What do we really know about vital pulp therapy?

DESIGN: Retrospective cohort study using STROBE cohort reporting guidelines. COHORT SELECTION: Patients from Mehr Dental Clinic in Tehran, Iran, who received different types of vital pulp therapy (VPT) by a single endodontist, due to carious pulpal exposure, between April 2011 and October 2022. These were: Full Pulpotomy (FP), Miniature Pulpotomy (MP) and Direct Pulp Capping (DPC). Data were accessed via the dental clinic's electronic database. Patients were deemed eligible if they had pulpal exposure due to caries, but not trauma. Pre-operative, immediate post-operative and at least one follow-up radiograph at a minimum 3-month interval were required. Demographic, diagnostic, and procedural data as well as informed consent were also required. Teeth with probing depths greater than 4 mm or pulpal necrosis were excluded. DATA ANALYSIS: Patient, tooth and treatment factors were statistically analysed for an outcome of success or failure using a Cox proportional hazards model. Kaplan/Meier curves were used to establish the mean survival times. The Log-rank test was used to compare survival across the three treatment groups. The Omnibus test of model and the -2 log likelihood ratio (-2LL) were used to assess sensitivity and model fitness. Statistical analyses were determined using the IBM SPSS Statistics for Windows Version 21.0, with P value set at <0.05. RESULTS: 1257 VPTs from 1149 patients had complete data and were used in the analysis. 802 cases were excluded due to no follow up radiograph. The VPT cases were divided into FP (n = 272), MP (n = 217) and DPC (n = 768). The average follow up was 42.21 months, with an overall 116-month survival rate of 99.1% and success rate of 91.6%. FP had a mean survival time of 99.43 months; for MP it was 104.26 months; for DPC it was 102.27 months. There were no significant differences between these groups (P = 0.363). There were statistically significant correlations between symptomatic Irreversible Periodontitis (IP), radiographic signs of Apical Periodontitis (AP), restoration type, restoration surfaces and the outcome of VPT. CONCLUSIONS: This is one of the largest cohort studies of its kind, with over 1250 cases of various VPT techniques in 10 years. There was deviation from gold standard practice, with lack of rubber dam. A lack of haemostasis after 2 min could be construed as bacterially infected pulpal tissue and require further resection of pulp. Yet, these approaches still resulted in successful outcomes. Another interesting finding was that symptomatic IP with associated AP was treated with VPT, with a 78% success rate. Considering this study and other emerging evidence in the literature, application of VPT as an alternative to conventional Root Canal Treatment could be adopted in general practice, depending on the skills and knowledge of the practitioner and patient preferences.

Which caries removal method to select?

DATA SOURCES: Searches were carried out using PubMed/MEDLINE and Web of Science databases between January 2008 and January 2023. Only articles in English language were included. Boolean operators were used to search: "permanent teeth" OR "permanent tooth" OR "permanent dentition" AND "deep caries" OR "stepwise" AND "partial caries removal OR "stepwise caries removal" OR "pulp vitality" OR "healing rate". STUDY SELECTION: Inclusion criteria were randomised controlled trials, which compared the total removal of carious tissue with either a selective or stepwise removal in permanent teeth with deep carious lesions. Criteria also required a follow up of at least 6 months and publications in English. Exclusion criteria were articles in other languages, articles not comparing different types of total or selective caries removal and articles published before January 2008. DATA EXTRACTION AND SYNTHESIS: Data extraction followed PRISMA guidelines. Two reviewers independently screened articles, analysing titles and abstracts using Rayyan's Intelligent Systematic Review Platform. They also collected data and risk of bias assessed using the Cochrane Risk of Bias Tool for Randomised Trials, dividing articles into high risk of bias, few concerns and low risk of bias. A third researcher resolved conflict or doubt in case of divided opinions. RESULTS: In total, 105 articles were identified, and 10 duplicates removed. 95 articles were reviewed by title and abstract and 75 of these did not meet the inclusion criteria. 20 articles were then read, excluding a further 15 due to comparing only partial removal or non-selective caries removal or absence of numerical data. This left 5 articles which met eligibility criteria. These were randomised controlled trials between 2010 and 2021. Follow up ranged from 1 month to 5 years. The inclusion and exclusion criteria in all studies had similar clinical parameters. 3 studies performed management only on permanent molars, whilst the rest also included management on permanent incisors/canines/premolars and molars. Management of caries was divided into non-selective caries removal vs partial caries removal (either selective or stepwise). All but 2 studies included specific information about the materials used. Liners were calcium hydroxide or Dycal, provisional restorations were glass ionomer cements or Ketax Molar and definitive restorations were Herculite Tetric N-Ceram resin, Ivolclar Vivadent or amalgam. Clinical success or failure was measured using pulp vitality, absence of periapical lesions, radiographic analysis and lack of symptoms. Clinical follow up was evaluated by external examiners, although 2 studies did not specify this clearly. There were a variety of tools used for statistical analysis in each study. CONCLUSIONS: When comparing non-selective caries removal with either selective or stepwise, 3 studies proposed statistically significant differences in terms of longevity, marginal integrity and success rate of restorations. 1 study stated inexistence of statistically relevant divergences between procedures. Non-selective caries removal is not highly recommended for deep carious lesions and may be considered invasive and risks pulpal exposure. Both selective and stepwise removal are considered conservative approaches. Selective removal is considered the best management option in the short term (with 1.5 years follow up), predominantly related to a lower risk of pulpal exposure. At 5 years, however, the results of selective were similar to those of non-selective, accepting the null hypothesis. There were also no differences in success rates for materials used for definitive restorations.

