Pain trajectories in the emergency department: Patient characteristics and clinical outcomes.

BACKGROUND: Little is known about pain trajectories in the emergency department (ED), which could inform the heterogeneous response to pain treatment. We aimed to identify clinically relevant subphenotypes of pain resolution in the ED and their relationships with clinical outcomes. METHODS: This retrospective cohort study used electronic clinical warehouse data from a tertiary medical center. We retrieved data from 733,398 ED visits over a 7-year period. We selected one ED visit per person and retrieved data including patient demographics, triage data, repeated pain scores evaluated on a numeric rating scale, pain characteristics, laboratory markers, and patient disposition. The primary outcome measures were hospitalization and ED revisit. RESULTS: 28,105 adult ED patients were included with a total of 154,405 pain measurements. Three distinct pain trajectory groups were identified: no pain (57.1%); moderate-to-severe pain, fast resolvers (17.9%); and moderate pain, slow resolvers (24.9%). The fast resolvers responded well to treatment and were independently associated with a lower risk of hospitalization (adjusted odds ratio [aOR], 0.75; 95% confidence interval [CI], 0.70-0.81). By contrast, the slow resolvers had lingering pain in the ED and were independently associated with a higher risk of ED revisit (aOR, 2.65; 95%CI, 1.85-3.69). This group also had higher levels of inflammatory markers, including a higher leukocyte count and a higher level of C-reactive protein. CONCLUSIONS: We identified three novel pain subphenotypes with distinct patterns in clinical characteristics and patient outcomes. A better understanding of the pain trajectories may help with the personalized approach to pain management in the ED.

Gender differences in clinical characteristics of emergency department patients involving illicit drugs use with analytical confirmation.

BACKGROUND: To compare gender differences in socio-demographics, clinical manifestations, and laboratory test results of individuals who visited emergency departments (EDs) involving drug use. METHODS: We retrospectively collected the data from 10 hospitals in Taiwan on drug-related ED visits from May 2017 to December 2020. We then examined the gender differences in their socio-demographics, clinical manifestations, urine toxicological results, and other laboratory tests results using chi-square or multivariable logistic regression. RESULTS: Among individuals with drug-related ED visits, there were 546 (73.7%) men and 195 (26.3%) women. The most commonly used drugs were meth/amphetamine, followed by synthetic cathinones, and ketamine and its analogs. Compared to men, women were younger (32.03 ± 10.86 vs. 36.51 ± 10.84 years, p < 0.001) and more likely to use new psychoactive substances (NPS) (p = 0.011). Men were more likely to have human immunodeficiency virus infection (p < 0.001), whereas women were more likely to report psychiatric comorbidities (p = 0.003). Women were less likely to have aggressive behaviors (odds ratio (OR): 0.59, 95% CI: 0.39-0.88). After adjusting for socio-demographics and drug types, women were still less likely to have aggressive behaviors than men (adjusted OR: 0.59, 95% CI: 0.38-0.93). The likelihood of rhabdomyolysis and intensive care unit admission was higher in men (p < 0.001). CONCLUSION: We found considerable gender differences in clinical characteristics among ED-visiting drug users, which could offer valuable information for the future development of more tailored gender-specific drug prevention and treatment strategies.

Characteristics of patients with analytically confirmed γ-hydroxybutyric acid/γ-butyrolactone (GHB/GBL)-related emergency department visits in Taiwan.

The recreational drug γ-hydroxybutyric acid (GHB) is a central nervous system depressant, and can produce euphoria at low doses. GHB is a controlled substance in Taiwan. However, the organic solvents γ-butyrolactone (GBL) and 1,4-butanediol (BD), which are unregulated, may be used as an alternative source of GHB. There is no clinical report of analytically confirmed GHB use in Taiwan. We retrospective reviewed the clinical characteristics from the medical charts between May 2017 and April 2020. The urine samples of patients presented to the emergency departments with drug-related complaints were sent for toxicological analysis. Patients with urine samples detected GHB >10 µg/mL by liquid chromatography/tandem mass spectrometry were included. Overall, 11 men and one woman with an average age of 35.3 ± 8.7 years were included. Most patients co-ingested amphetamine (n = 6) and initially presented with depressed consciousness levels (n = 7). One patient presented with out-of-hospital cardiac arrest and one with respiratory depression. All patients regained consciousness within 6 h of admission. All patients used GBL to evade conviction. Although patients recovered with supportive care, respiratory failure and cardiac arrest occurred after GHB/GBL use. It is important to legislate GBL and BD as controlled chemical substances in Taiwan.

