Diverse immunological dysregulation, chronic inflammation, and impaired erythropoiesis in long COVID patients with chronic fatigue syndrome.

A substantial number of patients recovering from acute SARS-CoV-2 infection present serious lingering symptoms, often referred to as long COVID (LC). However, a subset of these patients exhibits the most debilitating symptoms characterized by ongoing myalgic encephalomyelitis or chronic fatigue syndrome (ME/CFS). We specifically identified and studied ME/CFS patients from two independent LC cohorts, at least 12 months post the onset of acute disease, and compared them to the recovered group (R). ME/CFS patients had relatively increased neutrophils and monocytes but reduced lymphocytes. Selective T cell exhaustion with reduced naïve but increased terminal effector T cells was observed in these patients. LC was associated with elevated levels of plasma pro-inflammatory cytokines, chemokines, Galectin-9 (Gal-9), and artemin (ARTN). A defined threshold of Gal-9 and ARTN concentrations had a strong association with LC. The expansion of immunosuppressive CD71+ erythroid cells (CECs) was noted. These cells may modulate the immune response and contribute to increased ARTN concentration, which correlated with pain and cognitive impairment. Serology revealed an elevation in a variety of autoantibodies in LC. Intriguingly, we found that the frequency of 2B4+CD160+ and TIM3+CD160+ CD8+ T cells completely separated LC patients from the R group. Our further analyses using a multiple regression model revealed that the elevated frequency/levels of CD4 terminal effector, ARTN, CEC, Gal-9, CD8 terminal effector, and MCP1 but lower frequency/levels of TGF-ß and MAIT cells can distinguish LC from the R group. Our findings provide a new paradigm in the pathogenesis of ME/CFS to identify strategies for its prevention and treatment.

Geographic variation in breast reconstruction surgery after mastectomy for females with breast cancer in Alberta, Canada.

BACKGROUND: Breast cancer is the most common cancer affecting females in Canada, and about half of females with breast cancer are treated with mastectomy. We sought to evaluate geographic variation in breast reconstruction surgery in Alberta, Canada. METHODS: Using linked population-based administrative databases, we extracted data on all Alberta females aged 18 years and older who were diagnosed with breast cancer and treated with mastectomy during 2004-2017. Analyses included regression modelling of odds of reconstruction at 1 year and a spatial scan to identify geographic clusters of lower numbers of reconstruction. RESULTS: A total of 16 198 females diagnosed with breast cancer were treated with a mastectomy, and 1932 (11.9%) had reconstruction within 1 year postmastectomy. Those with reconstruction were more likely to be younger (adjusted odds ratio [OR] 16.7, 95% confidence interval [CI] 13.7-20.3; aged 21-44 yr v. ≥ 65 yr) and were less likely to be from lower-income neighbourhoods. They were more likely to have at least 1 comorbidity and were more likely to have advanced stages of cancer and to require chemotherapy (adjusted OR 0.55, 95% CI 0.47-0.65) or radiotherapy after mastectomy (adjusted OR 0.59, 95% CI 0.39-0.87) than females without reconstruction. We identified rural northern and southeastern clusters with frequencies of reconstruction that were 69.6% and 41.6% of what was expected, respectively. CONCLUSION: We found an overall postmastectomy rate of breast reconstruction of 11.9%, and we identified geographic variation. Predictors of reconstruction in Alberta were similar to those previously described in the literature, specifically with patients in rural communities having lower rates of reconstruction than their urban counterparts. These results suggest that further interventions are required to identify the specific barriers to reconstruction within rural communities and to create strategies to ensure equitable access to all residents.

Characteristics and outcomes of patients with COVID-19 who return to the emergency department: a multicentre observational study by the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN).