Artificial intelligence and dental panoramic radiographs: where are we now?

DATA SOURCES: Bielefeld Academic Search Engine (BASE), Google Scholar Association for Computing Machinery: Guide to Computing Literature (ACM) and National Library of Medicine: PubMed databases were searched for systematic reviews. STUDY SELECTION: This study addressed a structured PICO question (Population, Intervention, Comparison, Outcome). Population was panoramic radiographs in human subjects. Intervention was use of artificial intelligence (AI) diagnostics, compared to human-only diagnosis. Quantitative or qualitative AI efficiency was the outcome. Systematic reviews were considered if they stated 'systematic review' in their title or abstract, were published in English and were not bound by a certain time frame. No supplemental primary studies were included. Screening and removal of duplicates were performed using the Rayyan tool. DATA EXTRACTION AND SYNTHESIS: Data were extracted from each systematic review by two authors, with a third author having the deciding vote in cases of inconsistency. Cohen's Kappa co-efficient was used to measure reliability between authors, resulting in almost perfect agreement. The risk of bias was accounted for using the ROBIS method which resulted in one paper being rejected, so only 11 included in results. Data were then grouped into seven domains which were detected by AI: teeth identification and numbering, detection of periapical lesions, periodontal bone loss, osteoporosis, maxillary sinusitis, dental caries, and other tasks. The effectiveness of the AI systems was assessed by various outcome metrics - accuracy, sensitivity, specificity, and precision being the most common variables. RESULTS: Results of this overview show a significant increase in accuracy of AI in analysing OPTs between 1988-2023. Latest AI models are most accurate in teeth identification and numbering (93.67%) whilst caries detection and osteoporosis showed 91.5% and 89.29% accuracy, respectively. Accurate results were also observed for the detection of maxillary sinusitis and periodontal bone loss. However, given the heterogeneity of source studies used in these systematic reviews, results should be interpreted with caution. CONCLUSIONS: With improving AI technology, its use in dental radiology can be increasingly effective in supporting dentists in the detection of different pathologies. This overview has shown that systematic reviews of AI can quickly become outdated and that results of any systematic review should be treated with caution as this field advances. As such, regular updating and ongoing research is required.

Does Point-of-Care Ultrasonography Improve Clinical Outcomes in Emergency Department Patients With Undifferentiated Hypotension? An International Randomized Controlled Trial From the SHoC-ED Investigators.

STUDY OBJECTIVE: Point-of-care ultrasonography protocols are commonly used in the initial management of patients with undifferentiated hypotension in the emergency department (ED). There is little published evidence for any mortality benefit. We compare the effect of a point-of-care ultrasonography protocol versus standard care without point-of-care ultrasonography for survival and clinical outcomes. METHODS: This international, multicenter, randomized controlled trial recruited from 6 centers in North America and South Africa and included selected hypotensive patients (systolic blood pressure <100 mm Hg or shock index >1) randomized to early point-of-care ultrasonography plus standard care versus standard care without point-of-care ultrasonography. Diagnoses were recorded at 0 and 60 minutes. The primary outcome measure was survival to 30 days or hospital discharge. Secondary outcome measures included initial treatment and investigations, admissions, and length of stay. RESULTS: Follow-up was completed for 270 of 273 patients. The most common diagnosis in more than half the patients was occult sepsis. We found no important differences between groups for the primary outcome of survival (point-of-care ultrasonography group 104 of 136 patients versus standard care 102 of 134 patients; difference 0.35%; 95% binomial confidence interval [CI] -10.2% to 11.0%), survival in North America (point-of-care ultrasonography group 76 of 89 patients versus standard care 72 of 88 patients; difference 3.6%; CI -8.1% to 15.3%), and survival in South Africa (point-of-care ultrasonography group 28 of 47 patients versus standard care 30 of 46 patients; difference 5.6%; CI -15.2% to 26.0%). There were no important differences in rates of computed tomography (CT) scanning, inotrope or intravenous fluid use, and ICU or total length of stay. CONCLUSION: To our knowledge, this is the first randomized controlled trial to compare point-of-care ultrasonography to standard care without point-of-care ultrasonography in undifferentiated hypotensive ED patients. We did not find any benefits for survival, length of stay, rates of CT scanning, inotrope use, or fluid administration. The addition of a point-of-care ultrasonography protocol to standard care may not translate into a survival benefit in this group.

