Testosterone Therapy as an Isolated Risk Factor for Venous Thrombosis: A Case Report.

Healthcare providers in the emergency department (ED) diagnose and treat venous thrombus embolism (VTE). Current VTE clinical decision tools specifically mention estrogen but do not include the use of testosterone replacement therapy (TRT). A male in the early third decade of life presented to the ED with complaints of left calf pain and subjective swelling for one week. The patient was low risk using VTE scoring tools. The patient had multiple occlusive VTE on lower-extremity ultrasound and extensive central, bilateral segmental, and subsegmental pulmonary emboli. He was admitted to the hospital and placed on a heparin drip. TRT may be seen in clinical practice in both male and female patients. This bodes the question of whether TRT should be added to the risk analysis tools used to evaluate and predict the risk for VTE. There have been conflicting reports in research, with more recent studies indicating the risk associated with TRT. This case study demonstrates the risk of VTE with TRT. Further investigation is needed to determine if there is a correlation between VTE and TRT. Clinical decision tools should be updated to include TRT accordingly.

Evaluation of the Functionality in an Emergency Department Setting of an Intravenous Protection Device to Prevent Self-Injection.

Background: The United States has an opioid abuse crisis that has been increasing exponentially since 2013. In 2021, there were 220 deaths each day from opioid overdoses in the United States alone. Patients suffering from addiction often present to the emergency department (ED) anticipating that an intravenous (IV) catheter will be placed. This catheter is then accessible for patients to self-inject illicit drugs while under medical care or elope from the facility with the IV in place to self-inject. The misuse of medical IV access is a potential source of prolonged hospitalizations and fatal overdoses nationwide. On two separate occasions, patients were found dead in our ED bathroom after overdosing by accessing their IV site for self-injection. These events prompted the development of the IV SafeLock prototype. The IV SafeLock is designed to prevent intravenous access by the patient while allowing access by specified providers to administer medications. This study aims to investigate prototype usability and functionality by nursing staff in the ED. Methods: A prospective study was performed with twenty ED nurses in a clinical trial to use the IV SafeLock in the clinical setting. Each nurse was given two months to complete an evaluation of 20 patients requiring IV access. They used the IV SafeLock on infusion ports and Intermittent Needle Therapy (INT) access sites. A Likert scale was used to measure the ease of function and use of the IV SafeLock. Results and conclusion: The nurses felt that the IV SafeLock was easy to use and achieved its function of protecting the intravenous access site from self-injection. The IV SafeLock prototypes used in the trial were easy to use and functioned as intended most of the time. The IV SafeLock can be used by nursing staff in a clinical setting to help prevent self-injection. Clinical Trial Registration: NCT05695183 enrolled 01/12/2023.

Development of a Medical Device in Response to a Fatal Self-Injection of Non-prescribed Opioids: A Case Report.

Patients who inject drugs (PWID) pose unique challenges in their medical care due to risks of increased infection and overdose. There are no known commercially available devices to prevent patients from self-injecting non-prescribed substances into vascular access devices (VADs). A patient in the emergency department (ED) of a midsized suburban hospital self-injected an opioid in the ED restroom after the placement of a vascular catheter by the nursing staff as part of her ED care. Despite precautions taken for a patient with a known opioid use disorder (OUD) and a history of self-injecting non-prescribed substances into VADs, the patient suffered a self-induced fatal overdose. PWID are at significant risk of self-injection when requiring intravenous medications as part of their medical care. This case highlighted the need for formal reporting for patients who self-inject non-prescribed substances into VADs. It revealed a lack of medical devices to help providers ensure that PWID cannot access their medical devices when intravenous therapy is indicated.

Characteristics and Outcomes of Patients in the Emergency Department with Left Ventricular Assist Devices.

