Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Non-ST-Elevation Acute Coronary Syndromes.

This clinical policy from the American College of Emergency Physicians addresses key issues in the evaluation and management of patients with suspected non-ST-elevation acute coronary syndromes. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In adult patients without evidence of ST-elevation acute coronary syndrome, can initial risk stratification be used to predict a low rate of 30-day major adverse cardiac events? (2) In adult patients with suspected acute non-ST-elevation acute coronary syndrome, can troponin testing within 3 hours of emergency department presentation be used to predict a low rate of 30-day major adverse cardiac events? (3) In adult patients with suspected non-ST-elevation acute coronary syndrome in whom acute myocardial infarction has been excluded, does further diagnostic testing (eg, provocative, stress test, computed tomography angiography) for acute coronary syndrome prior to discharge reduce 30-day major adverse cardiac events? (4) Should adult patients with acute non-ST-elevation myocardial infarction receive immediate antiplatelet therapy in addition to aspirin to reduce 30-day major adverse cardiac events? Evidence was graded and recommendations were made based on the strength of the available data.

Choice of resuscitative fluids and mortality in emergency department patients with sepsis.

OBJECTIVE: Balanced resuscitative fluids (BF) have been associated with decreased incidence of hyperchloremic metabolic acidosis in sepsis. We hypothesized that higher proportions of BF during resuscitation would thus be associated with improved mortality in Emergency Department (ED) patients with sepsis. METHODS: This was a retrospective chart review of adult ED patients who presented with sepsis to a large, urban teaching hospital over one year. The choice of resuscitation fluid in the first 2days of hospitalization was defined as either normal saline (NS) or balanced fluids (BF; Lactated Ringer's or Isolyte). The primary study outcome was in-hospital mortality, which was analyzed with multivariable logistic regression based on the proportion of BF received during the initial ED resuscitation. RESULTS: Of 149 patients screened, 33 were excluded, leaving 115 for analysis, of whom 18 died (16% overall mortality). Sixty-one (53%) patients received BF and NS, 6 (5%) patients received BF exclusively, while 48 (42%) patients received NS only. The mean number of liters administered was 5.4, and the mean percentage of BF administered was 29%. In univariate analysis, a higher proportion of BF was associated with lower odds of mortality (OR 0.973 [95% CI 0.961-0.986], p=0.00003). This association held true in multivariable models controlling for comorbidities and admission lactate level. CONCLUSIONS: We found that the proportion of BF during the initial ED resuscitation in septic patients was associated with a significant reduction in mortality. This association provides the necessary rationale for future randomized clinical trials of BF resuscitation in sepsis.

A Hanging and Its Complications.

Hanging has become the second most common form of successful suicide in the United States. Along with a high mortality rate, the long-term morbidity is consequential for both the individual patient and society. A thorough knowledge of the clinical approach will assist the emergency physician in providing optimal care and helping to minimize delayed respiratory complications. Using a case-based scenario, the initial management strategies along with rational evidence-based treatments are reviewed.

Significant but reasonable radiation exposure from computed tomography-related medical imaging in the ICU.

Admission to an intensive care unit (ICU) is associated with increased medical imaging and radiation exposure, yet few studies have estimated the risk of cancer associated with these examinations. The purpose of this study was to review computed tomography (CT) scans performed on patients admitted to two urban academic ICUs, predict their radiation exposure, and calculate their estimated lifetime attributable risk of cancer (LAR). An electronic chart review was performed on all CT scans performed between January 2007 and December 2011. The estimated effective dose of radiation was calculated for each CT, and the LAR for each patient was predicted. Mean radiation exposure was 22.2 ± 25.0 mSv with a mean LAR of 0.1 ± 0.2 % and a median of 0.6 % with a range of <0.001 to 3.4 %. Our cohort received radiation doses higher than recommended by guidelines; however, the critical nature of their admission may have warranted these imaging studies. Estimated risk of cancer in this population was overall low.