A traumatic tale of two cities: does EMS level of care and transportation model affect survival in patients with trauma at level 1 trauma centres in two neighbouring Canadian provinces?

BACKGROUND: Two distinct Emergency Medical Services (EMS) systems exist in Atlantic Canada. Nova Scotia operates an Advanced Emergency Medical System (AEMS) and New Brunswick operates a Basic Emergency Medical System (BEMS). We sought to determine if survival rates differed between the two systems. METHODS: This study examined patients with trauma who were transported directly to a level 1 trauma centre in New Brunswick or Nova Scotia between 1 April 2011 and 31 March 2013. Data were extracted from the respective provincial trauma registries; the lowest common Injury Severity Score (ISS) collected by both registries was ISS≥13. Survival to hospital and survival to discharge or 30 days were the primary endpoints. A separate analysis was performed on severely injured patients. Hypothesis testing was conducted using Fisher's exact test and the Student's t-test. RESULTS: 101 cases met inclusion criteria in New Brunswick and were compared with 251 cases in Nova Scotia. Overall mortality was low with 93% of patients surviving to hospital and 80% of patients surviving to discharge or 30 days. There was no difference in survival to hospital between the AEMS (232/251, 92%) and BEMS (97/101, 96%; OR 1.98, 95% CI 0.66 to 5.99; p=0.34) groups. Furthermore, when comparing patients with more severe injuries (ISS>24) there was no significant difference in survival (71/80, 89% vs 31/33, 94%; OR 1.96, 95% CI 0.40 to 9.63; p=0.50). CONCLUSION: Overall survival to hospital was the same between advanced and basic Canadian EMS systems. As numbers included are low, individual case benefit cannot be excluded.

Clinical utility of scores on the Blaylock Risk Assessment Screen (BRASS): An analysis of administrative data.

PURPOSE: Project was undertaken to examine the utility of the Blaylock Risk Assessment Screen (BRASS) in identifying patients who may experience discharge complications as indicated by longer hospital stays or readmission within 30-days of a discharge to home. BACKGROUND: Before measures can be put in place to facilitate discharge planning and to prevent unplanned readmission by recently discharged patients, those at risk of such events must be identified. METHODS: Project involved an analysis of 13-months of administrative data from one tertiary care hospital. Utility of the BRASS was examined in terms of its sensitivity and specificity as well as its positive and negative predictive values. RESULTS: Majority (83%) of hospital discharges were to home. Approximately 7% of patients experienced at least one readmission within 30-days of being discharged to home. Using scores of 10 or higher as an indicator of risk, BRASS exhibited a high degree of specificity suggesting it is useful for 'ruling in' those who have the outcomes-of-interest. However low sensitivity indicates many who experienced the outcomes were incorrectly classified by the BRASS as low risk. The low positive predictive value for 30-day readmission also suggests many who were classified by the BRASS as being 'at risk' were not readmitted. CONCLUSION: The observed rate of 30-day readmission is likely conservative as the analysis involved data from only one acute care facility. One explanation for the low positive predictive value for 30-day readmission is that completion of the BRASS on admission enabled the implementation of preventive measures.

Delays to initial reduction attempt are associated with higher failure rates in anterior shoulder dislocation: a retrospective analysis of factors affecting reduction failure.

INTRODUCTION: Little is understood about the relationship between delay to treatment and initial reduction success for anterior shoulder dislocation. Our study examines whether delays to initial treatment, from injury and hospital presentation, are associated with higher reduction failure rates for anterior shoulder dislocation. METHODS: A retrospective database and chart review was performed for patients undergoing intravenous sedation for attempted reduction of anterior shoulder dislocation in the emergency department (ED). Stepwise regression analysis was performed to identify predictors of reduction failure. Key variables analysed were the duration of the wait in the ED, the interval between the time of injury and first intervention and the interval from time of injury to arrival at the ED. Possible confounding variables analysed included age, gender, dose of sedative agent, qualifications of the reducing physician and whether the dislocated shoulder was recurrent. RESULTS: The duration of the intervals from injury to first reduction attempt and from arrival at the ED to first reduction attempt were both independent predictors of a higher reduction failure rate (OR=1.07, 95% CI 1.02 to 1.13; OR=1.19, 95% CI 1.05 to 1.34). Every interval of 10 min increased the odds of a failed reduction attempt by 7% and 19%, respectively. Overall, shoulder reduction was successful during the initial sedation event in 97 cases (92%) and unsuccessful in nine cases (8%). CONCLUSIONS: Delays to first reduction attempt either from the time of injury or within the ED are associated with a lower reduction success rate for anterior shoulder dislocations.

A Diagnostic Dilemma of Prevertebral Abscess Versus Food Bolus on Lateral Neck X-Ray: A Case Report.

