Change in Pain and Quality of Life Among Women Enrolled in a Trial Examining the Use of Narrow Band Imaging During Laparoscopic Surgery for Suspected Endometriosis.

STUDY OBJECTIVE: To examine whether the addition of narrow band imaging (NBI) to traditional white light imaging during laparoscopic surgery impacts pain and quality of life (QOL) at 3 and 6 months after surgery among women with suspected endometriosis and/or infertility. DESIGN: A randomized controlled trial (Canadian Task Force classification level I). SETTING: The trial was conducted in 2 medical centers. PATIENTS: From October 2011 to November 2013, 167 patients undergoing laparoscopic examination for suspected endometriosis and/or infertility were recruited. The analytic study sample includes 148 patients with pain and QOL outcome data. INTERVENTIONS: Patients were randomized in a 3:1 ratio to receive white light imaging followed by NBI (WL/NBI) or white light imaging only (WL/WL). MEASUREMENTS AND MAIN RESULTS: Questionnaires were administered at baseline and at 3- and 6-month follow-up time points. Average and most severe pain at each time point were assessed using a 10-cm visual analog scale. QOL was measured using the Endometriosis Health Profile-30. Baseline characteristics were similar for the study groups. The WL/NBI and WL/WL groups had similar reductions in pain at 3 and 6 months. In addition, QOL improved similarly for both the WL/NBI and WL/WL groups at 3 and 6 months. CONCLUSION: Laparoscopic surgery for suspected endometriosis is associated with a reduction in pain and an improvement in QOL. The differences in pain reduction and QOL improvement, which are noted at 3 months and remain stable at 6 months after surgery, are similar for those undergoing surgery with WL/NBI compared with those undergoing surgery under traditional white light conditions.

Sensitivity of Narrow Band Imaging Compared With White Light Imaging for the Detection of Endometriosis.

STUDY OBJECTIVE: To evaluate the ability of narrow band imaging (NBI) in conjunction with standard white light imaging to improve the detection and diagnosis of endometriosis during laparoscopic evaluation compared with white light imaging alone. Sensitivity of NBI in detecting endometriosis was assessed and compared with white light imaging. DESIGN: Randomized controlled trial. CLASSIFICATION OF STUDY DESIGN: LEVEL I: Evidence obtained from a properly designed, randomized, controlled trial. SETTING: The trial was conducted in 2 medical centers. PATIENTS: One hundred sixty-seven women undergoing laparoscopic evaluation for suspected endometriosis and/or infertility were recruited. Of these, 150 were assessable to determine sensitivity of NBI compared with white light imaging for the detection of endometriotic lesions. INTERVENTIONS: Patients were randomized in a 3:1 ratio to receive white light imaging followed by NBI or white light imaging only. The pelvis was systematically visualized with each assigned imaging modality; lesions were recorded under each visualization and then resected. All patients had white light imaging on the first visualization followed by either a second white light examination (control arm) or NBI examination (intervention arm). MEASUREMENTS: Pathology of resected lesions was the criterion standard for evaluating sensitivity and was conducted at each institution. The method of detection of the lesion (white light or NBI) was masked. Central pathology review was conducted for a randomly selected 10% sample of specimens and for those lesions visualized under only 1 imaging modality among patients assigned to the intervention arm. The sensitivity was assessed for each modality (white light and NBI) and compared using a McNemar's test. MAIN RESULTS: Among the group randomized to receive both white light and NBI, 4 patients had lesions detected with NBI but no lesions detected with white light. Among the 255 lesions confirmed as endometriosis by pathologic review, all were detected by NBI for a sensitivity of 100%; 79% were detected by white light imaging (p < .001). CONCLUSION: The addition of NBI to white light imaging increased the number of endometriotic lesions identified during laparoscopy and the diagnosis of endometriosis compared with the use of white light imaging alone.

Statistical process control: separating signal from noise in emergency department operations.

