Severe hypocalcemia in the emergency department: a retrospective cohort study of prevalence, etiology, treatment and outcome.

The aim of this study was to evaluate the prevalence of severe hypocalcemia in patients attending the emergency department. Symptoms, causes, treatment, and outcome of severe hypocalcemia as well as course of calcium concentrations were assessed. This retrospective case series included all adult patients with measurements of serum calcium concentrations presenting to the emergency department of the Bürgerspital Solothurn between January 01 in 2017 and December 31 in 2020. Medical record reviews were performed of all patients with severe hypocalcemia, defined by a serum calcium concentration < 1.9 mmol/L, to assess clinical presentation and management. 1265 (3.95%) patients had a serum calcium concentration of < 2.1 mmol/L of which 139 (11%) had severe hypocalcemia of < 1.9 mmol/L. 113 patients had at least one measurement of albumin. Of these, 43 (3.4%) had an albumin-corrected serum calcium < 1.9 mmol/L defining true, severe hypocalcemia. Hypocalcemia was identified and documented in 35% of all cases. The mean serum calcium concentration was 1.74 ± 0.14 mmol/L. Calcium concentrations in malignancy-related hypocalcemia were similar to non-malignancy-related hypocalcemia. The main symptoms attributed to hypocalcemia were cardiac and neurologic. 12% of patients with severe hypocalcemia received intravenous and 23% oral calcium replacement. Active malignancy was the main cause of severe hypocalcemia in 28%, while in most cases, the main cause remained unclear. 41.9% of severely hypocalcemic patients reattended the emergency department for another episode of hypocalcemia within 1 year. Hypocalcemia is common in patients attending the emergency department, however, appears to be neglected frequently. The disorder is often a manifestation of severe disease, triggered by multiple causes. Calcium replacement was administered in less than half of the patients with severe hypocalcemia in this study. Due to frequent readmissions to the emergency department and a high mortality, increased awareness of the disorder and careful follow-up are desirable.

Renal function-adapted D-dimer cutoffs in combination with a clinical prediction rule to exclude pulmonary embolism in patients presenting to the emergency department.

D-dimer levels significantly increase with declining renal function and hence, renal function-adjusted D-dimer cutoffs to rule out pulmonary embolism were suggested. Aim of this study was to "post hoc" validate previously defined renal function-adjusted D-dimer levels to safely rule out pulmonary embolism in patients presenting to the emergency department. In this retrospective, observational analysis, all patients with low to intermediate pre-test probability receiving D-dimer measurement and computed tomography angiography (CTA) to rule out pulmonary embolism between January 2017 and December 2020 were included. Previously defined renal function-adjusted D-dimer cutoffs (1306 µg/l for moderate and 1663 µg/l for severe renal function impairment) were applied to determine sensitivity, specificity, negative and positive predictive values. One thousand, three hundred sixty-nine patients were included of which 229 (17%) were diagnosed with pulmonary embolism. The estimated glomerular filtration rate (eGFR) was ≥ 60 ml/min in 1079 (79%), 30-59 ml/min in 266 (19%) and < 30 ml/min in 24 (2%) patients. Only three patients (1.1%) with an eGFR < 60 ml/min had a D-dimer level < 500 µg/l. There was a significant correlation between D-dimer and eGFR (R = - 0.159, p < 0.001). Calculated on the standard D-dimer cutoff value of 500 µg/l, sensitivity of D-dimer testing was 97% for patients with an eGFR ≥ 60 ml/min and 100% for those with 30-60 ml/min, while specificity decreased in patients with renal function impairment. A negative predictive value of 0.99 as a premise to safely rule out pulmonary embolism was achieved by applying a D-dimer cutoff of 1480 µg/l for eGFR 30-59 ml/min and 1351 µg/l for eGFR < 30 ml/min. The findings of this study underline that application of renal function-adapted D-dimer levels in combination with a clinical prediction rule appears feasible to rule out pulmonary embolism. Out of the current dataset, renal function-adjusted D-dimer cutoffs to rule out pulmonary embolism were slightly different compared to previously defined cutoffs. Further studies on a larger scale are needed to validate possible renal function-adjusted D-dimer cutoffs.

Impact of junior doctor strikes on patient flow in the emergency department: a cross-sectional analysis.