In this case, a 76-year-old female presenting with globus sensation post-oral intake demonstrated radiographical evidence of mottled radiolucency and prevertebral widening on a lateral neck X-ray at the inferior C4/cricoid cartilage, leading to concern for a prevertebral abscess. A decision was made to proceed with an urgent gastrointestinal endoscopy, and a food bolus was identified and removed, leading to a full remission of the patients' symptoms. In this case, an appropriate diagnosis was achieved by combining multiple investigations, which highlights to clinicians that taking investigations in isolation, with the aforementioned lateral neck X-ray being the primary example, could lead to potential misdiagnosis and mismanagement of patients.

Nursing Home Residents' Use of Radiography in New Brunswick: A Case for Mobile Radiography?

Introduction: Identifying ways to eliminate unnecessary transfer of nursing home (NH) residents to hospitals provides an opportunity to improve outcomes and use scarce healthcare resources more efficiently. This study's goal was to better understand where NH residents access X-ray (XR) and computed tomography (CT) scans and to determine if there was a case for mobile radiography policies in New Brunswick. Methods: A retrospective analysis of all the visits to the emergency department (ED) and outpatient imaging departments in two hospitals in Saint John, New Brunswick, in 2020, that involved XR or CT investigations was conducted. Results: There were 521 visits by 311 unique NH residents and 920 investigations (688 XR and 232 CT scans). Most investigations were ordered in the ED (696 of 920; 75.6%; confidence interval: 72.8-78.3%). Of the NH residents who visited the ED and received either an XR or a CT scan, 33.2% received only XR imaging and were discharged back to the NH after a mean ED stay of 5.15 hours. Discussion: The pattern of NH residents' use of the ED for their imaging needs supports the creation of mobile XR policies to deliver more safe and efficient care in a Canadian medium population urban centre.

A multi-site service evaluation of silver diamine fluoride use for children.

Introduction The use of silver diamine fluoride (SDF) is relatively new to the UK. It is unknown how it is being used and for what indications in UK paediatric dental services.Aim To: 1) establish how SDF is being used across different paediatric dental settings in the UK; and 2) consider parental and patient views on the treatment experience and side effect of discolouration.Method A multi-site service evaluation was carried out across six paediatric dentistry units covering hospital and community services. Data were collected prospectively from 17/02/2020 to 02/03/2022. Simple descriptive statistics were used to analyse the data.Results Data were collected for 54 patients. The included patients had an age range of 2-13 years, with a mean of 4.9 years. The reason SDF was chosen was reported as: to avoid general anaesthetic (n = 25); to avoid extractions (n = 8); stabilisation (n = 25); acclimatisation (n = 24); and insufficient cooperation for other treatment (n = 17). In total, 42 cases had SDF applied to the primary dentition. This was in the anterior dentition for 18 patients and the posterior dentition for 15, with nine patients having SDF applied both anteriorly and posteriorly. The majority of children and parents were accepting of the technique and immediate aesthetic outcome.Conclusion In the services involved in this multi-site service evaluation, SDF is used for young patients in the primary dentition for the purpose of caries arrest. The technique was viewed positively by the majority of parents and children.

SHoC-IVC: Does assessment of the inferior vena cava by point-of-care ultrasound independently predict fluid status in spontaneously breathing patients with undifferentiated hypotension?

BACKGROUND: Accurately determining the fluid status of a patient during resuscitation in the emergency department (ED) helps guide appropriate fluid administration in the setting of undifferentiated hypotension. Our goal was to determine the diagnostic utility of point-of-care ultrasound (PoCUS) for inferior vena cava (IVC) size and collapsibility in predicting a volume overload fluid status in spontaneously breathing hypotensive ED patients. METHODS: This was a post hoc secondary analysis of the SHOC-ED data, a prospective randomized controlled trial investigating PoCUS in patients with undifferentiated hypotension. We prospectively collected data on IVC size and collapsibility for 138 patients in the PoCUS group using a standard data collection form, and independently assigned a fluid status (volume overloaded, normal, volume deplete) from a composite clinical chart review blinded to PoCUS findings. The primary outcome was the diagnostic performance of IVC characteristics on PoCUS in the detection of a volume overloaded fluid status. RESULTS: One hundred twenty-nine patients had completed determinant IVC assessment by PoCUS, with one hundred twenty-five receiving successful final fluid status determination, of which one hundred and seven were classified as volume deplete, thirteen normal, and seven volume overloaded. A receiver operating characteristic (ROC) curve was plotted using several IVC size and collapsibility categories. The best overall performance utilized the combined parameters of a dilated IVC (> 2.5 cm) with minimal collapsibility (less than 50%) which had a sensitivity of 85.7% and specificity of 86.4% with an area under the curve (AOC) of 0.92 for predicting an volume overloaded fluid status. CONCLUSION: IVC PoCUS is feasible in spontaneously breathing hypotensive adult ED patients, and demonstrates potential value as a predictor of a volume overloaded fluid status in patients with undifferentiated hypotension. IVC size may be the preferred measure.