Quantifying Patient-Physician Communication and Perceptions of Risk During Admissions for Possible Acute Coronary Syndromes.

STUDY OBJECTIVE: Disposition decision for patients with possible acute coronary syndrome in the emergency department (ED) is driven primarily by perception of short-term risks. We sought to evaluate communication between patient and physician about these risks by ascertaining the content of discussions surrounding disposition decision. METHODS: We conducted matched-pair surveys of patients admitted for possible acute coronary syndrome and their physicians in 2 academic, inner-city EDs. After disposition conversation, trained research assistants administered surveys querying perceived and communicated risk estimates and purpose of admission. Primary exclusion criteria were ECG or troponin value diagnostic of acute coronary syndrome. The primary outcome measure was agreement in assessment of the risk of myocardial infarction, defined as the proportion of patient-physician pairs whose risk estimates were within 10% of each other. RESULTS: A total of 425 patient-physician survey pairs were collected. Fifty-three percent of patients were men. Patients reported discussing the likelihood of their symptoms' being due to myocardial infarction in 65% of cases, whereas physicians reported this in 46%. After their discussion, physicians' (n=415) median estimate of short-term risk was 5% (95% confidence interval [CI] 3% to 7%), whereas patients' (n=401) was 8% (95% CI 5% to 11%). Most patients (63%; 95% CI 57% to 67%) reported that this estimate remained the same or increased after their conversation. Risk agreement within 10% occurred in 36% of cases (n=404; 95% CI 32% to 41%). Patients' median estimates of the mortality of myocardial infarction at home versus in the hospital were 80% (n=398; 95% CI 76% to 84%) and 10% (n=390; 95% CI 7% to 13%), respectively, whereas physician estimates were 15% (n=403; 95% CI 12% to 18%) and 10% (n=398; 95% CI 7% to 13%). CONCLUSION: Our survey demonstrates poor communication, with overestimation of both the risks of myocardial infarction and potential benefit of hospital admission. These findings suggest that communication surrounding disposition decisions in chest pain patients may at times be ineffective or misleading.

Renal trauma after blunt abdominal injury.

BACKGROUND: The kidney is the third most common solid organ injury in blunt abdominal trauma. The preferred treatment of blunt kidney injury varies according to grade of severity, with a preference for non-operative management in most instances. DISCUSSION: We examine an unusual case of blunt renal trauma. In this case, our patient presented with severe flank pain and hematuria after a game of softball. Our focused abdominal sonography for trauma revealed fluid in the splenorenal recess concerning for intra-abdominal injury, and subsequent abdominal computed tomography confirmed a grade IV kidney laceration. CONCLUSION: Our patient was managed medically despite his high grade of injury. This article reviews the diagnosis and management of blunt renal trauma and highlights the fact that despite significant injury, a patient can go on to do well with conservative management alone.

Radiation exposure among patients with the highest CT scan utilization in the emergency department.

The risk of cancer from computed tomography (CT) scan radiation is a rising concern in the medical field. Our objectives were to determine how many patients received more than ten CT scans in an academic emergency department (ED) over the course of 7 years and to quantify their radiation exposure and lifetime attributable risk of cancer. An electronic chart review was performed at our urban academic institution with an annual census of 110,000 patients. All patients who underwent a CT scan performed during ED management between the dates of January 2001 and December 2007 were identified. Specific predetermined data elements (e.g., subject demographics, type of CT scan) were extracted by two researchers blinded to hypothesis, using a preformatted data form. After identifying patients with more than ten CTs performed during the study period, radiation exposure was calculated based on accepted and reported radiation doses for the respective anatomic CTs, and lifetime attributable cancer risk was calculated based on the seventh report of the Biological Effects of Ionizing Radiation (BEIR VII) projections. Over the 7-year study period, 24,393 patients received 34,671 CT scans. The vast majority of patients (17,909) received a single CT. Twenty-six (0.1 %) patients received more than ten CTs totaling 374 scans with an average radiation exposure of 83.4 mSv. The maximum lifetime attributable risk for any individual in this cohort was 1.7 % above the baseline cancer risk. Among those undergoing CT imaging in our ED, high-exposure patients (greater than ten scans) constituted a significant minority, while more than one in four patients underwent more than one CT scan during the study period. While the presumed overall risk of radiation-induced cancer continues to be low, it is important for the emergency physician to use clinical knowledge as well as concern for the patient when utilizing radiographic imaging. Increasing attributable cancer risk may have important public health implications in the future, regardless of the low individual risk.

