Do monosymptomatic stroke patients with dizziness present a vestibular syndrome without nystagmus? An underestimated entity.

BACKGROUND AND PURPOSE: Vestibular symptoms are common in emergency department (ED) patients and have various causes, including stroke. Accurate identification of stroke in patients with vestibular symptoms is crucial for timely management. We conducted a prospective cross-sectional study from 2015 to 2019 to determine stroke prevalence and associated symptoms in ED patients with vestibular symptoms, aiming to improve diagnosis and outcomes. METHODS: As part of the DETECT project, we screened 1647 ED patients with acute vestibular symptoms. Following a retrospective analysis of 961 head and neck magnetic resonance imaging (MRI) scans, we included 122 confirmed stroke cases and assessed them for vestibular signs and symptoms. RESULTS: Stroke prevalence in dizzy patients was 13% (122/961 MRI scans). Most patients (95%) presented with acute vestibular symptoms with or without nystagmus, whereas 5% had episodic vestibular syndrome (EVS). Nystagmus was present in 50% of stroke patients. Eighty percent had a purely posterior circulation stroke, and nystagmus was absent in 46% of these patients. Seven patients (6%) had lesions in both the anterior and posterior circulation. Vertigo was experienced by 52% regardless of territory. CONCLUSIONS: A stroke was identified in 13% of ED patients presenting with acute vestibular symptoms. In 5%, it was EVS. Most strokes were in the posterior circulation territory; vertigo occurred with similar frequency in anterior and posterior circulation stroke, and absence of nystagmus was common in both.

Time for "code ICH"? - Workflow metrics of hyperacute treatments and outcome in patients with intracerebral haemorrhage.

INTRODUCTION: Knowledge about uptake and workflow metrics of hyperacute treatments in patients with non-traumatic intracerebral haemorrhage (ICH) in the emergency department are scarce. METHODS: Single centre retrospective study of consecutive patients with ICH between 01/2018-08/2020. We assessed uptake and workflow metrics of acute therapies overall and according to referral mode (stroke code, transfer from other hospital or other). RESULTS: We enrolled 332 patients (age 73years, IQR 63-81 and GCS 14 points, IQR 11-15, onset-to-admission-time 284 minutes, IQR 111-708minutes) of whom 101 patients (35%) had lobar haematoma. Mode of referral was stroke code in 129 patients (38%), transfer from other hospital in 143 patients (43%) and arrival by other means in 60 patients (18%). Overall, 143 of 216 (66%) patients with systolic blood pressure >150mmHG received IV antihypertensive and 67 of 76 (88%) on therapeutic oral anticoagulation received prothrombin complex concentrate treatment (PCC). Forty-six patients (14%) received any neurosurgical intervention within 3 hours of admission. Median treatment times from admission to first IV-antihypertensive treatment was 38 minutes (IQR 18-72minutes) and 59 minutes (IQR 37-111 minutes) for PCC, with significant differences according to mode of referral (p<0.001) but not early arrival (≤6hours of onset, p=0.92). The median time in the emergency department was 139 minutes (IQR 85-220 minutes) and among patients with elevated blood pressure, only 44% achieved a successful control (<140mmHG) during ED stay. In multivariate analysis, code ICH concordant treatment was associated with significantly lower odds for in-hopsital mortality (aOR 0.30, 95%CI 0.12-0.73, p=0.008) and a non-significant trends towards better functional outcome measured using the modified Rankin scale score at 3 months (aOR for ordinal shift 0.54 95%CI 0.26-1.12, p=0.097). CONCLUSION: Uptake of hyperacute therapies for ICH treatment in the ED is heterogeneous. Treatment delays are short but not all patients achieve treatment targets during ED stay. Code ICH concordant treatment may improve clinical outcomes. Further improvements seem achievable advocating for a "code ICH" to streamline acute treatments.

Epidemiology of maxillofacial trauma in elderly patients receiving oral anticoagulant or antithrombotic medication; a Swiss retrospective study.

BACKGROUND: The percentage of elderly trauma patients under anticoagulation and antiplatelet agents has been rising lately. As newer agents are introduced, each comes with its own advantages and precautions. Our study covered elderly patients admitted to the ED with maxillofacial trauma while on anticoagulation (AC) or antiplatelet therapy (APT). We aimed to investigate the demographic characteristics, causes, and types of maxillofacial trauma, along with concomitant injuries, duration of hospitalisation, haemorrhagic complications, and the overall costs of care in the emergency department (ED). METHODS: Data were gathered from the ED of Bern University Hospital. In this retrospective analysis, patients over 65 of age were included, who presented at our ED with maxillofacial trauma between 2013 and 2019 while undergoing treatment with therapeutic AC/APT. RESULTS: The study involved 188 patients with a median age of 81 years (IQR: 81 [74; 87]), of whom 55.3% (n=104) were male. More than half (54.8%, n=103) were aged 80 years or older. Cardiovascular diseases were present in 69.7% (n=131) of the patients, with the most common indications for AC/APT use being previous thromboembolic events (41.5%, n=78) and atrial fibrillation (25.5%, n=48). The predominant cause of facial injury was falls, accounting for 83.5% (n=157) of cases, followed by bicycle accidents (6.9%, n=13) and road-traffic accidents (5.3%, n=10). The most common primary injuries were fractures of the orbital floor and/or medial/lateral wall (60.1%, n=113), zygomatic bone (30.3%, n=57), followed by isolated orbital floor fractures (23.4%, n=44) and nasal bone fractures (19.1%, n=36). Fractures of the mandible occurred in 14.9% (n=28). Facial hematomas occurred in 68.6% of patients (129 cases), primarily in the midface area. Relevant facial bleeding complications were intracerebral haemorrhage being the most frequent (28.2%, n=53), followed by epistaxis (12.2%, n=23) and retrobulbar/intraorbital hematoma (9%, n=17). Sixteen patients (8.5%) experienced heavy bleeding that required emergency treatment. The in-hospital mortality rate was 2.1% (4 cases). CONCLUSIONS: This study indicates that falls are the leading cause of maxillofacial trauma in the elderly, with the most common diagnoses being orbital, zygomatic, and nasal fractures. Haemorrhagic complications primarily involve facial hematomas, especially in the middle third of the face, with intracerebral haemorrhage being the second most frequent. Surgical intervention for bleeding was required in 8.5% of cases. Given the aging population, it is essential to improve prevention strategies and update safety protocols, particularly for patients on anticoagulant/antiplatelet therapy (AC/APT). This can ensure rapid diagnostic imaging and prompt treatment in emergencies.