RéSUMé: CONTEXTE: La détermination précise de l'état du liquide d'un patient pendant la réanimation au service des urgences (SU) aide à guider l'administration appropriée du liquide dans le cadre d'une hypotension indifférenciée. Notre objectif était de déterminer l'utilité diagnostique de l'échographie au point de soins (PoCUS) pour la taille de la veine cave inférieure (IVC) et l'collapsibilité dans la prédiction d'un état de liquide de surcharge volumique chez les patients souffrant d'une hypotension respiratoire spontanée. MéTHODES: Il s'agissait d'une analyse secondaire post-hoc des données SHOC-ED, un essai contrôlé randomisé prospectif examinant PoCUS chez des patients atteints d'hypotension indifférenciée. Nous avons collecté prospectivement des données sur la taille et la collapsibilité des IVC pour 138 patients du groupe PoCUS à l'aide d'un formulaire de collecte de données standard, et attribué indépendamment un état de fluide (volume surchargé, normal, épuisement du volume) à partir d'une revue de dossier clinique composite mise en aveugle aux résultats PoCUS. Le résultat principal était la performance diagnostique des caractéristiques IVC sur PoCUS dans la détection d'un état de fluide surchargé en volume. RéSULTATS: 129 patients avaient terminé l'évaluation IVC des déterminants par PoCUS, dont 125 ont reçu une détermination finale du statut hydrique, dont 107 ont été classés comme étant une diminution du volume, 13 normaux et 7 surchargés. Une courbe des caractéristiques de fonctionnement du récepteur (ROC) a été tracée en utilisant plusieurs catégories de taille et d'affaissement IVC. La meilleure performance globale a utilisé les paramètres combinés d'une IVC dilatée (> 2,5 cm) avec une collapsibilité minimale (moins de 50%) qui avait une sensibilité de 85,7% et une spécificité de 86,4% avec une zone sous la courbe (AOC) de 0,92 pour prédire un état de fluide surchargé en volume. CONCLUSION: IVC PoCUS est faisable chez les patients adultes souffrant d'une hypotension respiratoire spontanée et démontre une valeur potentielle en tant que prédicteur d'un état de liquide surchargé en volume chez les patients atteints d'hypotension indifférenciée. La taille IVC peut être la mesure préférée.

Emergency department occupancy is useful as a simple real-time measure of crowding.

INTRODUCTION: Emergency department (ED) crowding compromises patient outcomes. Existing crowding measures are complex and difficult to use in real-time. This study evaluated readily available single flow variables as crowding measures. METHODS: Over 2 weeks in a tertiary Canadian ED, we recorded the following potential crowding measures during 168 consecutive two-hour study intervals: total ED patients (census), patients in beds, patients in waiting rooms, patients in treatment areas awaiting MD assessment; number of inpatients boarding, and ED occupancy. We also calculated four complex crowding scores-NEDOCS, EDWIN, ICMED, and a local modification of NEDOCS. We performed ROC analyses to assess the predictive validity of these measures against a reference standard of physician perception of crowding. RESULTS: We gathered data for 144 (63.9%) of 168 study intervals. ED census correlated strongly with crowding (AUC = 0.82, 95% CI 0.76-0.89), as did ED occupancy (AUC = 0.75, 95% CI 0.66-0.83). Their performance was similar to NEDOCS (AUC = 0.80) and to the local modification of NEDOCS (AUC = 0.83). CONCLUSION: ED occupancy as a single measure has similar predictive accuracy to complex crowding scores and is easily generalizable to diverse emergency departments. Real-time tracking of this simple indicator could be used to prompt investigation and implementation of crowding interventions.

RéSUMé: INTRODUCTION: L'encombrement des services d'urgence (SU) compromet les résultats pour les patients. Les mesures d'encombrement existantes sont complexes et difficiles à utiliser en temps réel. Cette étude a évalué des variables de débit unique facilement disponibles comme mesures d'encombrement. LES MéTHODES: Pendant deux semaines dans un service d'urgence tertiaire canadien, nous avons enregistré les mesures d'encombrement potentiel suivantes au cours de 168 intervalles d'étude consécutifs de deux heures : nombre total de patients dans le service d'urgence (recensement), patients dans les lits, patients dans les salles d'attente, patients dans les zones de traitement en attente d'une évaluation médicale ; nombre de patients hospitalisés en internat et occupation du service d'urgence. Nous avons également calculé quatre scores de surpeuplement complexes : NEDOCS, EDWIN, ICMED et une modification locale de NEDOCS. Nous avons effectué des analyses ROC pour évaluer la validité prédictive de ces mesures par rapport à une norme de référence de perception du surpeuplement par les médecins. RéSULTATS: Nous avons recueilli des données pour 144 (63,9 %) des 168 intervalles d'étude. Le recensement des urgences est fortement corrélé avec le surpeuplement (ASC = 0.82, IC 95 % = 0.76­0.89), tout comme l'occupation des urgences (ASC = 0.75, IC 95 % = 0.66­0.83). Leur performance était similaire à celle des NEDOCS (ASC = 0.80) et à la modification locale des NEDOCS (ASC = 0.83). CONCLUSION: L'occupation des urgences en tant que mesure unique a une précision prédictive similaire aux scores complexes de surpeuplement et est facilement généralisable à divers services d'urgence. Le suivi en temps réel de ce simple indicateur pourrait être utilisé pour accélérer l'enquête et la mise en œuvre des interventions en cas de surpeuplement.