Determination of synthetic cathinone α-pyrrolidinovalero-phenone and its metabolite in urine using solid-phase extraction and gas chromatography-mass spectrometry.

RATIONALE: The presence of α-pyrrolidinovalerophenone (α-PVP) and its metabolites in urine is evidence of the administration of α-PVP. A toxicological challenge is that the metabolites of α-PVP exhibit amphoteric properties, which make them unsuitable for detection using gas chromatography-mass spectrometry (GC/MS). In the study reported, proper derivatization and sample extraction were essential for improving the sensitivity for GC/MS analysis. METHODS: An automated solid-phase extraction (SPE) method has been developed and optimized. The derivatization efficiency was tested using longer reaction time and the addition of polar pyridine into a mixture of N,O-bis(trimethylsilyl)trifluoroacetamide (BSTFA) with 1% trimethylchlorosilane. Method validation, including linearity, limit of detection, precision, accuracy, and recovery, was evaluated using automatic SPE and GC/MS. RESULTS: The results suggested that adding pyridine to BSTFA (1:1, v/v) significantly improved derivatization efficiency and precision. After optimization, the linear range was from 25 to 1000 ng mL-1 with R2 > 0.9950. The limit of detection was 5 ng mL-1 for α-PVP and 25 ng mL-1 for OH-α-PVP. The recovery for SPE was over 88%. The inter-day and intra-day precisions were less than 15%. A forensic sample has been found containing α-PVP (67.3 ng mL-1 ) and OH-α-PVP (560.2 ng mL-1 ). CONCLUSIONS: This study is the first to validate an auto-SPE-GC/MS method for the quantification and qualification of α-PVP and OH-α-PVP in urine. We have successfully improved the derivatization efficiency and developed a sensitive and semi-automatic approach. This approach is desirable for the detection of synthetic cathinone at trace levels in biological samples.

Characteristics of analytically confirmed illicit substance-using patients in the Emergency Department.

BACKGROUND/PURPOSE: Although illicit substance use-induced toxicity or complication is a frequent cause of visit to the emergency department (ED), there are limited data on cases confirmed by liquid chromatography tandem-mass spectrometry (LC-MS/MS) analysis. This study aimed to describe clinical presentations of patients who visited the ED because of acute illicit substance-related complications. METHODS: We performed a retrospective study between May 2017 and August 2018 on patients presenting to the ED with positive urine illicit substance analysis by LC-MS/MS. RESULTS: Of 203 patients with at least one illicit substance detected in their urine, 162 (79.8%) showed traditional illicit substances, and 56 (32.0%) showed new psychoactive substances (NPS). Methamphetamine was the most common illicit substance (67.9%). The most common NPS was ketamine (21.7%), followed by synthetic cathinones (14.8%). We divided patients into traditional, NPS and combined (both traditional illicit substance and NPS) groups. Polysubstance use was more common in the NPS group than in the traditional group (P < 0.001). Most patients were men (78.3%), and the average age was lower in the NPS group compared to the traditional group (P < 0.001). Although the chemical structures of cathinones are similar to that of amphetamine, 92.0% of the cathinone use cases without combination with methamphetamine use showed negative immunoassay results. CONCLUSION: Our study provided the acute illicit substance complications at ED by LC-MS/MS analysis in Taiwan. Our study showed that more than one-third cases studied were NPS users. Young adults and polysubstance users were more common among NPS users.

A novel depth estimation algorithm of chest compression for feedback of high-quality cardiopulmonary resuscitation based on a smartwatch.