Introduction: Left ventricular assist devices (LVAD) are increasingly common among patients with heart failure. The unique physiologic characteristics of patients with LVADs present a challenge to emergency clinicians making treatment and disposition decisions. Despite the increasing prevalence of LVADs, literature describing emergency department (ED) visits among this population is sparse. We aimed to describe clinical characteristics and outcomes among patients with LVADs seen in two quaternary-care EDs in a five-year period. Secondarily, we sought to evaluate mortality rates and ED return rates for bridge to transplant (BTT) and destination therapy (DT) patients. Methods: We conducted a retrospective cohort study of adult patients known to have an LVAD who were evaluated in two quaternary-care EDs from 2013-2017. Data were collected from the electronic health record and summarized with descriptive statistics. We assessed patient outcomes with mixed-effects logistic regression models including a random intercept to account for patients with multiple ED visits. Results: During the five-year study period, 290 ED visits among 107 patients met inclusion criteria. The median patient age was 61 years. The reason for LVAD implantation was BTT in 150 encounters (51.7%) and DT in 140 (48.3%). The most common presenting concerns were dyspnea (21.7%), bleeding (18.6%), and chest pain (11.4%). Visits directly related to the LVAD were infrequent (7.9%). Implantable cardioverter-defibrillator discharge was reported in 3.4% of visits. A majority of patients were dismissed home from the ED (53.8%), and 4.5% required intensive care unit admission. Among all patients, 37.9% returned to the ED within 30 days, with similar rates between DT and BTT patients (32.1 vs 43.3%; P = 0.055). The LVAD was replaced in three cases (1.0%) during hospitalization. No deaths occurred in the ED, and the mortality rate within 30 days was 2.1% among all patients. Conclusion: In this multicenter cohort study of ED visits among patients with an LVAD, dyspnea, bleeding, and chest pain were the most common presenting concerns. Visits directly related to the LVAD were uncommon. Approximately half of patients were dismissed home, although return ED visits were common.

Robotics in Simulated COVID-19 Patient Room for Health Care Worker Effector Tasks: Preliminary, Feasibility Experiments.

The coronavirus disease 2019 (COVID-19) pandemic has strained health care systems and personal protective equipment (PPE) supplies globally. We hypothesized that a collaborative robot system could perform health care worker effector tasks inside a simulated intensive care unit (ICU) patient room, which could theoretically reduce both PPE use and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) exposures. We planned a prospective proof-of-concept feasibility and design pilot study to test 5 discrete medical tasks in a simulated ICU room of a COVID-19 patient using a collaborative robot: push a button on intravenous pole machine when alert occurs for downstream occlusion, adjust ventilator knob, push button on ICU monitor to silence false alerts, increase oxygen flow on wall-mounted flow meter to allow the patient to walk to the bathroom and back (dial-up and dial-down oxygen flow), and push wall-mounted nurse call button. Feasibility was defined as task completion robotically. A training period of 45 minutes to 1 hour was needed to program the system de novo for each task. In less than 30 days, the team completed 5 simple effector task experiments robotically. Selected collaborative robotic effector tasks appear feasible in a simulated ICU room of the COVID-19 patient. Theoretically, this robotic approach could reduce PPE use and staff SARS-CoV-2 exposure. It requires future validation and health care worker learning similar to other ICU device training.

Association of Bartholin cysts and abscesses and sexually transmitted infections.

INTRODUCTION: Bartholin gland cysts or abscesses account for many gynecologic visits in the emergency department (ED). Previous smaller studies have suggested a link between Bartholin cysts/abscesses and sexually transmitted infections (STIs), but few studies have involved the ED. METHODS: We retrospectively identified patients aged 18 years or older seen in 1 ED between January 2012 and March 2017 who had urinalysis and urine culture and/or were tested for gonorrhea, chlamydia, or trichomonas by nucleic acid amplification testing. Univariate and multivariate analyses were used to evaluate associations between Bartholin cysts/abscess and demographics, laboratory findings, and ED diagnoses. RESULTS: Data were collected for 75,000 ED patients; 64 patients had a diagnosis of Bartholin cyst or abscess, 40 of whom were also tested for Neisseria gonorrhoeae or Chlamydia trachomatis. Ten percent of patients with a Bartholin cyst/abscess were infected with N gonorrhoeae, compared with 3% of those without a Bartholin cyst/abscess (P = .008). The rates of C trachomatis and Trichomonas vaginalis infections were 13% and 26%, respectively, among patients with a Bartholin cyst/abscess, compared with 8% and 30%, respectively, among those without a Bartholin cyst/abscess (P > .05 for both). On regression analysis, only increased urobilinogen level (ß, 0.31; odds ratio, 1.36; 95% CI, 1.11-1.66; P = .003) and infection with N gonorrhoeae (ß, 1.69; odds ratio, 5.40; 95% CI, 1.43-20.35; P = .01) were associated with a Bartholin cyst/abscess. CONCLUSIONS: Clinicians in the ED should consider testing patients with a Bartholin cyst/abscess for gonorrhea.

