospective observational study performed in a community-based and consisted of consecutive patients with a chief complaint of headache who presented to any 1 of 6 study investigators. Patients recorded historical data on a standard form; Clinical data were recorded by the investigators. Ninety-five percent confidence intervals and the Fisher exact test were calculated as appropriate. One hundred eighty-five patients were enrolled (study group): 70% were women, 43% had prior imaging studies to diagnose the etiology of the headache, and 26% had a diagnostic workup during the current emergency department visit; the probable headache etiology was found in 12 of these cases. Only 3 patients that had an ED workup that fit IHSC. Forty-nine percent of all patients had a prior diagnosis of migraines; 41 of these patients (45%) met IHSC. Forty-two percent of all patients had an emergency discharge diagnosis of acute migraine; of these, 43 (56%) met IHSC. Forty-four out of 96 (46%; 95% confidence interval = 35%-57%) patients with a prior diagnosis of migraine and/or discharge diagnosis of acute migraine met IHSC. Modification of the IHSC, by removing restrictions for headache duration and number of prior episodes, would have markedly increased the percentage of patients with a previous migraine and/or emergency discharge diagnosis of acute migraine that met other qualitative IHSC (94%). Of the patients with prior migraine diagnosis and/or emergency department diagnosis of acute migraine, men and women were equally as likely to meet IHSC (41% v 48%, P = 0.79). Less than half of patients with a prior diagnosis and/or final emergency discharge diagnosis of acute migraine met IHSC. Our findings raise concerns about the external validity of prior emergency department-based research of acute migraine therapy and the utility of the IHSC for future research. Modification of the IHSC for emergency medicine research should be considered.