OBJECTIVE: Unplanned return emergency department (ED) visits can reflect clinical deterioration or unmet need from the original visit. We determined the characteristics and outcomes of patients with COVID-19 who return to the ED for COVID-19-related revisits. METHODS: This retrospective observational study used data for all adult patients visiting 47 Canadian EDs with COVID-19 between 1 March 2020 and 31 March 2022. Multivariable logistic regression assessed the characteristics associated with having a no return visit (SV=single visit group) versus at least one return visit (MV=return visit group) after being discharged alive at the first ED visit. RESULTS: 39 809 patients with COVID-19 had 44 862 COVID-19-related ED visits: 35 468 patients (89%) had one visit (SV group) and 4341 (11%) returned to the ED (MV group) within 30 days (mean 2.2, SD=0.5 ED visit). 40% of SV patients and 16% of MV patients were admitted at their first visit, and 41% of MV patients not admitted at their first ED visit were admitted on their second visit. In the MV group, the median time to return was 4 days, 49% returned within 72 hours. In multivariable modelling, a repeat visit was associated with a variety of factors including older age (OR=1.25 per 10 years, 95% CI (1.22 to 1.28)), pregnancy (1.86 (1.46 to 2.36)) and presence of comorbidities (eg, 1.72 (1.40 to 2.10) for cancer, 2.01 (1.52 to 2.66) for obesity, 2.18 (1.42 to 3.36) for organ transplant), current/prior substance use, higher temperature or WHO severe disease (1.41 (1.29 to 1.54)). Return was less likely for females (0.82 (0.77 to 0.88)) and those boosted or fully vaccinated (0.48 (0.34 to 0.70)). CONCLUSIONS: Return ED visits by patients with COVID-19 within 30 days were common during the first two pandemic years and were associated with multiple factors, many of which reflect known risk for worse outcomes. Future studies should assess reasons for revisit and opportunities to improve ED care and reduce resource use. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov, NCT04702945.

Transitions in health care settings for frequent and infrequent users of emergency departments: a population-based retrospective cohort study.

BACKGROUND: Efforts to reduce emergency department (ED) volumes often target frequent users. We examined transitions in care across ED, hospital, and community settings, and in-hospital death, for high system users (HSUs) compared to controls. METHODS: Population-based databases provided ED visits and hospitalizations in Alberta and Ontario, Canada. The retrospective cohort included the top 10% of all the ED users during 2015/2016 (termed HSUs) and a random sample of controls (4 per each HSU) from the bottom 90% per province. Rates of transitions among ED, hospitalization, community settings, and in-hospital mortality were adjusted for sociodemographic and ED variables in a multistate statistical model. RESULTS: There were 2,684,924 patients and 579,230 (21.6%) were HSUs. Patient characteristics associated with shorter community to ED transition times for HSUs included Alberta residence (ratio of hazard ratio [RHR] = 1.11, 95% confidence interval [CI] 1.11,1.12), living in areas in the lower income quintile (RHR = 1.06, 95%CI 1.06,1.06), and Ontario residents without a primary health care provider (RHR = 1.13, 95%CI 1.13,1.14). Once at the ED, characteristics associated with shorter ED to hospital transition times for HSUs included higher acuity (e.g., RHR = 1.70, 95% CI 1.61, 1.81 for emergent), and for many diagnoses including chest pain (RHR = 1.71, 95%CI 1.65,1.76) and gastrointestinal (RHR = 1.66, 95%CI 1.62,1.71). Once admitted to hospital, HSUs did not necessarily have longer stays except for conditions such as chest pain (RHR = 0.90, 95% CI 0.86, 0.95). HSUs had shorter times to death in the ED if they presented for cancer (RHR = 2.51), congestive heart failure (RHR = 1.93), myocardial infarction (RHR = 1.53), and stroke (RHR = 1.84), and shorter times to death in-hospital if they presented with cancer (RHR = 1.29). CONCLUSIONS: Differences between HSUs and controls in predictors of transitions among care settings were identified. Co-morbidities and limitations in access to primary care are associated with more rapid transitions from community to ED and hospital among HSUs. Interventions targeting these challenges may better serve patients across health systems.. TRIAL REGISTRATION: Not applicable.

Perinatal and early life factors and asthma control among preschoolers: a population-based retrospective cohort study.