INTRODUCTION: High-quality cardiopulmonary resuscitation (CPR) is a key factor affecting cardiac arrest survival. Accurate monitoring and real-time feedback are emphasized to improve CPR quality. The purpose of this study was to develop and validate a novel depth estimation algorithm based on a smartwatch equipped with a built-in accelerometer for feedback instructions during CPR. METHODS: For data collection and model building, researchers wore an Android Wear smartwatch and performed chest compression-only CPR on a Resusci Anne QCPR training manikin. We developed an algorithm based on the assumptions that (1) maximal acceleration measured by the smartwatch accelerometer and the chest compression depth (CCD) are positively correlated and (2) the magnitude of acceleration at a specific time point and interval is correlated with its neighboring points. We defined a statistic value M as a function of time and the magnitude of maximal acceleration. We labeled and processed collected data and determined the relationship between M value, compression rate and CCD. We built a model accordingly, and developed a smartwatch app capable of detecting CCD. For validation, researchers wore a smartwatch with the preinstalled app and performed chest compression-only CPR on the manikin at target sessions. We compared the CCD results given by the smartwatch and the reference using the Wilcoxon Signed Rank Test (WSRT), and used Bland-Altman (BA) analysis to assess the agreement between the two methods. RESULTS: We analyzed a total of 3978 compressions that covered the target rate of 80-140/min and CCD of 4-7 cm. WSRT showed that there was no significant difference between the two methods (P = 0.084). By BA analysis the mean of differences was 0.003 and the bias between the two methods was not significant (95% CI: -0.079 to 0.085). CONCLUSION: Our study indicates that the algorithm developed for estimating CCD based on a smartwatch with a built-in accelerometer is promising. Further studies will be conducted to evaluate its application for CPR training and clinical practice.

Risk of stroke associated with use of nonsteroidal anti-inflammatory drugs during acute respiratory infection episode.

BACKGROUND: Previous studies suggested that acute respiratory infection (ARI) could trigger stroke and that use of nonsteroidal anti-inflammatory drugs (NSAIDs) was associated with increased risk of stroke. In many countries, NSAIDs have been widely used among patients with ARI or common cold for pain and fever relief. However, studies evaluating whether NSAIDs use during ARI episodes may further increase the risk of stroke were very limited. METHODS AND RESULTS: During 2007 to 2011, 29 518 patients with an incident hospitalization of stroke were identified. The date of admission was defined as the index date. Using case-crossover design, we compared the following exposure status between the case period (1- to 7-d period before the index date) and matched control period (366- to 372-d period before the index date): NSAIDs use during ARI episodes, ARI episodes without NSAIDs use, NSAIDs use only, or no exposure. Multivariable conditional regression models were used to estimate odds ratios adjusting potential confounders. The results suggested that NSAIDs use during ARI episodes was associated with a 2.3-fold increased risk of stroke (ischemic: adjusted odds ratio, aOR 2.27, 95% confidence interval, 95% CI, 2.00-2.58; hemorrhagic: aOR 2.28, 95% CI, 1.71-3.02). We also determined that parenteral NSAIDs were associated with much higher risk of stroke in patients with ARI. CONCLUSIONS: Nonsteroidal anti-inflammatory drugs use during ARI episodes, especially parenteral NSAIDs use, was associated with a further increased risk of stroke.

Diabetes mellitus, superoxide dismutase and peroxisome proliferator activated receptor gamma polymorphisms modify the outcome of end-stage renal disease patients of Han Chinese origin.

AIM: Increased oxidative stress significantly modifies the outcome of patients with diabetes mellitus (DM) and end-stage renal disease (ESRD), and is counteracted by antioxidative capacity. We aimed to investigate whether antioxidant single nucleotide polymorphisms (SNPs) influence the outcome of ESRD individuals and the influences exerted by DM, which has not been tested before. METHODS: We prospectively enrolled multi-centre ESRD patients of Han Chinese origin between 2002 and 2003, recording their antioxidant (superoxide dismutase [SOD2], glutathione peroxidase [GPX1]) and peroxisome proliferator activated receptor-γ (PPAR-γ) genotyping results, and stratified based on DM. They were followed up until 2008, with risk factors for mortality analyzed by Cox proportional hazard regression. RESULTS: We discovered that diabetic ESRD carriers of CC genotype of SOD2 exon 2 had an increased risk of mortality compared to non-diabetic ones with other genotypes (hazard ratio [HR] 4.04, P = 0.04), while GPX1 SNPs had no influence. Interactions between SOD2 and PPAR-γ SNPs regarding the mortality influence were also detected (for SOD2 CC genotype x PPAR-γ exon 6 CT genotype, HR 3.19, P = 0.008), suggesting the importance of considering a combination panel of SNPs on patient survival. CONCLUSION: This might be the largest study focusing on the relationship between antioxidant SNPs and the outcomes of diabetic ESRD patients of Han Chinese origin. More studies are needed to validate our findings.