Biological activities of meroterpenoids isolated from different sources.

Meroterpenoids are natural products synthesized by unicellular organisms such as bacteria and multicellular organisms such as fungi, plants, and animals, including those of marine origin. Structurally, these compounds exhibit a wide diversity depending upon the origin and the biosynthetic pathway they emerge from. This diversity in structural features imparts a wide spectrum of biological activity to meroterpenoids. Based on the biosynthetic pathway of origin, these compounds are either polyketide-terpenoids or non-polyketide terpenoids. The recent surge of interest in meroterpenoids has led to a systematic screening of these compounds for many biological actions. Different meroterpenoids have been recorded for a broad range of operations, such as anti-cholinesterase, COX-2 inhibitory, anti-leishmanial, anti-diabetic, anti-oxidative, anti-inflammatory, anti-neoplastic, anti-bacterial, antimalarial, anti-viral, anti-obesity, and insecticidal activity. Meroterpenoids also possess inhibitory activity against the expression of nitric oxide, TNF- α, and other inflammatory mediators. These compounds also show renal protective, cardioprotective, and neuroprotective activities. The present review includes literature from 1999 to date and discusses 590 biologically active meroterpenoids, of which 231 are from fungal sources, 212 are from various species of plants, and 147 are from marine sources such as algae and sponges.

Impact of COVID-19 on Emergency Medicine Residency Programs: A Cross-Sectional Study in New York State.

INTRODUCTION: The 2019 novel coronavirus pandemic has caused significant disruptions in the clinical operations of hospitals as well as clinical education, training, and research at academic centers. New York State was among the first and largest epicenters of the pandemic, resulting in significant disruptions across its 29 emergency medicine (EM) residency programs. We conducted a cross-sectional observational study of EM residency programs in New York State to assess the impact of the pandemic on resident education and training programs. METHODS: We surveyed a cross-sectional sample of residency programs throughout New York State in June 2020, in the timeframe immediately after the state's first "wave" of the pandemic. The survey was distributed to program leadership and elicited information on pandemic-prompted curricular modifications and other educational changes. The survey covered topics related to disruptions in medical education and sought details on solutions to educational issues encountered by programs. RESULTS: Of the 29 accredited EM residency programs in New York State, leadership from 22 (76%) responded. Of these participating programs, 11 (50%) experienced high pandemic impact on clinical services, 21 (95%) canceled their own trainees' off-service rotations, 22 (100%) canceled or postponed visiting medical student rotations, 22 (100%) adopted virtual conference formats (most within the first week of the pandemic wave), and 11 (50%) stopped all prospective research (excluding COVID-19 research), while most programs continued retrospective research. CONCLUSION: This study highlights the profound educational impact of the pandemic on residency programs in one of the hardest- and earliest-hit regions in the United States. Specifically, it highlights the ubiquity of virtual conferencing, the significant impact on research, and the concerns about canceled rotations and missed training opportunities for residents, as well as prehospital and non-physician practitioner trainees. This data should be used to prompt discussion regarding the necessity of alternate educational modalities for pandemic times and the sequelae of implementing these plans.