Emergency Department Visits Among Lung Transplant Patients: A 4-Year Experience.

BACKGROUND: Emergency department (ED) visits by lung transplant (LT) patients have not been well documented in the literature. OBJECTIVES: To analyze outcomes among LT recipients with ED visits, to better inform clinicians regarding evaluation and treatment. METHODS: This was a retrospective cohort study of LT patients at our ED (2015-2018). Demographics, transplant indication, laboratory studies, ED interventions, disposition, death, and revisit data were collected. Logistic regression models were used to identify univariable and multivariable predictors of ED revisit, intensive care unit (ICU) admission, or death. RESULTS: For 505 ED visits among 160 LT recipients, respiratory-related concerns were most frequent (n = 152, 30.1%). Infection was the most common ED diagnosis (n = 101, 20.0%). Many patients were sent home from the ED (n = 235, 46.5%), and 31.3% (n = 158) returned to the ED within 30 days. Fourteen patients (2.8%) needed advanced airway measures. One patient died in the ED, and 18 died in the hospital. On multivariable analysis, more previous ED visits significantly increased the probability of 30-day ED revisit. Heart rate faster than 100 beats/min and systolic blood pressure < 90 mm Hg were significantly associated with ICU admission or death. CONCLUSION: Infection should be prominent on the differential diagnosis for LT patients in the ED. A large proportion of patients were discharged from the ED, but a higher number of previous ED visits was most predictive of ED revisit within 30 days. Mortality rate was low in our study, but higher heart rate and lower systolic blood pressure were associated with ICU admission or death.

Epidemiologic and Clinical Characteristics of Tubo-Ovarian Abscess, Hydrosalpinx, Pyosalpinx, and Oophoritis in Emergency Department Patients.

Introduction Pelvic inflammatory disease (PID) is a spectrum of illness ranging from mild illness to more severe forms including tubo-ovarian abscess, hydrosalpinx, pyosalpinx, oophoritis (THPO). The objective of the study was to report rates and clinical characteristics of females presenting to the ED with a diagnosis of THPO in relationship to the presence or absence of sexually transmitted infections (STIs). Methods A database of ED patient encounters occurring from April 18, 2014, to March 7, 2017 was created. Analysis of women diagnosed with THPO and who had testing for gonorrhea, chlamydia, or trichomonas by nucleic acid amplification testing or who had a vaginal wet preparation was performed. Patient demographics, ED diagnoses, laboratory tests, medications administered in the ED, and medications prescribed were examined. Categorical variables were summarized as count and percentages and analyzed using the Chi-square test. Continuous variables were summarized as the mean and standard deviation and analyzed using the t-test. All statistical tests were two-sided with a significance level of 0.05. Results THPO was diagnosed in 0.3% (56/17,905) of patient encounters. There were 50% (28/56) of women with THPO admitted to the hospital. There were 25.0% (12/48) women who received a positive test result for Neisseria gonorrhoeae, Chlamydia trachomatis, and/or Trichomonas vaginalis. Women with THPO were significantly older, more likely to be infected with gonorrhea, and more likely to be diagnosed with sepsis and PID (P<.05 for all). Conclusions THPO is an infrequently encountered entity in the ED. A diagnosis of STI, PID, and sepsis can accompany these presentations. Although an uncommon diagnosis, ED providers must be attentive to patients presenting with pelvic symptoms that could be consistent with THPO to mitigate any complications that may arise and to direct the appropriate treatment.

Diagnosis of a Case of Suspected COVID-19 Using Telemedicine Technology in the Emergency Department.