Acute Respiratory Infection and Use of Nonsteroidal Anti-Inflammatory Drugs on Risk of Acute Myocardial Infarction: A Nationwide Case-Crossover Study.

Background: Previous studies have suggested that acute respiratory infection (ARI) and nonsteroidal anti-inflammatory drugs (NSAIDs) use could trigger acute myocardial infarction (AMI). In some countries, physicians prescribe NSAIDs for patients with ARI for symptom relief. However, there is no research evaluating whether NSAIDs use during ARI episodes may increase the risk of AMI. Methods: We identified 9793 patients with an incident hospitalization of AMI (index date) between 2007 and 2011. Using case-crossover design, we compared the following exposure status between the case (1-7-day before index date) and matched control period (366-372-day before index date): NSAIDs use during ARI episodes, ARI episodes without NSAIDs use, NSAIDs use only, or no exposure. Multivariable conditional logistic regression models were used to estimate odds ratios adjusted for potential confounders. Results: Nonsteroidal anti-inflammatory drugs use during ARI was associated with a 3.4-fold increased risk of AMI (adjusted odds ratio [aOR] = 3.41; 95% confidence interval [CI] = 2.80-4.16), ARI without NSAIDs use was associated with a 2.7-fold increased risk (aOR = 2.65; 95% CI = 2.29-3.06), and NSAIDs use only was associated with a 1.5-fold increased risk (aOR = 1.47; 95% CI = 1.33-1.62). Moreover, parenteral NSAIDs were associated with much higher risk in ARI patients (aOR = 7.22; 95% CI = 4.07-12.81). Conclusions: Nonsteroidal anti-inflammatory drugs use during ARI episodes, especially parenteral NSAIDs, was associated with a further increased risk of AMI.

Periarrest Modified Early Warning Score (MEWS) predicts the outcome of in-hospital cardiac arrest.

BACKGROUND/PURPOSE: The Modified Early Warning Score (MEWS) reflects the physiological changes of cardiac arrest and has been used in identifying patient deterioration. Physiological reserve capacity is an important outcome predictor, but is seldom reported due to recording limitations in cardiac arrest patients. The aim of the study was to evaluate whether periarrest MEWS could be a further prognostic factor in in-hospital cardiac arrest. METHODS: This was a retrospective cohort study of nontrauma adult patients who had experienced in-hospital cardiac arrest during emergency department stays at an urban, 2600-bed tertiary medical center in Taiwan from February 2011 to July 2013. Data regarding patients' characteristics, Charlson Comorbidity Score, MEWS score before events, mode of arrest, and outcome details were extracted following the Utstein guidelines for uniform reporting of cardiac arrest. RESULTS: During the 30-month period, 234 patients suffered in-hospital cardiac arrest during emergency department stays, and 99 patients with periarrest MEWS were included in the final analysis. The MEWS at triage did not differ significantly between survival-to-discharge and mortality groups (3.42 ± 2.2 vs. 4.02 ± 2.65, p = 0.811). Periarrest MEWS was lower in the survival-to-discharge group (4.41 ± 2.28 vs. 5.82 ± 2.84, p = 0.053). In multivariate logistic regression analysis, periarrest MEWS was an independent predictors for survival to discharge. A rise in periarrest MEWS reduced the chance of survival to discharge by 0.77-fold (95% confidence interval: 0.60-0.97, p = 0.028). CONCLUSION: The simplest MEWS system not only can be used as a prevention measure, but the periarrest MEWS could also be considered as an independent predictor of mortality after in-hospital cardiac arrest.