BACKGROUND: Preventing poor childhood asthma control is crucial for short-term and long-term respiratory health. This study evaluated associations between perinatal and early-life factors and early childhood asthma control. METHODS: This retrospective study used administrative health data from mothers and children born 2010-2012 with a diagnosis of asthma before age 5 years, in Alberta, Canada. The outcome was asthma control within 2 years after diagnosis. Associations between perinatal and early-life factors and risk of partly and uncontrolled asthma were evaluated by multinomial logistic regression. RESULTS: Of 7206 preschoolers with asthma, 52% had controlled, 37% partly controlled and 12% uncontrolled asthma 2 years after diagnosis. Compared with controlled asthma, prenatal antibiotics (adjusted risk ratio (aRR): 1.19; 95% CI 1.06 to 1.33) and smoking (aRR: 1.18; 95% CI 1.02 to 1.37), C-section delivery (aRR: 1.11; 95% CI 1.00 to 1.25), summer birth (aRR: 1.16; 95% CI 1.00 to 1.34) and early-life hospitalisation for respiratory illness (aRR: 2.24; 95% CI 1.81 to 2.76) increased the risk of partly controlled asthma. Gestational diabetes (aRR: 1.41; 95% CI 1.06 to 1.87), C-section delivery (aRR: 1.18; 95% CI 1.00 to 1.39), antibiotics (aRR: 1.32; 95% CI 1.08 to 1.61) and hospitalisation for early-life respiratory illness (aRR: 1.65; 95% CI 1.19 to 2.27) were associated with uncontrolled asthma. CONCLUSION: Maternal perinatal and early-life factors including antibiotics in pregnancy and childhood, gestational diabetes, prenatal smoking, C-section and summertime birth, and hospitalisations for respiratory illness are associated with partly or uncontrolled childhood asthma. These results underline the significance of perinatal health and the lasting effects of early-life experiences on lung development and disease programming.

Impact of airway challenges on cardiovascular risk in asthma - a randomized controlled trial.

BACKGROUND: People experiencing asthma exacerbations are at increased risk of cardiovascular events. To better understand the relationship between asthma exacerbations and cardiovascular risk, this randomized case-control, cross-over controlled trial assessed the immediate systemic inflammatory and vascular responses to acutely induced pulmonary inflammation and bronchoconstriction in people with asthma and controls. METHODS: Twenty-six people with asthma and 25 controls underwent three airway challenges (placebo, mannitol, and methacholine) in random order. Markers of cardiovascular risk, including serum C-reactive protein, interleukin-6, and tumor necrosis factor, endothelial function (flow-mediated dilation), microvascular function (blood-flow following reactive hyperemia), and arterial stiffness (pulse wave velocity) were evaluated at baseline and within one hour following each challenge. The systemic responses in a) asthma/control and b) positive airway challenges were analyzed. (ClinicalTrials.gov reg# NCT02630511). RESULTS: Both the mannitol and methacholine challenges resulted in clinically significant reductions in forced expiratory volume in 1 second (FEV1) in asthma (-7.6% and -17.9%, respectively). Following positive challenges, reduction in FEV1 was -27.6% for methacholine and -14.2% for mannitol. No meaningful differences in predictors of cardiovascular risk were observed between airway challenges regardless of bronchoconstrictor response. CONCLUSION: Neither acutely induced bronchoconstriction nor pulmonary inflammation and bronchoconstriction resulted in meaningful changes in systemic inflammatory or vascular function. These findings question whether the increased cardiovascular risk associated with asthma exacerbations is secondary to acute bronchoconstriction or inflammation, and suggest that other factors need to be further evaluated such as the cardiovascular impacts of short-acting inhaled beta-agonists.

A retrospective review of tension-free vaginal tape/transobturator tape procedures done concomitantly with prolapse repair.

OBJECTIVE: Midurethral slings have become the standard of care for women with stress urinary incontinence; prolapse repair is often also required. The primary objective of our study was to compare voiding dysfunction rates and the need for reoperation between patients having midurethral sling procedures alone versus those having midurethral sling procedures with concomitant prolapse repair. METHODS: We performed a retrospective chart review over a two-year period in a tertiary urogynaecology clinic. Of 108 charts, 93 had complete data for analysis. RESULTS: Patients having concomitant prolapse repair had a longer operating time, a longer hospital stay, and a longer time to resume normal voiding in the immediate postoperative period. CONCLUSION: Although tension-free vaginal tape or transobturator tape procedures with concomitant prolapse repair have a higher incidence of voiding dysfunction in the immediate postoperative period, we found that this did not persist to the six-week follow-up visit. There appeared to be no greater risk of lasting voiding dysfunction or need for reoperation after concomitant procedures.