BACKGROUND Coronavirus disease 2019 (COVID-19) is an ongoing worldwide pandemic infection. Healthcare workers must utilize appropriate personal protective equipment (PPE) and infection control prevention techniques given the high risk of transmission and potential morbidity associated with COVID-19. We present a case report highlighting the strengths and potential applications of telemedicine technology in a patient's evaluation during an ongoing emerging, novel infectious disease. CASE REPORT A 67-year-old male presented to the Emergency Department (ED) with complaints of fever. His presentation coincided with a recent declaration of a pandemic caused by COVID-19 and a known exposure. Telemedicine evaluation was performed using InTouch Provider® software (InTouch Health, Goleta, CA, USA). The treating clinician was able to interact with the patient entirely through observations via web camera. COVID-19 nasopharyngeal swab polymerase chain reaction testing was ordered and was performed by a dedicated triage nurse. The patient was deemed stable for discharge given his normal vital signs and well appearance. Approximately 72 hours after discharge from the ED, the patient was contacted with positive COVID-19 swab results. CONCLUSIONS We present the first known case report highlighting use of telemedicine to diagnosis COVID-19 in a patient present in the ED. With the appropriate systems in place, this method of evaluating the patient helped to limit clinician exposure, decrease risk of transmission to key personnel, and assisted with preserving PPE supplies. Use of telemedicine affords multiple benefits in the effective diagnosis, evaluation, and potential prevention of spread of COVID-19.

Fractured aluminum nasopharyngeal swab during drive-through testing for COVID-19: radiographic detection of a retained foreign body.

The ongoing coronavirus disease 2019 (COVID-19) pandemic has increased the need for safe and efficient testing as a key containment strategy. Drive-through testing with nasopharyngeal swab has been implemented in many places in the USA as it allows for expeditious testing of large numbers of patients, limits healthcare workers' risk of exposure, and minimizes the use of personal protective equipment. We present a case where the aluminum shaft of the nasopharyngeal swab fractured during specimen collection at a drive-through testing facility and was suspected to have remained in the asymptomatic patient. Initial evaluation with a series of radiographs covering the skull base, neck, chest, and abdomen did not reveal the swab. On further clinical evaluation, the swab was found endoscopically, lodged between the left inferior turbinate and nasal floor, and was removed by an otorhinolaryngologist. Using a phantom model, we aimed to delineate an imaging technique to better visualize the aluminum shaft of the nasopharyngeal swab on radiographs to help in identification. A technique using lower tube voltage (kVp) with tight collimation centered at the nasal bones area produced the best visualization of the aluminum shaft of the swab. Recognition that aluminum foreign bodies may be difficult to visualize radiographically and  optimization of radiograph acquisition technique may help guide clinical management in unusual cases. Further evaluation with computed tomography or endoscopy should be considered in suspected cases where radiographs are negative.

Differences Between Esophageal and Tracheal Intubation Ultrasound View Proficiency: An Educational Study of Novice Prehospital Providers.

Objectives Airway ultrasound is now possible in the prehospital setting due to advances in ultrasound equipment portability. We questioned how well prehospital providers without prior experience could determine both esophageal and tracheal placement of an endotracheal tube in cadavers after a brief training course in ultrasound.  Methods This educational prospective study at the Simulation Center in Mayo Clinic Jacksonville Florida enrolled 50 prehospital providers. Demographic and practice background information was obtained through surveys. Each participant performed a baseline ultrasound to determine endotracheal tube placement in a cadaver that was randomly assigned to an esophageal or tracheal intubation. Participants then repeated the randomized testing after a 15-minute tutorial. Before and after overall accuracy as well as proportions of correct identification of esophageal and tracheal intubations were determined and compared using standard binomial proportion and McNemar's tests. Results  None of the participants had prior experience of performing airway ultrasound. Baseline group scores were 60% (CI 45%-74%) for overall accuracy (n=50), 55% (CI 32%-76%) for correct identification of an esophageal intubation, and 64% (CI 44%-81%) for correct tracheal detection. Baseline scores were not significantly different from standard binomial distributions. Post-test scores were 82% (CI 69%-91%) for overall accuracy, 96% (CI 80%-100%) for esophageal intubation detection, and 66.7% (CI 45%-84%) for tracheal intubation detection, with corresponding binomial p-values of <0.001, <0.001, and 0.15. P-values for McNemar's paired test for combined overall accuracy, correct esophageal detection, and correct tracheal detection were 0.04, 0.02, and 0.62, respectively. Conclusions Prehospital participants without prior ultrasound experience demonstrated significant gains in airway ultrasound proficiency after a limited introductory course. Post-training score increases were largely due to a notable increase in correct esophageal intubation detection rates. Learners did not make significant progress in correctly identifying a tracheal intubation. Airway ultrasound educational design may benefit from added emphasis on the potentially more difficult to recognize tracheal intubation view.