BACKGROUND: Statistical process control (SPC) is a visually appealing and statistically rigorous methodology very suitable to the analysis of emergency department (ED) operations. OBJECTIVE: We demonstrate that the control chart is the primary tool of SPC; it is constructed by plotting data measuring the key quality indicators of operational processes in rationally ordered subgroups such as units of time. Control limits are calculated using formulas reflecting the variation in the data points from one another and from the mean. SPC allows managers to determine whether operational processes are controlled and predictable. We review why the moving range chart is most appropriate for use in the complex ED milieu, how to apply SPC to ED operations, and how to determine when performance improvement is needed. DISCUSSION: SPC is an excellent tool for operational analysis and quality improvement for these reasons: 1) control charts make large data sets intuitively coherent by integrating statistical and visual descriptions; 2) SPC provides analysis of process stability and capability rather than simple comparison with a benchmark; 3) SPC allows distinction between special cause variation (signal), indicating an unstable process requiring action, and common cause variation (noise), reflecting a stable process; and 4) SPC keeps the focus of quality improvement on process rather than individual performance. CONCLUSION: Because data have no meaning apart from their context, and every process generates information that can be used to improve it, we contend that SPC should be seriously considered for driving quality improvement in emergency medicine.

Propofol for procedural sedation and analgesia reduced dedicated emergency nursing time while maintaining safety in a community emergency department.

INTRODUCTION: Procedural sedation and analgesia is a core competency in emergency medicine. Propofol is replacing midazolam in many emergency departments. Barriers to performing procedural sedation include resource utilization. We hypothesized that emergency nursing time is shorter with propofol than midazolam, without increasing complications. METHODS: Retrospective analysis of a procedural sedation registry for two community emergency departments with combined census of 100,000 patients/year. Demographics, procedure, and ASA physical classification status of adult patients receiving procedural sedation between 2007-2010 with midazolam or propofol were analyzed. Primary outcome was dedicated emergency nursing time. Secondary outcomes were procedural success, ED length of stay, and complication rate. Comparative statistics were performed with Mann-Whitney, Kruskal-Wallis, chi-square, or Fisher's exact test. Linear regression was performed with log-transformed procedural sedation time to define predictors. RESULTS: Of 328 procedural sedation and analgesia, 316 met inclusion criteria, of which 60 received midazolam and 256 propofol. Sex distribution varied between groups (midazolam 3% male; propofol 55% male; P = 0.04). Age, procedure, and ASA status were not significantly different. Propofol had shorter procedural sedation time (propofol 32.5 ± 24.2 minutes; midazolam 78.7 ± 51.5 minutes; P < 0.001) and higher rates of procedural success (propofol 98%; midazolam 92%; P = 0.02). There were no significant differences between complication rates (propofol 14%; midazolam 13%; P = 0.88) or emergency department length of stay (propofol 262.5 ± 132.8 minutes; midazolam 288.6 ± 130.6 minutes; P = 0.09). DISCUSSION: Use of propofol resulted in shorter emergency nursing time and higher procedural success rate than midazolam with a comparable safety profile.

Development of a university-based emergency department network: lessons learned.

BACKGROUND: As part of the growth of emergency medical care in our state, our university-based emergency medicine practice developed a network of affiliated emergency department (ED) practices. The original practices were academic and based on a faculty practice model; more recent network development incorporated a community practice model less focused on academics. OBJECTIVE: This article discusses the growth of that network, with a focus on the recent addition of a county-wide two-hospital emergency medicine practice. During the transition of the two EDs from a contract management group to the university network, six critical areas in need of restructuring were identified: 1) departmental leadership, 2) recruitment and retention of clinical staff members, 3) staffing strategies, 4) relationships with key constituents, 5) clinical operations, supplies, and equipment, and 6) compensation structure. The impact of changes was measured by comparison of core measures, efficiency metrics, patient volumes, admissions, and transfers to the academic medical center before and after the implementation of our practice model. CONCLUSION: Our review and modification of these components significantly improved the quality and efficiency of care at the community hospital system. The consistent presence of board certified emergency physicians optimized utilization of clinical resources in the community hospital and the academic health system. This dynamic led to a mutually beneficial merger of these major state healthcare systems.

Clinical evaluation of Sofia Rapid Antigen Assay for detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) among emergency department to hospital admissions.