Active compression-decompression resuscitation and impedance threshold device for out-of-hospital cardiac arrest: a systematic review and metaanalysis of randomized controlled trials.

OBJECTIVE: Active compression-decompression resuscitation and impedance threshold device are proposed to improve survival of patients of cardiac arrest by lowering intrathoracic pressure and increasing cardiac output. The results of clinical studies of active compression-decompression resuscitation or impedance threshold device were controversial. This metaanalysis pooled results of randomized controlled trials to examine whether active compression-decompression resuscitation or impedance threshold device would improve outcomes of out-of-hospital cardiac arrest in comparison with standard cardiopulmonary resuscitation and to explore factors modifying these effects. DATA SOURCES: Medline and Embase were searched from inception to September 2013. STUDY SELECTION: Randomized controlled trials comparing active compression-decompression resuscitation or impedance threshold device with standard cardiopulmonary resuscitation in out-of-hospital cardiac arrest patients were selected. There were no restrictions for language, population, or publication year. DATA EXTRACTION: Data on study characteristics, including patients, intervention details, and outcome measures, were independently extracted. DATA SYNTHESIS: Fifteen trials, including 16,088 patients, were identified from 331 potentially relevant references. Return of spontaneous circulation was designated as the primary outcome. The pooled result showed no significant improvement in return of spontaneous circulation by active compression-decompression resuscitation or impedance threshold device in comparison with standard cardiopulmonary resuscitation (risk ratio, 1.04; 95% CI, 0.93-1.16; I, 46%). There was also no significant difference in survival or neurologic outcome at hospital discharge between active compression-decompression resuscitation or impedance threshold device and standard cardiopulmonary resuscitation. The meta-regression indicated that this minimal effect might be modified by two important prognostic factors, that is, witnessed status and response time. After adjustment of these two factors, impedance threshold device appeared to improve return of spontaneous circulation, which could be further augmented by advanced airway use. CONCLUSIONS: Active compression-decompression resuscitation or impedance threshold device seemed not to improve return of spontaneous circulation in out-of-hospital cardiac arrest patients. The meta-regression indicated two probable prognostic factors causing this minimal effect. Nonetheless, these findings referred to differences between trials and could not necessarily be extrapolated to individual patients. The individual patient-level extrapolation may need to be solved by a future randomized controlled trial.

An observational study of extracorporeal CPR for in-hospital cardiac arrest secondary to myocardial infarction.

OBJECTIVE: To determine the effects of extracorporeal cardiopulmonary resuscitation (ECPR) in patients with in-hospital cardiac arrest (IHCA) due to acute myocardial infarction (AMI). METHODS: IHCA patients due to AMI undergoing CPR between 1 January 2006 and 1 July 2010 were analysed retrospectively. We compared the survival outcome of 43 patients who received ECPR with that of 23 patients who underwent conventional CPR. RESULTS: The survival rate was 34.9% for patients who received ECPR and 21.8% for those who received conventional CPR (p=0.4). Increased survival rates to hospital discharge were seen in patients with ST segment elevation (p<0.01), or had initial rhythm of ventricular tachycardia/ventricular fibrillation (VT/VF) during resuscitation (p=0.031). CONCLUSIONS: ECPR may improve survival in cardiac arrest patients who have a ST segment elevation or initial rhythm of VT/VF myocardial infarction.

Citrobacter peritoneal dialysis peritonitis: rare occurrence with poor outcomes.