Emergency Physicians Ability to Recognize and Diagnose Opiate Use Disorder: A Qualitative Study.

Introduction The opioid crisis is a significant public health problem for this generation. Proper treatment of patients with opiate use disorder (OUD) during vulnerable times is vital to their engagement in opiate agonist therapy (OAT). There is limited information as to the efficacy of ED practitioners in recognition of opioid withdrawal or OUD; this research was designed to fill this gap to advance our care of vulnerable populations. Methods Interviews were conducted with seven convenience-sampled ED physicians and nurse practitioners from the Saint John Regional Hospital by providing a clinical vignette. These one-on-one, scripted interviews, conducted by the principal and co-investigator, tell us about the ED physician's understanding of OUD and withdrawal by posing questions around the presentation within the clinical vignette, as well as around general knowledge of OUD and acute withdrawal. Results All seven participants identified the patient in the case as being in opioid withdrawal but did not identify all symptoms in the vignette. Two correctly diagnosed our patient as having OUD based on the scene provided. Five physicians identified criteria that pointed toward this diagnosis but did not vocalize the connection. Only one discussed prescription of OAT as a treatment, most opting for symptom management and information on sites of self-referral for treatment. Finally, six of our interviewees expressed interest in prescribing buprenorphine but cited a need for more education around its use and initiation before feeling comfortable prescribing it. Conclusions While ED practitioners correctly recognize opiate withdrawal, there is a knowledge gap in the related diagnosis and evidence-based management of OUD. The development of education around these gaps will allow for stronger advocacy and better outcomes for this patient population.

Medical and Undergraduate Student Perceptions on Scribing in an Emergency Department.

Background  A shift towards electronic medical records (EMR) has increased physician burnout and decreased physician satisfaction and productivity. One solution to alleviate EMR stressors is the implementation of medical scribes. Scribes have been shown to increase physician productivity and satisfaction. The study objective was to elucidate medical and undergraduate student scribing experience to determine if that experience can incentivize scribes to work in the emergency department. Methods  Ten students scribed and shadowed at a tertiary ED between July 4, 2019, and August 10, 2019. Medical students participated in two scribing and two non-scribing (shadowing) sessions, each lasting four hours. Undergraduate students only had a scribing condition. To facilitate scribing, a laptop with a wireless keyboard was provided, as well as a stand-up laptop tray.  An exit survey and semi-structured interviews were conducted after the scribing experience. The majority of insights were extracted from interviews. Transcripts were coded into thematic coding trees and analyzed using thematic analysis.  Results  All undergraduate students preferred volunteering in the ED over other volunteer experiences. All undergraduates cited direct access to the medical field, resume building, and perceived value added to the health care team as motivators to continue scribing. Most students credited demystification of the medical profession as a motivator. Most medical students felt scribing should be integrated into their curriculum. Based on survey results, five undergraduate students would volunteer 40 hours/week. Conclusion Our study showed that a volunteer model of scribing is feasible. Importantly, scribing may be an invaluable experience for directing career goals and ensuring that students intrinsically interested in medicine pursue the profession. Although a volunteer model may not provide the desired benefit in terms of ED efficiency, it may be an integral part of training the next wave of physicians.

Sonographic Findings of Left Ventricular Dysfunction to Predict Shock Type in Undifferentiated Hypotensive Patients: An Analysis From the Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED) Study.

Introduction Patients that present to the emergency department (ED) with undifferentiated hypotension have a high mortality rate. Hypotension can be divided into four categories: obstructive, hypovolemic, distributive, and cardiogenic. While it is possible to have overlapping or concomitant shock states, being able to differentiate between cardiogenic shock and the other categories is important as it entails a different treatment regime and extra cautions. In this secondary analysis, we investigate if using focused cardiac ultrasonography (FOCUS) to determine left ventricular dysfunction (LVD) can serve as a reliable test for cardiogenic shock. Methods We prospectively collected FOCUS findings performed in 135 ED patients with undifferentiated hypotension as part of an international study. Patients with clearly identified etiologies for hypotension were excluded, along with other specific presumptive diagnoses. LVD was defined as the identification of a generally hypodynamic left ventricle in the setting of shock. FOCUS findings were collected using a standardized protocol and data collection form. All scans were performed by emergency physicians trained in ultrasound. Final shock type was defined as cardiogenic or noncardiogenic by independent specialist blinded chart review. Results In our findings, 135 patients had complete records for assessment of left ventricular function and additional follow-up data and so were included in this secondary analysis. The median age was 56 years and 53% of patients were male. Disease prevalence for cardiogenic shock was 12% and the mortality rate was 24%. The presence of LVD on FOCUS had a sensitivity of 62.50% (95% confidence interval 35.43% to 84.80%), specificity of 94.12% (88.26% to 97.60%), positive likelihood ratio (LR) 10.62 (4.71 to 23.95), negative LR 0.40 (0.21 to 0.75) and accuracy of 90.37% (84.10% to 94.77%) for detecting cardiogenic shock. Conclusion Detecting left ventricular dysfunction on FOCUS may be useful in the early identification of cardiogenic shock in otherwise undifferentiated hypotensive adult patients in the emergency department.