OBJECTIVE: To determine the utility of the Sofia SARS rapid antigen fluorescent immunoassay (FIA) to guide hospital-bed placement of patients being admitted through the emergency department (ED). DESIGN: Cross-sectional analysis of a clinical quality improvement study. SETTING: This study was conducted in 2 community hospitals in Maryland from September 21, 2020, to December 3, 2020. In total, 2,887 patients simultaneously received the Sofia SARS rapid antigen FIA and SARS-CoV-2 RT-PCR assays on admission through the ED. METHODS: Rapid antigen results and symptom assessment guided initial patient placement while confirmatory RT-PCR was pending. The sensitivity, specificity, positive predictive values, and negative predictive values of the rapid antigen assay were calculated relative to RT-PCR, overall and separately for symptomatic and asymptomatic patients. Assay sensitivity was compared to RT-PCR cycle threshold (Ct) values. Assay turnaround times were compared. Clinical characteristics of RT-PCR-positive patients and potential exposures from false-negative antigen assays were evaluated. RESULTS: For all patients, overall agreement was 97.9%; sensitivity was 76.6% (95% confidence interval [CI], 71%-82%), and specificity was 99.7% (95% CI, 99%-100%). We detected no differences in performance between asymptomatic and symptomatic individuals. As RT-PCR Ct increased, the sensitivity of the antigen assay decreased. The mean turnaround time for the antigen assay was 1.2 hours (95% CI, 1.0-1.3) and for RT-PCR it was 20.1 hours (95% CI, 18.9-40.3) (P < .001). No transmission from antigen-negative/RT-PCR-positive patients was identified. CONCLUSIONS: Although not a replacement for RT-PCR for detection of all SARS-CoV-2 infections, the Sofia SARS antigen FIA has clinical utility for potential initial timely patient placement.

Hemolytic anemia induced by ingestion of paradichlorobenzene mothballs.

Hemolytic anemia and methemoglobinemia are well-known adverse effects that follow ingestion of naphthalene mothballs. They are only rarely reported in association with ingestion of paradichlorobenzene mothballs. An asymptomatic boy presented to our pediatric emergency department after ingesting paradichlorobenzene mothballs. Three daysafter the ingestion, the boy returned with hemolysis and mild methemoglobinemia.

Serial analysis of gene expression reveals differential expression between endometriosis and normal endometrium. Possible roles for AXL and SHC1 in the pathogenesis of endometriosis.

BACKGROUND: Endometriosis is a clinical condition that affects up to 10% of the women of reproductive age. Endometriosis is characterized by the presence of endometrial tissues outside the uterine cavity and can lead to chronic pelvic pain, infertility and, in some cases, to ovarian cancer. METHODS: In order to better understand the pathogenesis of endometriosis, we have used Serial Analysis of Gene Expression (SAGE) to identify genes differentially in this disease by studying three endometriotic tissues and a normal endometrium sample. Promising candidates (AXL, SHC1, ACTN4, PI3KCA, p-AKT, p-mTOR, and p-ERK) were independently validated by immunohistochemistry in additional normal and endometriotic tissues. RESULTS: We identified several genes differentially expressed between endometriosis and normal endometrium. IGF2, ACTN4, AXL, and SHC1 were among the most upregulated genes. Comparison of the endometriosis gene expression profiles with the gene expression patterns observed in normal human tissues allowed the identification of endometriosis-specific genes, which included several members of the MMP family (MMP1,2,3,10,11,14). Immunohistochemical analysis of several candidates confirmed the SAGE findings, and suggested the involvement of the PI3K-Akt and MAPK signaling pathways in endometriosis. CONCLUSION: In human endometriosis, the PI3K-Akt and MAPK signaling pathways may be activated via overexpression of AXL and SHC1, respectively. These genes, as well as others identified as differentially expressed in this study, may be useful for the development of novel strategies for the detection and/or therapy of endometriosis.

Polypharmacy and the geriatric patient.

The older adult population is increasing and with it, the risk of polypharmacy. Multiple physicians treating one patient, increasing comorbidities, and an increase in the variety of drugs available contribute to the adverse effects of polypharmacy on the elderly patient. Application of Beers criteria, appropriate therapeutic drug monitoring, and careful, periodic review of the patient's medication list will assist with preventing the sometimes lethal complications of polypharmacy.

Impact of Health Policy Changes on Emergency Medicine in Maryland Stratified by Socioeconomic Status.