INTRODUCTION: Non-Pseudomonas gram-negative bacteria are responsible for an increasing proportion of cases of peritoneal dialysis (PD)-related peritonitis. The role of Citrobacter species in the etiology of PD-related peritonitis is often underestimated. In the present study, we aimed to describe the clinical features, laboratory findings, and short- and long-term outcomes in PD-related peritonitis caused by Citrobacter. METHODS: A retrospective review of all episodes of PD-related peritonitis caused by Citrobacter from a single center between 1990 and 2010 was performed. Clinical features, microbiological data, and outcomes of these episodes were analyzed. RESULTS: Citrobacter species was responsible for 11 PD-related episodes (1.8% of all peritonitis episodes) in 8 patients. Citrobacter freundii was the most common etiologic species (73%), and mixed growth was found in the other 3 episodes (27%). Approximately half (46%) of the episodes were associated with constipation and/or diarrhea. Of the Citrobacter isolates from all episodes, 54% were resistant to cefazolin, and only 18% were susceptible to cefmetazole. All isolates were susceptible to ceftazidime, cefepime, carbapenem, and aminoglycosides. More than half of the patients (54%) were hospitalized for index peritonitis, and 27% of the episodes involved a change in antibiotic medication. One patient had relapsing peritonitis caused by C. koseri (9%). The mortality rate of PD-related peritonitis caused by Citrobacter was 18%, and 89% of surviving patients developed technique failure requiring a modality switch after an average of 12 months of follow-up (range 1.2-31.2 months). CONCLUSION: PD-related peritonitis caused by Citrobacter is associated with poor outcomes, including high rates of antibiotic resistance, a high mortality rate, and a high rate of technique failure among survivors during the follow-up period.

Biphasic versus monophasic defibrillation in out-of-hospital cardiac arrest: a systematic review and meta-analysis.

OBJECTIVE: Biphasic defibrillation is more effective than monophasic one in controlled in-hospital conditions. The present review evaluated the performance of both waveforms in the defibrillation of patients of out-of-hospital cardiac arrest (OHCA) with initial ventricular fibrillation (Vf) rhythm under the context of current recommendations for cardiopulmonary resuscitation. METHODS: From inception to June 2012, Medline, Embase, and the Cochrane Central Register of Controlled Trials were searched systemically for randomized controlled trials (RCTs) and observational cohort studies that compared the effects of biphasic and monophasic shocks on Vf termination, return of spontaneous circulation (ROSC), and survival to hospital discharge in OHCA patients with initial Vf rhythm. No restrictions were applied regarding language, population, or publication year. RESULTS: Four RCTs including 572 patients were identified from 131 potentially relevant references for meta-analysis. The synthesis of these RCTs yielded fixed-effect pooled risk ratios (RRs) for biphasic and monophasic waveforms on Vf termination survival to hospital discharge (RR, 1.14; 95% CI, [0.84-1.54]). CONCLUSION: Biphasic waveforms did not seem superior to monophasic ones with respect to Vf termination, ROSC, or survival to hospital discharge in OHCA patients with initial Vf rhythm under the context of current guidelines. However, most trials were conducted in accordance with previous guidelines for cardiopulmonary resuscitation. Therefore, further trials are needed to clarify this issue.

Peritoneal dialysis peritonitis by anaerobic pathogens: a retrospective case series.

BACKGROUND: Bacterial infections account for most peritoneal dialysis (PD)-associated peritonitis episodes. However, anaerobic PD peritonitis is extremely rare and intuitively associated with intra-abdominal lesions. In this study, we examined the clinical characteristics of PD patients who developed anaerobic peritonitis. METHODS: We retrospectively identified all anaerobic PD peritonitis episodes from a prospectively collected PD registry at a single center between 1990 and 2010. Only patients receiving more than 3 months of PD were enrolled. We analyzed clinical features as well as outcomes of anaerobic PD peritonitis patients. RESULTS: Among 6 patients, 10 episodes of PD-associated peritonitis were caused by anaerobic pathogens (1.59% of all peritonitis episodes during study the period), in which the cultures from 5 episodes had mixed growth. Bacteroides fragilis was the most common species identified (4 isolates). Only 3 episodes were associated with gastrointestinal lesions, and 4 episodes were related to a break in sterility during exchange procedures. All anaerobic pathogens were susceptible to clindamycin and metronidazole, but penicillin resistance was noted in 4 isolates. Ampicillin/sulbactam resistance was found in 2 isolates. In 5 episodes, a primary response was achieved using the first-generation cephalosporin and ceftazidime or aminoglycoside. In 3 episodes, the first-generation cephalosporin was replaced with aminoglycosides. Tenckhoff catheter removal was necessary in 2 episodes. Only one episode ended with mortality (due to a perforated bowel). CONCLUSION: Anaerobic PD-associated peritonitis might be predominantly caused by contamination, rather than intra-abdominal events. Half of anaerobic PD-associated peritonitis episodes had polymicrobial growth. The overall outcome of anaerobic peritonitis is fair, with a high catheter survival rate.