Use of a simulation-based advanced resuscitation training curriculum: Impact on cardiopulmonary resuscitation quality and patient outcomes.

BACKGROUND: Despite a continued focus on improved cardiopulmonary resuscitation quality, survival remains low from in-hospital cardiac arrest. Advanced Resuscitation Training has been shown to improve survival to hospital discharge and survival with good neurological outcome following in-hospital cardiac arrest at its home institution. We sought to determine if Advanced Resuscitation Training implementation would improve patient outcomes and cardiopulmonary resuscitation quality at our institution. METHODS: This was a prospective, before-after study of adult in-hospital cardiac arrest victims who had cardiopulmonary resuscitation performed. During phase 1, standard institution cardiopulmonary resuscitation training was provided. During phase 2, providers received the same quantity of training, but with emphasis on Advanced Resuscitation Training principles. Primary outcomes were return of spontaneous circulation, survival to hospital discharge, and neurologically favorable survival. Secondary outcomes were cardiopulmonary resuscitation quality parameters. RESULTS: A total of 156 adult in-hospital cardiac arrests occurred during the study period. Rates of return of spontaneous circulation improved from 58.1 to 86.3% with an adjusted odds ratios of 5.31 (95% CI: 2.23-14.35, P < 0.001). Survival to discharge increased from 26.7 to 41.2%, adjusted odds ratios 2.17 (95% CI: 1.02-4.67, P < 0.05). Survival with a good neurological outcome increased from 24.8 to 35.3%, but was not statistically significant. Target chest compression rate increased from 30.4% of patients in P1 to 65.6% in P2, adjusted odds ratios 4.27 (95% CI: 1.72-11.12, P = 0.002), and target depth increased from 23.2% in P1 to 46.9% in P2, adjusted odds ratios 2.92 (95% CI: 1.16-7.54, P = 0.024). CONCLUSIONS: After Advanced Resuscitation Training implementation, there were significant improvements in cardiopulmonary resuscitation quality and rates of return of spontaneous circulation and survival to discharge.

A Longitudinal Curriculum In Point-Of-Care Ultrasonography Improves Medical Knowledge And Psychomotor Skills Among Internal Medicine Residents.

PURPOSE: Despite its growing popularity and clinical utility among hospital-based physicians, there are no formal competency requirements nor training standards for United States based Internal Medicine Residencies for learning point-of-care ultrasonography (POCUS). The purpose of this investigation was to study the impact and effectiveness of a novel POCUS curriculum for an Internal Medicine (IM) residency program. PATIENTS AND METHODS: This was a Single-Group Educational Quasi-Experiment involving Categorical and Preliminary Internal Medicine Residents in Post-Graduate Years 1 through 3 at a single United States academic tertiary center. The study period was from January 1, 2017, through June 30, 2017, during which time the residents participated in monthly modules including didactics and hands-on ultrasound scanning skills with live models. Participants completed a comprehensive knowledge examination at the beginning and end of the six-month period. Participants were also tested regarding hands-on image acquisition and interpretation immediately before and after the hands-on skills labs. The primary outcome measure was performance improvement in a comprehensive medical knowledge assessment. RESULTS: In total, 42 residents consented for participation. The residents' monthly rotations were adjusted in order to accommodate the new educational process. Among 29 participants with complete data sets for analysis, the mean (SD) comprehensive knowledge examination score improved from 60.9% before curriculum to 70.2% after curriculum completion (P<0.001). Subgroup analysis determined that improvement in medical knowledge required attending at least 2 out of the 6 (33%) educational sessions. Attendance at hands-on skills labs correlated significantly with improvement; didactics alone did not. CONCLUSION: A longitudinal POCUS curriculum consisting of both didactic sessions and hands-on skills labs improves knowledge, image acquisition, and interpretation skills of residents. Having this curriculum span at least 6 months provides learners the opportunity to attend multiple classes which strengthens learning through repetition while also providing learners flexibility in schedule.