CO-aVoID: coronavirus outbreak affecting variability of presentations to a local emergency department.

BACKGROUND: The impact of the COVID-19 pandemic on public health, specifically on patients presenting to the emergency department (ED) with non-COVID-related diseases, remains largely undocumented. OBJECTIVE: This study explored how overall rates of presentations to the emergency department were impacted immediately after the declaration of the COVID-19 pandemic, and specifically how key presenting symptoms representing emergency, standard and low-acuity conditions were impacted. METHODS: A sequential modified Delphi survey and cross-sectional analysis of administrative census data from a tertiary care center in New Brunswick, Canada, were performed. Details of ED presentations for emergency, standard and low-acuity conditions from February 1 to April 30, 2020, were compared to data from previous years. RESULTS: There was a significant decrease in the number of patients visiting the ED with emergency, standard and low-acuity complaints immediately after March 13, 2020, compared to 2019. The proportion of females and males remained similar, with a median age of 48 years in 2020 and 44 years in 2019. Total presentation patterns to the ED (registrations, admissions to hospital and left without being seen numbers) decreased, compared to previous years. CONCLUSIONS: We report a predictable decrease in patient visits to the ED with minor, non-life-threatening conditions during a pandemic. However, we also report a decrease in presentations for emergency and standard conditions. Improved messaging highlighting the need to seek help for "true" emergencies, while providing non-ED options for minor, non-life-threatening conditions, may be helpful under normal circumstances and during future pandemics.

RéSUMé: CONTEXTE: L'impact de la pandémie COVID-19 sur la santé publique, en particulier sur les patients se présentant aux services d'urgence (SU) avec des maladies non liées à la COVID, demeure en grande partie non documenté. OBJECTIF: Cette étude a exploré la façon dont les taux globaux de présentations au service des urgences ont été touchés immédiatement après la déclaration de la pandémie de COVID-19, et plus particulièrement la façon dont les principaux symptômes représentant des conditions d'urgence, standard et de faible acuité ont été touchés. MéTHODES: Une enquête Delphi séquentielle modifiée et une analyse transversale des données du recensement administratif provenant d'un centre de soins tertiaires du Nouveau-Brunswick, au Canada, ont été réalisées. Les détails des présentations du SU pour les conditions d'urgence, standard et de faible acuité du 1er février au 30 avril 2020 ont été comparés aux données des années précédentes. RéSULTATS: Il y a eu une diminution significative du nombre de patients se rendant au service d'urgence avec des plaintes d'urgence, standard et de faible gravité immédiatement après le 13 mars 2020, par rapport à 2019. La proportion de femmes et d'hommes est demeurée semblable, avec un âge médian de 48 ans en 2020 et de 44 ans en 2019. Le nombre total de modèles de présentation à l'urgence (inscriptions, admissions à l'hôpital et nombre laissé sans être vu) a diminué par rapport aux années précédentes. CONCLUSIONS: Nous faisons état d'une diminution prévisible des visites de patients aux urgences pour des affections mineures qui ne mettent pas leur vie en danger pendant une pandémie. Toutefois, nous signalons également une diminution des présentations pour les situations d'urgence et les conditions normales. Des messages améliorés soulignant la nécessité de demander de l'aide pour les urgences « réelles ¼, tout en offrant des options non urgentes pour des conditions mineures et qui ne mettent pas la vie en danger peuvent être utiles dans des circonstances normales et lors de futures pandémies.

Deferasirox-induced liver injury and Fanconi syndrome in a beta-thalassemia major male.

A 33-year-old male presenting with subacute abdominal pain was found to have hyperbilirubinaemia, hypokalaemia and hyponatraemia. This was in the setting of transitioning between deferasirox iron chelator formulations, from dispersible tablets to film-coated tablets for ongoing treatment of chronic iron overload secondary to transfusion requirement for beta-thalassemia major. A liver biopsy demonstrated acute cholestasis with patchy confluent hepatocellular necrosis and mild to moderate microvesicular steatosis. Based on the histological, biochemical and clinical findings, the diagnosis of hepatotoxicity and Fanconi-like syndrome was made. The patient improved clinically and biochemically with cessation of the deferasirox film-coated tablets and supportive management. To our knowledge, this is the first case report of hepatotoxicity and Fanconi-like syndrome occurring due to deferasirox film-coated tablets with previous tolerance of dispersible deferasirox tablets. It is important to raise clinical awareness of this potentially severe complication.