Full-face motorcycle helmets to reduce injury and death: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: While motorcycle helmets reduce mortality and morbidity, no guidelines specify which is safest. We sought to determine if full-face helmets reduce injury and death. METHODS: We searched for studies without exclusion based on: age, language, date, or randomization. Case reports, professional riders, and studies without original data were excluded. Pooled results were reported as OR (95% CI). Risk of bias and certainty was assessed. (PROSPERO #CRD42021226929). RESULTS: Of 4431 studies identified, 3074 were duplicates, leaving 1357 that were screened. Eighty-one full texts were assessed for eligibility, with 37 studies (n = 37,233) eventually included. Full-face helmets reduced traumatic brain injury (OR 0.40 [0.23-0.70]); injury severity for the head and neck (Abbreviated Injury Scale [AIS] mean difference -0.64 [-1.10 to -0.18]) and face (AIS mean difference -0.49 [-0.71 to -0.27]); and facial fracture (OR 0.26 [0.15-0.46]). CONCLUSION: Full-face motorcycle helmets are conditionally recommended to reduce traumatic brain injury, facial fractures, and injury severity.

Detection of COVID-19 using multimodal data from a wearable device: results from the first TemPredict Study.

Early detection of diseases such as COVID-19 could be a critical tool in reducing disease transmission by helping individuals recognize when they should self-isolate, seek testing, and obtain early medical intervention. Consumer wearable devices that continuously measure physiological metrics hold promise as tools for early illness detection. We gathered daily questionnaire data and physiological data using a consumer wearable (Oura Ring) from 63,153 participants, of whom 704 self-reported possible COVID-19 disease. We selected 73 of these 704 participants with reliable confirmation of COVID-19 by PCR testing and high-quality physiological data for algorithm training to identify onset of COVID-19 using machine learning classification. The algorithm identified COVID-19 an average of 2.75 days before participants sought diagnostic testing with a sensitivity of 82% and specificity of 63%. The receiving operating characteristic (ROC) area under the curve (AUC) was 0.819 (95% CI [0.809, 0.830]). Including continuous temperature yielded an AUC 4.9% higher than without this feature. For further validation, we obtained SARS CoV-2 antibody in a subset of participants and identified 10 additional participants who self-reported COVID-19 disease with antibody confirmation. The algorithm had an overall ROC AUC of 0.819 (95% CI [0.809, 0.830]), with a sensitivity of 90% and specificity of 80% in these additional participants. Finally, we observed substantial variation in accuracy based on age and biological sex. Findings highlight the importance of including temperature assessment, using continuous physiological features for alignment, and including diverse populations in algorithm development to optimize accuracy in COVID-19 detection from wearables.

Can we defer/omit a type and screen blood test for pregnant women who know their blood type?

BACKGROUND: Current clinical practice in many emergency departments (EDs) includes checking a type and screen blood test (T&S) for Rhesus (Rh) status on all pregnant patients presenting with vaginal bleeding or abdominal pain. The test is expensive, and awaiting results may delay disposition. OBJECTIVE: To determine if there is a subset of pregnant women who reliably know their blood type and for whom a T&S blood test to determine Rh status can be safely omitted or deferred. METHODS: A prospective study at two associated urban academic centers with an annual ED census of 150,000 patients was performed between January 2007 and June 2008. Pregnant patients who had a T&S obtained as part of their ED evaluation were enrolled. Subjects completed a standardized data form that requested demographic information and were asked to select "no," "maybe," or "yes, definitely" if they knew their blood type. Standard descriptive statistics with 95% confidence intervals were performed. RESULTS: There were 319 pregnant women enrolled in the study. Among the 106 subjects that reported "yes, definitely" they knew their blood type, 103 (97.2%; 95% confidence interval [CI] 94.0-100%]) identified their correct blood type and 105 (99.1%; 95% CI 97.2-100%) identified their correct Rh status. None of these subjects selected a positive Rh when they were in fact a negative Rh. All 14 (13.2%) subjects with a negative Rh status identified themselves as having a negative Rh. CONCLUSION: Pregnant women reporting that "yes, definitely" they know their blood type, are reliable. Deferring T&S testing test may be reasonable.