Objectif : Les interventions de fronde mi-urétrale sont devenues la norme pour les femmes qui présentent une incontinence urinaire à l'effort; une réparation du prolapsus est également souvent nécessaire. Notre étude avait pour objectif principal de comparer, chez les patientes ne subissant qu'une intervention de fronde mi-urétrale et chez celles qui subissaient une intervention de fronde mi-urétrale et une réparation concomitante du prolapsus, les taux de dysfonction mictionnelle et la nécessité de procéder à une deuxième opération. Méthodes : Nous avons mené une analyse rétrospective des dossiers sur une période de deux ans au sein d'une clinique tertiaire d'urogynécologie. Sur 108 dossiers, 93 comptaient des données complètes aux fins de l'analyse. Résultats : Les patientes subissant une réparation concomitante du prolapsus connaissaient une durée d'opération prolongée, une hospitalisation prolongée et un délai prolongé avant le retour de la miction normale au cours de la période postopératoire immédiate. Conclusion : Bien que les interventions par bandelette vaginale sans tension ou par bandelette transobturatrice s'accompagnant d'une réparation concomitante du prolapsus comptent une incidence accrue de dysfonction mictionnelle au cours de la période postopératoire immédiate, nous avons constaté que cette situation s'était résorbée au moment de la consultation de suivi à six semaines. À la suite de la tenue d'interventions concomitantes, il ne semblait pas y avoir de hausse du risque de dysfonction mictionnelle prolongée et nous n'avons également pas constaté une nécessité accrue de procéder à une deuxième opération.

Use of paralysis in silo-assisted closure of gastroschisis.

OBJECTIVE: To examine the association between pre-closure neuromuscular paralysis and time to final surgical closure for infants with gastroschisis undergoing silo reduction. STUDY DESIGN: This study was an exploratory review of observational variables obtained from the Canadian Pediatric Surgery Network database. The focus was on the subset of infants with gastroschisis undergoing silo reduction between May 2005 and March 2009. Of the 186 infants, paralysis use could be ascertained for 167 infants (79 received pre-closure paralysis and 88 received none). Groups were compared by using statistical tests, with relationships explored using regression analysis. RESULTS: Infants receiving paralysis took longer to achieve closure by an average of 3 days (8 versus 5 days; P < .001) and had greater mean number of ventilation days (12 versus 7 days; P < .001). The relationship between paralysis and days to closure remained after adjusting for other variables. CONCLUSIONS: In infants with gastroschisis undergoing silo reduction, use of paralysis was associated with longer time to closure. Pre-closure paralysis should be carefully weighed in this population.

Central nervous system (CNS) tumor trends in children in a western Canadian province: a population-based 22-year retrospective study.

In Canada, CNS tumors accounted for nearly 22% of the new childhood cancer diagnoses during 1995-2000 in the ≤ 15 year age group. The study's objective was to describe children and youth (age <20 years) diagnosed with CNS tumors in Alberta, Canada during a 22-year period using population-based data. The Alberta Cancer registry was used to extract information, including sex, age and geography, on all CNS (ICCC-3 III) tumor diagnoses during April 1, 1982, and March 31, 2004. Analyses included population summaries and rates. During 22 fiscal years, 568 Alberta children were diagnosed with CNS tumors and nearly 82% of the cases were malignant (461). The majority of cases were male (322, 57%) and the median age at diagnosis was 8 years. The crude rate per 100,000 children increased over the study period from 2.1 in 1983/1984 to 4.2 in 2003/2004. Astrocytoma was the most common diagnosis (257, 45%), followed by medulloblastoma (12%), mixed and unspecified glioma (9%) and ependymoma (9%). There were 86 diagnoses of juvenile pilocytic astrocytoma (55% male) and the crude rates per 100,000 increased during the study (<0.5 in the early years to 1.15 in 2003/2004). Our data suggests an emerging trend with the latter few years having a seemingly higher standardized incidence rate than earlier years. Further study is required to determine if the trend persists.

Leukemia and lymphoma incidence in children in Alberta, Canada: a population-based 22-year retrospective study.