The impact of adding clinical assistants on patient waiting time in a crowded emergency department.

BACKGROUND: Emergency department (ED) crowding causes prolonged waiting times. OBJECTIVE: To evaluate the potential benefit of introducing clinical assistants to a busy and crowded ED. METHODS: This was a retrospective cohort study at an urban, academic tertiary medical centre. We introduced one clinical assistant to each ED shift. The main task of clinical assistants was managing the flow of incoming ED patients. The case group consisted of all adult non-trauma emergency patients during the case period from 1 September to 30 November 2008. The first control group consisted of all adult non-trauma emergency patients between 1 June and 31 August 2008 and the second control group consisted of all patients treated between 1 September and 30 November 2007. The primary outcome was the 'waiting time', defined as the time from triage to the time of the first medical order entered into the computer system. The secondary outcome was the number of adult non-trauma emergency patients who left the ED without being seen. RESULTS: There were 12 257 cases and 25 950 controls. The mean and median waiting times were significantly shorter in the case group. The mean waiting time of the case group was 20.86 min, which was 4.51 min (17.8%) shorter than that of the first control group and 7.41 min (26.2%) shorter than that of the second control group. The median waiting time of the case group was also significantly shorter than those of the control groups. The number of the patients who left without being seen was significantly smaller in the case period. CONCLUSIONS: In a busy and crowded ED, the introduction of clinical assistants to an existing emergency health service effectively reduces patient waiting times and decreases the number of patients leaving without being seen.

Social network analysis of nationwide interhospital emergency department transfers in Taiwan.

Transferring patients between emergency departments (EDs) is a complex but important issue in emergency care regionalization. Social network analysis (SNA) is well-suited to characterize the ED transfer pattern. We aimed to unravel the underlying transfer network structure and to identify key network metrics for monitoring network functions. This was a retrospective cohort study using the National Electronic Referral System (NERS) database in Taiwan. All interhospital ED transfers from 2014 to 2016 were included and transfer characteristics were retrieved. Descriptive statistics and social network analysis were used to analyze the data. There were a total of 218,760 ED transfers during the 3-year study period. In the network analysis, there were a total of 199 EDs with 9516 transfer ties between EDs. The network demonstrated a multiple hub-and-spoke, regionalized pattern, with low global density (0.24), moderate centralization (0.57), and moderately high clustering of EDs (0.63). At the ED level, most transfers were one-way, with low reciprocity (0.21). Sending hospitals had a median of 5 transfer-out partners [interquartile range (IQR) 3-7), while receiving hospitals a median of 2 (IQR 1-6) transfer-in partners. A total of 16 receiving hospitals, all of which were designated base or co-base hospitals, had 15 or more transfer-in partners. Social network analysis of transfer patterns between hospitals confirmed that the network structure largely aligned with the planned regionalized transfer network in Taiwan. Understanding the network metrics helps track the structure and process aspects of regionalized care.

Machine learning to predict in-hospital cardiac arrest from patients presenting to the emergency department.