INTRODUCTION: On January 1, 2014, the financing and delivery of healthcare in the state of Maryland (MD) profoundly changed. The insurance provisions of the Patient Protection and Affordable Care Act (ACA) began implementation and a major revision of MD's Medicare waiver ushered in a Global Budget Revenue (GBR) structure for hospital reimbursement. Our objective was to analyze the impact of these policy changes on emergency department (ED) utilization, hospitalization practices, insurance profiles, and professional revenue. We stratified our analysis by the socioeconomic status (SES) of the ED patient population. METHODS: We collected monthly mean data including patient volume, hospitalization percentages, payer mix, and professional revenue from January 2013 through December 2015 from a convenience sample of 11 EDs in Maryland. Using regression models, we compared each of the variables 18 months after the policy changes and a six-month washout period to the year prior to ACA/GBR implementation. We included the median income of each ED's patient population as an explanatory variable and stratified our results by SES. RESULTS: Our 11 EDs saw an annualized volume of 399,310 patient visits during the study period. This ranged from a mean of 41 daily visits in the lowest volume rural ED to 171 in the highest volume suburban ED. After ACA/GBR, ED volumes were unchanged (95% confidence interval [CI] [-1.58-1.24], p=.817). Hospitalization percentages decreased significantly by 1.9% from 17.2% to 15.3% (95% CI [-2.47%-1.38%], p<.001). The percentage of uninsured patients decreased from 20.4% to 11.9%. This 8.5% change was significant (95% CI [-9.20%-7.80%], p<.001). The professional revenue per relative value unit increased significantly by $3.97 (95% CI [3.20-4.74], p<.001). When stratified by the median patient income of each ED, changes in each outcome were significantly more pronounced in EDs of lower SES. CONCLUSION: Health policy changes at the federal and state levels have resulted in significant changes to emergency medicine practice and finances in MD. Admission and observation percentages have been reduced, fewer patients are uninsured, and professional revenue has increased. All changes are significantly more pronounced in EDs with patients of lower SES.

Tetramethylenedisulfotetramine: old agent and new terror.

Tetramethylenedisulfotetramine has accounted for numerous intentional and unintentional poisonings in China. In May 2002, the first known case of human illness in the United States caused by tetramethylenedisulfotetramine, a banned neurotoxic rodenticide from China, occurred in New York City. The clinical presentation after tetramethylenedisulfotetramine exposure is dose dependent, and the most recognized complication is status epilepticus. Poisonings may be fatal within hours. No known antidote exists, and treatment is mainly supportive. Anecdotal reports, case reports, and 2 animal studies suggest possible success with certain pharmacologic interventions, including pyridoxine and chelation therapy. Pesticide and rodenticide poisonings, whether intentional or unintentional, pose a serious threat to populations, and the availability of a banned rodenticide such as tetramethylenedisulfotetramine, with its associated morbidity and lethality, is a serious public health concern. Given the recent case report that confirms the presence of tetramethylenedisulfotetramine in the United States, the toxicity of the compound, its unique physical properties, the absence of an antidote, and the history of its use as an agent of intentional mass poisoning, public health entities have undertaken educational efforts to inform the public, health care providers, and emergency personnel of this potentially lethal rodenticide.

Amiodarone fails to improve survival in amitriptyline-poisoned mice.

OBJECTIVE: Amiodarone, a class III antidysrhythmic agent, blocks Na+, Ca2+, and K+ channels as well as the beta-adrenergic receptor. Despite increased use of amiodarone for wide-complex tachycardia, its efficacy in the treatment of dysrhythmias induced by tricyclic antidepressants has not been tested. We investigated the effect of amiodarone and amitriptyline in a mouse lethality model. METHODS: The LD50 of amitriptyline obtained from reference sources was confirmed by giving 100 mg/kg to 40 mice by intraperitoneal (IP) injection. The safety of the treatment dose of amiodarone was confirmed by giving 50 mg/kg by IP injection to 10 mice. One hundred and nine mice were randomized to receive pretreatment with 50 mg/kg amiodarone (n=55) or an equal volume of saline or water as a volume control (n=54). Thirty minutes after pretreatment or control injection, the mice received amitriptyline, 100 mg/kg. Outcome was defined as death or survival 3 h after amitriptyline injection. RESULTS: In our confirmation of the LD50 of amitriptyline, 25/40 mice died (62.5%). None of the 10 mice that received only amiodarone died. In the control + amitriptyline arm, 36/54 (66.7%) died, compared with 39/55 (70.9%) in the amiodarone+amitriptyline arm (X2, p=0.663). Power analysis demonstrated a 90% chance of finding a 28% difference. CONCLUSIONS: Pretreatment with amiodarone does not appear to significantly alter the lethality of amitriptyline poisoning in mice. Given the inability to monitor cardiac activity in this model, further investigation in a larger animal is required.