BACKGROUND AND IMPORTANCE: Healthcare worker strikes are a global phenomenon. Mortality and morbidity seem to be unaffected by doctor strikes, but there is little evidence on the impact on emergency department (ED) flow and patient characteristics. In March and April 2023, two consecutive UK junior doctor strikes occurred. OBJECTIVES: This study investigated the impact of junior doctor strikes on ED patient flow. Additionally, variation in patient presentations was compared between non-strike and strike days. DESIGN, SETTING AND PARTICIPANTS: This cross-sectional study was conducted at King's College Hospital ED, a university hospital in London. All ED attendances during the 72- and 96-hour strike actions were compared with the corresponding non-strike days of the previous week. OUTCOME MEASURES AND ANALYSIS: National key performance indicators (KPIs) were analysed and compared between non-strike and strike days. Patients' demographics, acuity and diagnoses were compared. Outcome measures included number of 4-hour breaches, number of patients admitted or discharged and ED mortality. Staff seniority was categorised into levels for analysis. MAIN RESULTS: There was increased ED patient flow during strike days with a significantly shorter total time in department in March [240 min (IQR 155-469) vs. 286 min (IQR 198.5-523.5), P  < 0.001] and in April [222.5 min (IQR 147-351) vs. 251.5 min (IQR 174-443), P  < 0.001]. Time to first clinician, treatment, and decision to admit were all shorter during both strike actions. Number of attendances, acuity, diagnoses, admission, discharge, and mortality rates were similar during strike and non-strike days. Staffing numbers were lower or equivalent on strike days but level of seniority was higher ( P  < 0.001). CONCLUSION: The improved KPIs and increased patient flow during strike days, while multifactorial, seem largely attributed to the higher number of senior staff. Patient presentations and outcomes were unaffected by junior doctor strike action.

Characteristics and outcome of severe hypercalcemia on admission to the emergency department: a retrospective cohort study.

AIMS OF THE STUDY: To investigate the prevalence of hypercalcemia (>2.60 mmol/l) and severe hypercalcemia (≥2.80 mmol/l) on admission. Symptoms, causes, course of serum calcium, treatment and outcome of severe hypercalcemia were evaluated and compared to historical data from previous studies. METHODS: In this retrospective cohort study, all patients presenting to the interdisciplinary emergency department of the Buergerspital Solothurn between 01 January 2017 and 31 December 2020 with measurements of serum calcium were included. Chart reviews were performed for patients with calcium ≥2.80 mmol/l to assess clinical presentation, course of disease and treatment for severe hypercalcemia. RESULTS: Of 31,963 tested patients, 869 patients (2.7%) had hypercalcemia on the admission, of which 161 had severe hypercalcemia. Non-albumin corrected calcium was 3.07 (0.32) while albumin corrected calcium was 3.34 (0.44). Calcium was higher in patients with malignancy-related hypercalcemia (3.18 [0.34] versus 3.00 [0.3], p <0.001). Neuropsychiatric (35%) and gastrointestinal (24%) were the leading symptoms. Malignancy was the most common identifiable cause of hypercalcemia (40%), with lung cancer (20%), multiple myeloma (14%) and renal cell carcinoma (11%) being the main cancer types. 36% of patients with severe hypercalcemia took calcium supplements. Bisphosphonate treatment was an independent predictor of a fall in calcium until day 5 (regression coefficient: -0.404, standard error 0.11, p <0.001). Hypercalcemia was not mentioned in the final discharge report in 38% of cases. CONCLUSION: Severe hypercalcemia is common and malignancy-related in almost half of the cases. Neuropsychiatric and gastrointestinal symptoms were most prevalent. Awareness of hypercalcemia, particularly in cancer patients and those with known triggering factors, should be raised in order to identify and treat this harmful disorder early.

Gender Equality in National Cardiology Societies: A Cross-Sectional Study.

BACKGROUND: Higher productivity and team stability have been shown for gender-diverse teams. However, there is a relevant and well-known gender gap in clinical and academic cardiovascular medicine. So far, no data concerning gender distribution in presidents and executive boards of national cardiology societies exist. METHODS: In this cross-sectional analysis, gender equality in presidents and representatives of all national cardiology societies, which were members of, or affiliated with, the European Society of Cardiology (ESC) in 2022, was analyzed. In addition, representatives of the American Heart Association (AHA) were evaluated. RESULTS: A total of 106 national societies were screened, of which 104 were included in the final analysis. Overall, 90 of 106 (85%) presidents were men, while 14 (13%) were women. In the analysis of board members and executives, a total of 1128 individuals were included. Overall, 809 (72%) board members were men, 258 (23%) women, and 61 (5%) of unknown gender. Except for society presidents in Australia, women were relevantly outnumbered by men in all world regions. CONCLUSION: Women were underrepresented in leading positions of national cardiology societies in all world regions. As national societies are important regional stakeholders, improving gender equality in executive boards might create women role models, help foster careers, and narrow the global cardiology gender gap.

Emergency medicine in Switzerland: an analysis of physician workforce, gender equality and academics.