The Metrics of Acute Care Reentry and Emergency Department Visits by Recently Discharged Inpatients.

Research on acute care reentry by recently discharged inpatients has generally focused on hospital readmissions, with less attention given to presentations to the emergency department (ED). This omission results in underestimation of the extent of reentry and its impact on ED patient volumes and flow. This project involved an analysis of administrative data to examine the rate of ED presentations by recently discharged inpatients using 3 time metrics-within 0-3 days, 0-7 days, and 0-30 days of discharge. Descriptive-correlational analyses were conducted to examine the rates of reentry and ability to predict ED presentations using patient demographic (age and sex) and clinical profile (length of hospital stay and day of presentation). Approximately 12% of hospital discharges to home involved patients who presented to the ED within 30 days, and almost half occurred within the first week. Results of multivariable analyses suggest that the influences of ED presentations differ depending on the time metric examined. Emergency department presentations within 3 and 7 days of discharge compared with 30 days were not predicted by patient age or sex but were more likely to involve those with shorter hospital stays. A weekend presentation was also more likely among case patients presenting within 3 days of discharge. Only about one third of ED presentations resulted in readmission. Emergency department presentations are an important component of acute care reentry. Establishment of a common reentry metric for ED presentations would facilitate efforts to determine the impact of these events. Emergency nurses working in advanced practice roles are ideally positioned to assume a leadership role in addressing the needs of recently discharged inpatients who present to the ED. By reviewing these cases and collaborating with the inpatient unit staff, it may be possible to identify strategies for augmenting discharge planning and the provision of transitional care.

Combatting Sedentary Lifestyles: Can Exercise Prescription in the Emergency Department Lead to Behavioral Change in Patients?

Introduction Emergency department (ED) patients with chronic disease are known to benefit from exercise; however, there are few studies examining the prescription of exercise in the ED. We asked, is exercise prescription in the ED feasible and effective? Methods In this pilot prospective block randomized trial, consented patients were divided into control and intervention groups. The control group received routine care. The intervention group received combined written and verbal prescriptions for moderate exercise of 150 minutes/week. Both groups were followed up by phone at two months. The primary outcome was achieving 150 minutes of exercise per week. Secondary outcomes included change in exercise and differences in reported median weekly exercise. Results Follow-up was completed for 23/28 patients (11 control; 12 intervention). Baseline reported median (with interquartile range) weekly exercise was similar between groups: control 0 (0-0) minutes, intervention 0 (0-45) minutes. There was no difference between groups for the primary outcome at two months (control 3/11; intervention 4/12, relative risk [RR] 1.33 (95% confidence interval [CI] 0.38-4.6; p=1.0). There was a significant increase in median exercise from baseline in both groups, but no difference between the groups (control 75 (10-225) minutes; intervention 120 (52.5-150) minutes; NS). A post hoc comparison of patients actually receiving intervention vs. no intervention revealed a significant increase in patients meeting the primary outcome (no intervention 0/8; intervention 7/15, RR 2.0 (95% CI 1.2-3.4); p=0.05). Conclusion The improvement seen in patients receiving the exercise prescription intervention, and the increase in reported exercise in both groups suggests that exercise prescription for ED patients may be beneficial.

Clinical Presentation, Treatment, and Mortality Rate in Liver Transplant Recipients With Coronavirus Disease 2019: A Systematic Review and Quantitative Analysis.

Liver transplant recipients may be at increased risk for adverse outcomes with coronavirus disease 2019 (COVID-19) infection because of chronic immunosuppression and associated comorbidities. There is a paucity of literature describing clinical presentation, treatments, and outcomes in liver transplant recipients with COVID-19. A systematic search was performed for articles published up to June 15, 2020, revealing 223 liver transplant recipients with COVID-19 in 15 studies. Patients most commonly presented with fever (66.7%), dyspnea (34.0%), and diarrhea (28.4%). Of these, 77.7% required hospitalization, 24% had mild disease, 40% had moderate disease, and 36% had severe disease. Immunosuppression was modified in 32.8% of recipients. The case fatality rate was 19.3%. Dyspnea on presentation, diabetes mellitus, and age 60 years or older were significantly associated with increased mortality (P ≤ .01) with a trend to higher mortality rate observed in those with hypertension and those receiving corticosteroids at the time of COVID-19 diagnosis. The median time from symptoms to death was 11.5 days (2-45 days). In conclusion, liver transplant recipients with severe acute respiratory syndrome coronavirus 2 are overrepresented with regard to severe disease and hospitalizations. Older liver transplant patients with diabetes mellitus or hypertension, who are on maintenance corticosteroids, with a diagnosis of COVID-19 and describing breathlessness should be aggressively monitored for signs of deterioration because of the risk for mortality.