Investigation of a Cost-effective and Durable Material for Containing Ballistic Gel in the Construction of Ultrasound Phantoms.

There is significant variability in the realism, cost, and structural integrity of sonographic simulators available for use currently. A common material that is used for the production of sonographic simulators is synthetic ballistic gelatin, which requires a high melting temperature for molding. In this experiment, we investigated the structural integrity of high-density polyethylene (HDPE) when exposed to melted ballistics gel for the assimilation of a sonographic lumbar puncture simulator.

Sleep quality correlates with the carotid intima-media thickness in stroke-free community-dwelling adults living in rural Ecuador. The Atahualpa Project.

BACKGROUND/OBJECTIVES: Evidence of an association between sleep disorders and extracranial atherosclerosis is limited and has not been studied in remote rural settings, where living conditions and cardiovascular risk factors are different than in urban centers. We assessed the relationship between the carotid intima-media thickness (cIMT) and sleep quality in stroke-free individuals aged ≥40 years living in rural Ecuador. METHODS: Applying a population-based study design, participants underwent face-to-face interviews using the Pittsburgh Sleep Quality Index (PSQI) to assess sleep quality, and sonographic examinations for measurement of the carotid intima-media thickness (cIMT). The association between the cIMT and sleep quality (as the dependent variable) was assessed by means of generalized linear models, adjusted for relevant confounders. RESULTS: The mean age of 561 participants was 60.4 ± 12.6 years (58% women). The mean PSQI was 4.6 ± 2.2 points. Of those, 79 (14%) individuals had an increased cIMT (>1 mm). A model adjusted for demographics showed a significant association between increased cIMT and the PSQI score (ß: 0.602; 95% C.I.: 0.027-1.177; p = 0.040). This relationship was reduced when cardiovascular risk factors were added to the model (ß: 0.514; 95% C.I.: -0.072 - 1.101; p = 0.086). When the model was adjusted for demographics and psychological distress, the association between increased cIMT and the PSQI score became significant (ß: 0.573; 95% C.I.: 0.013-1.133; p = 0.045). In addition, both symptoms of depression (p = 0.032) and anxiety (p < 0.001) remained independently significant. CONCLUSIONS: This study shows an association between increased cIMT and the PSQI score, which is, at least, partly mediated by manifestations of psychological distress.

The relationship between the neck circumference and the carotid intima-media thickness in Amerindians. Potential links to health risks?

The carotid intima media thickness (cIMT) is a predictor of cardiovascular events. The neck circumference (NC) has been investigated as a risk factor for increased cIMT with contradictory results. This study assessed the relationship between NC and cIMT in Atahualpa residents aged ≥40 years who had sonographic examination of carotid arteries (n = 590). We also discussed on potential pathogenetic mechanisms underlying this association. Participants belonged to the Native Ecuadorian (Amerindians) ethnic group. Non-parametric regression models were used to assess the aforementioned relationship, after adjusting for relevant confounders. The mean age of participants was 60.9 ± 12.7 years (58% women). The mean value of the cIMT was 0.85 ± 0.19 mm. The mean NC was 35.8 ± 34 cm. The NC was normally distributed, but the cIMT was not. Mean values of NC and cIMT were significantly greater in men than in women. Non-parametric models showed significant differences in median cIMT values according to quartiles of NC. Predictive cIMT margins increased by quartiles of NC, significantly among individuals in the 1st quartile as compared to the 3rd quartile. In this population of Amerindians, smaller NC is associated with lower values of cIMT. The pattern of this association is different in men than in women. Sex-related differences in cervical fat tissue distribution probably accounted for such differences.