BACKGROUND: Globally, emergency medicine is continuously evolving and in numerous countries, societies and colleges help develop the specialty on a professional and academic level. However, there are countries, including Switzerland, where emergency medicine is not a fully recognised specialty and there is a historical gender gap. AIMS OF THE STUDY: It was the aim of this study to investigate the trends and developments in Swiss emergency medicine in terms of physician workforce, gender equality and academic posts over time. METHODS: In this observational longitudinal analysis, the number and gender distribution of Swiss Society of Emergency and Rescue Medicine (SSERM) members as well as SSERM-certified physicians were analysed in 2011, 2016 and 2021. Additionally, head and leading physicians of SSERM-certified emergency departments of category 1 and 2 were analysed in 2021 with special regard to gender distribution. Finally, an analysis of Swiss academic emergency medicine including Swiss academic tracks, professors in emergency medicine as well as committees, chairs and speakers of the annual SSERM conference was performed. RESULTS: From 2011 to 2021, there was an increase in SSERM members of 52% and a growing proportion of women from 26% to 35%. Similarly, there was a rise of 66% in physicians certified in in-hospital and 79% certified in prehospital emergency medicine. The proportion of women increased by 153% and 131%, respectively. In the analysed emergency departments, 69% of all head physicians were men whereas 50% of senior consultants and consultants with extended responsibility were women in 2021. Concerning academics, emergency medicine was a mandatory subject at all Swiss universities offering a master's degree in medical studies in 2021. However, 11 Swiss universities reported only six full professors, of whom only one was a woman, and three associate professors in emergency medicine in 2021. The analysis of the annual SSERM conferences from 2016 to 2019 revealed that men outnumbered women at every conference in terms of committees, chairs and speakers. CONCLUSIONS: The number of SSERM members and board-certified emergency physicians, women in particular, remarkably increased in 10 years. Equality appears to be within reach for clinical emergency physicians, but women continue to be underrepresented in academic positions, at scientific conferences and among professors. In Switzerland, academic emergency medicine appears to be lagging behind in view of the growing emergency physician and women workforce, which might complicate further progress in and development of Swiss emergency medicine on a scientific and professional level..

Hypernatremia at presentation to the emergency department: a case series.

Disorders of serum sodium are common findings in patients presenting to the emergency department (ED). The aim of this study was to systematically investigate the prevalence, symptoms, etiology, treatment as well as the course of hypernatremia present on admission to the ED. All adult patients with measurements of serum sodium presenting to the ED between 01 January 2017 and 31 December 2020 were included in this retrospective cohort study. Chart reviews were performed for all patients with hypernatremia defined as serum sodium > 147 mmol/L. 376 patients (0.7%) had a serum sodium > 145 mmol/L on admission and 109 patients (0.2%) had clinically relevant hypernatremia > 147 mmol/L. Main symptoms included somnolence (42%) followed by disorientation (30%) and recent falls (17%). An impaired sense of thirst was the main cause of hypernatremia as present in 76 patients (70%), followed by a lack of free access to water in 50 patients (46%). Regarding treatment, only one patient received targeted oral hydration and 38 patients (35%) experienced inadequate correction of hypernatremia as defined as either a correction of < 2 mmol/L or further increasing sodium during the first 24 h. 25% of patients with hypernatremia died during the course of their hospital stay. Patients who died had significantly lower correction rates of serum sodium (0 mmol/L (-3 - 1.5) versus - 6 mmol/L (-10 - 0), p < 0.001). Hypernatremia is regularly encountered in the ED and patients present with unspecific neurologic symptoms. Initial treatment and correction of hypernatremia are frequently inadequate with no decrease or even increase in serum sodium during the first 24 h.

Hyponatremia in the emergency department.

Hyponatremia, defined as a serum sodium <135 mmol/L, is frequently encountered in patients presenting to the emergency department. Symptoms are often unspecific and include a recent history of falls, weakness and vertigo. Common causes of hyponatremia include diuretics, heart failure as well as Syndrome of Inappropriate Antidiuresis (SIAD) and correct diagnosis can be challenging. Emergency treatment of hyponatremia should be guided by presence of symptoms and focus on distinguishing between acute and chronic hyponatremia.

Age- and sex-related differences in community-acquired pneumonia at presentation to the emergency department: a retrospective cohort study.