In-hospital cardiac arrest (IHCA) in the emergency department (ED) is not uncommon but often fatal. Using the machine learning (ML) approach, we sought to predict ED-based IHCA (EDCA) in patients presenting to the ED based on triage data. We retrieved 733,398 ED records from a tertiary teaching hospital over a 7 year period (Jan. 1, 2009-Dec. 31, 2015). We included only adult patients (≥ 18 y) and excluded cases presenting as out-of-hospital cardiac arrest. Primary outcome (EDCA) was identified via a resuscitation code. Patient demographics, triage data, and structured chief complaints (CCs), were extracted. Stratified split was used to divide the dataset into the training and testing cohort at a 3-to-1 ratio. Three supervised ML models were trained and performances were evaluated and compared to the National Early Warning Score 2 (NEWS2) and logistic regression (LR) model by the area under the receiver operating characteristic curve (AUC). We included 316,465 adult ED records for analysis. Of them, 636 (0.2%) developed EDCA. Of the constructed ML models, Random Forest outperformed the others with the best AUC result (0.931, 95% CI 0.911-0.949), followed by Gradient Boosting (0.930, 95% CI 0.909-0.948) and Extra Trees classifier (0.915, 95% CI 0.892-0.936). Although the differences between each of ML models and LR (AUC: 0.905, 95% CI 0.882-0.926) were not significant, all constructed ML models performed significantly better than using the NEWS2 scoring system (AUC 0.678, 95% CI 0.635-0.722). Our ML models showed excellent discriminatory performance to identify EDCA based only on the triage information. This ML approach has the potential to reduce unexpected resuscitation events if successfully implemented in the ED information system.

Clinical characteristics of new psychoactive substances: A multicenter study.

BACKGROUND: New psychoactive substances (NPS) are synthetic alternatives to illicit drug abuse that are not under international control but may pose a public health threat. Moreover, the symptoms and signs of NPS users may be quite variable. This study aimed to figure out the clinical characteristics of NPS users presented to the emergency department (ED). METHODS: A total of 1385 cases were tested via urine toxicity screening from March 25, 2019, to January 28, 2020, in six medical centers, and ten hospitals, in Taiwan. A total of 123 non-NPS cases and 77 NPS-use cases were enrolled in this study. We compared the patient data-vital signs, presentation, co-morbidities, behaviors, symptoms, electrocardiograms, laboratory data, length of stays-and outcomes of NPS users and non-NPS drug users. RESULTS: NPS users were 5.7 years younger than the non-NPS drug users (37 vs. 42.7 years, p = 0.022). Presently, NPS users had a 2.6-fold (27.2%) higher rate of suicide and a 2.9-fold (11.7%) greater possibility of violence than non-NPS drug users. Moreover, in NPS users, eye-opening was affected at a scale of 3.1 versus 3.4 (p = 0.048) in non-NPS drug users in the evaluation of consciousness and they experienced a 4.3-fold greater feeling of palpitation (p = 0.024) and had 8.1-fold higher chance of presenting facial flush (p = 0.032) than non-NPS drug users. CONCLUSION: NPS users are relatively younger, are more likely to experience facial flush and palpitation and engage in more self-harm, violence, and suicide than non-NPS drug users. Physicians need to pay attention to people who have altered, bizarre mental statuses with the clinical characteristics described above.

Occult Staphylococcus aureus bacteremia in adult emergency department patients: rare but important.

BACKGROUND: We sought to elaborate the epidemiology and outcomes of adult patients with occult Staphylococcus aureus bacteremia who were inadvertently discharged from the emergency department (ED) before positive blood culture results were obtained. METHODS: Between 2001 and 2010, 759 true occult bacteremia cases were identified, including 65 patients with S. aureus bacteremia. Sixty-two patients were enrolled (case group) and analyzed using two 1:2 case-control strategies. Control group I patients were selected from among 997 S. aureus bacteremia patients directly admitted from the ED. Control group II patients were selected from 694 ED patients with occult bacteremia other than S. aureus. Cox regression analyses were used to assess the independent effect of occult S. aureus bacteremia on patient mortality. RESULTS: There was no significant difference between the case group and control group I with respect to organ failure, septic shock, intensive care unit (ICU) admission proportion, length of ICU stay, and 30-day mortality. However, compared with control group II, the case group had significantly higher rates of hospital admission, organ failure, septic shock, ICU admission, and 30-day mortality. Age, endocarditis, and S. aureus infection were independent predictors of mortality among adult occult bacteremia patients. CONCLUSIONS: Among patients with occult bacteremia, S. aureus infections had significantly greater adverse impacts on a variety of outcome variables than other bacterial infections. Because S. aureus bacteremia is frequently associated with endovascular or deep-seated infection, it is imperative that first-line clinicians perform prudent evaluations of cases with nonapparent infection foci before discharging febrile patients from EDs.