There is a paucity of published literature on the epidemiology of childhood acute leukemias and lymphomas in Canada. This study was designed to describe children and youth (age <20 years) diagnosed with acute lymphoblastic leukemia (ALL), acute myeloid leukemia (AML), Hodgkin lymphoma (HL), and non-Hodgkin lymphoma (NHL) in Alberta, Canada, during 22 fiscal years. The Alberta Cancer Registry was used to extract data all ALL, AML, HL, and NHL cases diagnosed between April 1, 1982, and March 31, 2004. Population data for Alberta were also obtained. Descriptive statistics and cluster detection tests were used. During 22 years, 525, 117, 257, and 111 children (total = 1010) were diagnosed with ALL, AML, HL, and NHL, respectively. The median ages at diagnosis were 4, 11, 16, and 12 years for ALL, AML, HL, and NHL, respectively. The majority were male for ALL (287/525, 55%), AML (64/117, 55%), and NHL (81/111, 73%), and female for HL (133/257, 52%). The crude rates per 100,000 children were variable, without significant trends, over time and for each diagnosis; the median annual rates, per 100,000 children, were 3.00 (ranging from 1.87 to 3.75) for ALL, 0.62 (ranging from 0.26 to 1.27) for AML, 1.42 (ranging from 0.76 to 2.67) for HL, and 0.54 (ranging from 0.24 to 1.40) for NHL. A few potential spatiotemporal clusters were identified. They are likely due to small number of cases and plausibly clinically insignificant. Overall, childhood leukemia and lymphoma rates in Alberta have remained relatively stable, with no clear epidemiological trends and no significant spatiotemporal clustering. Further investigations are warranted to see if such stability continues and if spatiotemporal patterns arise from longer studies and studies in larger geographic regions with a larger sample size, whilst analyzing for other causal/associated factors, individual susceptibilities, and disease outcomes.

Childhood cancer trends in a western Canadian province: a population-based 22-year retrospective study.

OBJECTIVES: The objective of this study was to describe children and youth <20 years of age diagnosed with malignant cancer in Alberta, Canada over 22 years. We consider both temporal and geographical variations. PROCEDURE: The Alberta Cancer registry was used to extract information on cancer diagnoses during April 1, 1982, and March 31, 2004. Data extracted included gender, age at diagnosis, diagnosis, and geographic information. Population data were also obtained and analyses included descriptive summaries, rates, and cluster detection tests. RESULTS: During 22 fiscal years, 2,758 Alberta children and youth were diagnosed with malignant cancer. The average age of diagnosis was 9.6 years. The most common diagnoses were leukemia (24.8%), central nervous system (16.7%), lymphoma (15.8%), and other epithelial neoplasm and melanoma (11.2%). The number of malignant cases varied over year with crude rates of 13.4 per 100,000 in 1982/1983 to 17.3 per 100,000 in 2003/2004. Variation was also seen over diagnosis sub-group and geographic region. CONCLUSIONS: Although a relatively rare number of children and youth in Alberta were diagnosed with cancer during the study period, there were suggestions that an increase incidence in childhood cancer occurred in later years and some geographic areas have more cases than expected by chance. Further study is required to see if emerging trends continue and explain higher rate areas.

Metabolic risk varies according to waist circumference measurement site in overweight boys and girls.

OBJECTIVES: To compare waist circumference (WC) values measured at 4 commonly recommended sites and examine the relationships between WC sites and markers of metabolic risk in a sample of overweight boys and girls referred for weight management. STUDY DESIGN: Overweight (mean body mass index percentile, 98.7; SD, 1.0) children and adolescents (n = 73; 41 girls, 32 boys; mean age, 12.5 years; SD, 2.6 years) had WC measured at 4 sites: iliac crest (WC1), narrowest waist (WC2), midpoint between the floating rib and iliac crest (WC3), and umbilicus (WC4). Height, weight, fasting insulin level, glucose level, cholesterol level, and systolic and diastolic blood pressure were also measured. RESULTS: Overall, WC1 (108.5 cm; SD, 16.3 cm) was greater than WC2 (97.4 cm; SD, 13.6 cm; P < .003), and WC2 was smaller than WC3 (104.3 cm; SD, 15.3 cm; P = .02) and WC4 (108.7 cm; SD, 16.2 cm; P < .0003). With logistic regression, WC2 and WC3 were revealed to be more consistently associated with metabolic syndrome by using 3 different definitions. CONCLUSION: In our sample, we observed differences in 4 commonly recommended WC measurement sites and found that all sites were not equivalently associated with metabolic risk. Our findings provide preliminary support suggesting that WC measured at the narrowest waist and midpoint between the floating rib and iliac crest may represent the measurement sites most closely associated with metabolic risk in overweight boys and girls.

The association between iron deficiency and febrile seizures in childhood.