BACKGROUND AND IMPORTANCE: Because of its associated high morbidity and mortality, early identification and treatment of community-acquired pneumonia (CAP) are essential. OBJECTIVES: To investigate age- and sex-related differences in clinical symptoms, radiologic findings and outcomes in patients presenting to the emergency department (ED) with CAP. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Patients admitted to one Swiss ED with radiologically confirmed CAP between 1 January 2017 and 31 December 2018. OUTCOME MEASURES AND ANALYSIS: Primary aim was to evaluate differences in clinical and radiologic presentation of men vs. women and patients >65 years vs. <65 years with CAP. Secondary outcomes were age- and sex-related differences in terms of Pneumonia Severity Index (PSI) risk class, need for ICU referral, mechanical ventilation, in-hospital mortality, 30-day readmission and 180-day pneumonia recurrence. MAIN RESULTS: In total 467 patients with CAP were included. 211 were women (45%). 317 were ≥65 years (68%), of which 145 were women (46%). Older patients less commonly reported chest pain (13 vs. 27%; effect size 14%; 95% CI, 0.07-0.23), fever (39 vs. 53%, effect size 14%; 95% CI, 0.05-0.24), chills (6 vs. 20%; effect size 14%; 95% CI, 0.08-0.0.214), cough (44 vs. 57%; effect size 13%; 95% CI, 0.03-0.22), headache (5 vs. 15%, effect size 10%, 95% CI, 0.04-0.17) and myalgias (5 vs. 19%; effect size 14%; 95% CI, 0.07-0.21). However, 85% of patients with no symptoms were ≥65 years. PSI was lower in women [95 (SD 31) vs. 104 (SD 31); 95% CI, -14.44 to 2.35] and sputum was more common in men (32 vs. 22%; effect size 10%; 95% CI, -0.18 to -0.02). Raw mortality was higher in elderly patients [14 vs. 3%; odds ratio (OR), 4.67; 95% CI, 1.81-12.05], whereas it was similar in men and women (11 vs. 10%; OR, 1.22; 95% CI, 0.67-2.23). CONCLUSION: Patients, less than 65 years with CAP presenting to the ED had significantly more typical symptoms such as chest pain, fever, chills, cough, headache and myalgias than those being above 65 years. No relevant differences between men and women were found in clinical presentation, except for PSI on admission, and radiologic findings and neither age nor sex was a predictor for mortality in CAP.

Sodium and potassium disorders in patients with COPD exacerbation presenting to the emergency department.

BACKGROUND: Electrolyte disorders are common in the emergency department. Hyponatremia is known to be associated with adverse outcome in community-acquired pneumonia (CAP) and acute exacerbation of chronic obstructive pulmonary disease (AECOPD). No studies investigating the prevalence and influence of hypernatremia or potassium disorders in patients with AECOPD exist. METHODS: In this retrospective cohort analysis, the prevalence of sodium and potassium disorders was investigated in patients with AECOPD presenting to an emergency department (ED) between January 1st 2017 and December 31st 2018 and compared to all ED patients with electrolyte measurements and patients presenting with CAP. Exclusion criteria were age younger than 18 years, written or verbal withdrawal of consent and outpatient treatment. Additionally, the influence of dysnatremias and dyskalemias on outcome measured by ICU admission, need for mechanical ventilation, length of hospital stay, 30-day re-admission, 180-day AECOPD recurrence and in-hospital mortality and their role as predictors of disease severity measured by Pneumonia Severity Index (PSI) were investigated in patients with AECOPD. RESULTS: Nineteen point nine hundred forty-eight ED consultations with measurements of sodium and potassium were recognized between January 1st 2017 and December 31st 2018 of which 102 patients had AECOPD. Of these 23% had hyponatremia, 5% hypernatremia, 16% hypokalemia and 4% hyperkalemia on admission to the ED. Hypo- and hypernatremia were significantly more common in patients with AECOPD than in the overall ED population: 23 versus 11% (p = 0.001) for hypo- and 5% versus 0.6% (p < 0.001) for hypernatremia. In the logistic regression analysis, no association between the presence of either sodium or potassium disorders and adverse outcome were found. CONCLUSION: Dysnatremias and dyskalemias are common in patients with AECOPD with as many as 1 in 5 having hyponatremia and/or hypokalemia. Hypo- and hypernatremia were significantly more common in AECOPD than overall. No significant association was found for dysnatremias, dyskalemias and adverse outcomes in AECOPD.

Gender distribution in boards of intensive care medicine societies.

PURPOSE: The established gender gap in intensive care medicine is larger compared to other medical specialties. The aim of this study was to evaluate gender distribution in boards of intensive care medicine societies worldwide. METHODS: In this cross-sectional analysis, board members and presidents of all intensive care medicine societies associated with the European Society of Intensive Care Medicine were eligible for study inclusion. Exclusion criteria were: A) society without focus on intensive care and B) online information unavailable. RESULTS: In 2021, 65 presidents and 820 board members were analyzed. Ten presidents (15%) and 231 board members (28%) were women. The proportion of women presidents reached from 0% in Africa to 20% in Europe and South America. The proportion of women board members was highest in North and South America with 42% and 46% respectively and lowest in Africa (21%) and Asia (10%). In Europe, 31% of board members were women and 35% in Australia/New Zealand. Among presidents, women were underrepresented in all continents while gender distribution among board members varied significantly between countries (p < 0.0001). CONCLUSION: Our analysis reveals an inequality in gender distribution in the boards of national intensive care medicine societies which varies but persists for all global regions.