The impact of electronic health record implementation on emergency physician efficiency and patient throughput.

BACKGROUND: In emergency departments (EDs), the implementation of electronic health records (EHRs) has the potential to impact the rapid assessment and management of life threatening conditions. In order to quantify this impact, we studied the implementation of EHRs in the EDs of a two hospital system. METHODS: using a prospective pre-post study design, patient processing metrics were collected for each ED physician at two hospitals for 7 months prior and 10 months post-EHR implementation. Metrics included median patient workup time, median length of stay, and the composite outcome indicator "processing time." RESULTS: median processing time increased immediately post-implementation and then returned to, and surpassed, the baseline level over 10 months. Overall, we see significant decreases in processing time as the number of patients treated increases. CONCLUSIONS: implementation of new EHRs into the ED setting can be expected to cause an initial decrease in efficiency. With adaptation, efficiency should return to baseline levels and may eventually surpass them. IMPLICATIONS: while EDs can expect long term gains from the implementation of EHRs, they should be prepared for initial decreases in efficiency and take preparatory measures to avert adverse effects on the quality of patient care.

Updates in the general approach to the pediatric poisoned patient.

Poison prevention remains essential to prevent the most vulnerable population from becoming exposed to potentially lethal toxins. The evaluation of a child presumed to have been exposed to a toxic substance should include a precise history of the exposure, a physical examination, and knowledge of current ingestions and recreational practices. New treatments and research guiding therapy continue to evolve. Poison centers and medical toxicologists can be consulted to assist with the diagnosis of medicinal/drug overdoses, for advice about the pitfalls inherent in stabilizing children who have been exposed to toxic compounds, and for treatment recommendations based on the latest research.

Drug-induced hyperthermic syndromes: part I. Hyperthermia in overdose.

Drugs and natural compounds that affect the thermoregulatory system can induce or contribute to hyperthermia when used in excess. Hyperthermia associated with drug overdose is dangerous and potentially lethal. This article reviews the body's process of maintaining thermodynamic equilibrium, and describes the mechanisms by which it is influenced by sympathomimetic and anticholinergic drugs, salicylates, and thyroid replacement medications. Appropriate treatment strategies such as cooling and the administration of counteractive medications are discussed.

Intraperitoneal elemental mercury exposure from a mercury-weighted bougie.

INTRODUCTION: Significant exposure to elemental mercury can occur if a mercury-weighted medical device is damaged during use. We report a case of an elemental mercury spill into the peritoneum of a patient undergoing laparoscopic gastric bypass surgery. CASE REPORT: A 64-year-old man with multiple comorbidities underwent an elective Roux-en-Y gastric bypass procedure for the treatment of morbid obesity. A mercury-weighted esophageal bougie was inadvertently used during construction of the anastomosis. A suture placed through the distal tip of the device caused elemental mercury to leak into the peritoneum. Two days later, the patient underwent another surgical procedure for removal of the mercury. Intermittent air measurements taken from the laparoscope exhaust showed a peak intraperitoneal mercury concentration of 98,169 ng/m³. Blood mercury levels peaked at 146 µg/L on day 22 after the exposure, and urine mercury concentrations peaked on day 43 at 227 µg/L. The patient had no evidence of acute toxicity, but he was found to have proteinuria on follow-up evaluation. DISCUSSION: Patients can be exposed inadvertently to toxic amounts of elemental mercury when the integrity of medical devices is compromised. We encourage hospitals to discontinue the use of devices that contain mercury. Effective alternatives that do not pose exposure risks to patients or health care workers are readily available.

Refractory priapism associated with ingestion of yohimbe extract.

Extracts of the bark of the central African tree Pausinystalia yohimbe contain yohimbine, an indole alkaloid, which is used to treat erectile dysfunction. The reported side effects of over-the-counter preparations of yohimbine include gastrointestinal upset, anxiety, increased blood pressure, headache, agitation, rash, tachycardia, and frequent urination. In this report, we describe a severe case of intractable priapism associated with the ingestion of yohimbe extract. Management required insertion of a proximal cavernosal spongiosum shunt (Quackles shunt) in the operating room.