PURPOSE: The purpose of this study was to determine the association between iron deficiency and febrile seizures in a large cohort of children aged 6 to 36 months. METHODS: A retrospective case control study with 361 patients who presented with febrile seizures to the emergency department and 390 otherwise healthy controls who presented with a febrile illness to the emergency department were reviewed to determine iron status using the MCV, RDW, and hemoglobin. RESULTS: A total of 9% of cases had iron deficiency (ID) and 6% had iron deficiency anemia (IDA), compared to 5% and 4% of controls respectively. The conditional logistic regression odds ratio for ID in patients with febrile seizures was 1.84 (95% CI, 1.02-3.31). CONCLUSION: Children with febrile seizures were almost twice as likely to be iron deficient as those with febrile illness alone. The results suggest that screening for ID should be considered in children presenting with febrile seizure.

Plasma matrix metalloproteinases in neonates having surgery for congenital heart disease.

During cardiopulmonary-bypass matrix-metalloproteinases released may contribute to ventricular dysfunction. This study was to determine plasma matrix-metalloproteinases in neonates after cardiopulmonary-bypass and their relation to post-operative course. A prospective observational study included 18 neonates having cardiac surgery. Plasma matrix-metalloproteinases-2 and 9 activities were measured by gelatin-zymography pre-operatively, on starting cardiopulmonarybypass, 7-8 min after aortic cross-clamp release, and 1h, 4h, 24h, and 3d after cardiopulmonary-bypass. Plasma concentrations of their tissue inhibitors 1 and 2 were determined by enzyme-linked immunosorbent assay. Cardiac function was assessed by serial echocardiography. Paired t-tests and Wilcoxon tests were used to assess temporal changes, and linear correlation with simultaneous clinical and cardiac function parameters were assessed using Pearson's product-moment correlation coefficient. Plasma matrix-metalloproteinases activities and their tissue inhibitor concentrations decreased during cardiopulmonary-bypass. Matrix-metalloproteinase-2 plasma activity increased progressively starting 1h after cardiopulmonarybypass and returned to pre-operative levels at 24h. Matrix-metalloproteinase-9 plasma activity increased significantly after release of aortic cross-clamp, peaked 7-8min later, and returned to baseline at 24h. Plasma tissueinhibitor 1 and 2 concentrations increased 1h after cardiopulmonary-bypass. Cardiac function improved from 4h to 3d after surgery (p<0.05). There was no evidence of significant correlations between matrix-metalloproteinases or their inhibitors and cardiac function, inotrope scores, organ dysfunction scores, ventilation days, or hospital days. The temporal profile of plasma matrix-metalloproteinases and their inhibitors after cardiopulmonary-bypass in neonates are similar to adults. In neonates, further study should determine whether circulating matrix-metalloproteinases are useful biomarkers of disease activity locally within the myocardium, and hence of clinical outcomes.

Characteristics of patients who leave emergency departments without being seen.

OBJECTIVES: Patients leaving the emergency department (ED) without being seen (LWBS) by a physician have become a growing concern in overcrowded EDs. The purpose of this study was to determine the acuity level, reasons, and outcomes of LWBS cases. METHODS: LWBS patients (or their guardians) from two linked Canadian EDs (one adult, one pediatric), identified during 11 sampling periods of seven days' duration each, were contacted by telephone. Descriptive statistics are provided. RESULTS: A total of 711 (4.5%) of 15,660 registered emergency patients left without being seen (50% male; median age, 33 years). Triage-matched controls waited a median of 87 minutes before seeing a physician. Of the 711 LWBS cases, 512 (72%) were contacted and 498 agreed to participate. The most common major reason for leaving was "fed up with waiting" (44.8%). Overall, 60% of LWBS cases sought medical attention within one week; 14 patients were hospitalized, and one required urgent surgery. Triage level was not associated with the probability of subsequently seeking medical attention (61%, 61%, and 60% in triage levels 3, 4, and 5, respectively). Of the 198 (39%) who did not subsequently seek medical attention, 50 patients (26%) had been triaged as urgent and one patient died six days after ED registration. CONCLUSIONS: The most common reason for LWBS is impatience during peak ED periods. Many of these patients seek medical care within one week. Complications occurred rarely; however, "high-risk" patients who leave without being seen do experience adverse health outcomes. Further research is required to examine ways to reduce LWBS cases.