Diagnostic accuracy of a pragmatic, ultrasound-based approach to adult patients with suspected acute appendicitis in the ED.

BACKGROUND: Systematic imaging reduces the rate of missed appendicitis and negative appendectomies in patients with suspected acute appendicitis (AA). Little is known about the utility of ultrasound as a first diagnostic measure in patients with suspected AA. The aim of this retrospective study is to determine whether ultrasound, performed by emergency physicians or radiologists, can be used as first diagnostic measure in suspected cases to rule out AA and to avoid unnecessary CT. METHODS: We performed a retrospective analysis at the ED of the University Hospital Bern, Switzerland, from 2012 to 2014. Our standard protocol is that all adult patients suspected of appendicitis receive an ultrasound as their first imaging test, either by an emergency physician or a radiologist. The test characteristics of conclusive and inconclusive ultrasound exams were compared with a pragmatic gold standard. RESULTS: The study included 508 patients with suspected AA. 308 patients (60.4%) had a conclusive ultrasound. Among these, sensitivity for appendicitis was 89.6% (95% CI 82.1% to 94.3%), specificity 93.8% (89.1% to 96.6%), the positive predictive value was 87.98 (80.84 to 92.71) and the negative predictive value was 94.65 (91.18 to 96.80). The remaining 200 (39.4%) patients had an inconclusive ultrasound exam. 29% (59/200) of these patients ultimately had appendicitis. Less experienced emergency physician sonographers came to a definitive conclusion in 48.1% (95% CI 36.9% to 59.5%), experienced emergency physician sonographers in 76.0% (68.4% to 82.5%) and radiologists in 52.4% (44.5% to 60.2%). CONCLUSION: A conclusive ultrasound of the appendix performed by either emergency physicians or radiologists is a sensitive and specific exam to diagnose or exclude AA in patients with suspected AA. Because of 6% false negative exams, clinical follow-up is mandatory for patients with negative ultrasound. An inconclusive ultrasound warrants further imaging or a follow-up visit, since 29% of patients with inconclusive ultrasound had an AA.

Frequency and predictors of unspecific medical diagnoses in the emergency department: a prospective observational study.

BACKGROUND: Misdiagnosis is a major public health problem, causing increased morbidity and mortality. In the busy setting of an emergency department (ED) patients are diagnosed under difficult circumstances. As a consequence, the ED diagnosis at hospital admittance may often be a descriptive diagnosis, such as "decreased general condition". Our objective was to determine in how far patients with such an unspecific ED diagnosis differ from patients with a specific ED diagnosis and whether they experience a worse outcome. METHODS: We conducted a prospective observational study in Bern university hospital in Switzerland for all adult non-trauma patients admitted to any internal medicine ward from August 15th 2015 to December 7th 2015. Unspecific ED diagnoses were defined through the clinical classification software for ICD-10 by two outcome assessors. As outcome parameters, we assessed in-hospital mortality and length of hospital stay. RESULTS: Six hundred eighty six consecutive patients were included. Unspecific diagnoses were identified in 100 (14.6%) of all consultations. Patients receiving an unspecific diagnosis at ED discharge were significantly more often women (56.0% vs. 43.9%, p = 0.024), presented more often with a non-specific complaint (34% vs. 21%, p = 0.004), were less often demonstrating an abnormal heart rate (5.0% vs. 12.5%, p = 0.03), and less often on antibiotics (32.0% vs. 49.0%, p = 0.002). Apart from these, no studied drug intake, laboratory or clinical data including change in diagnosis was associated significantly with an unspecific diagnosis. Unspecific diagnoses were neither associated with in-hospital mortality in multivariable analysis (OR = 1.74, 95% CI: 0.60-5.04; p = 0.305) adjusted for relevant confounders nor with length of hospital stay (GMR = 0.87, 95% CI: 0.23-3.32; p = 0.840). CONCLUSIONS: Women and patients with non-specific presenting complaints and no abnormal heart rate are at risk of receiving unspecific ED diagnoses that do not allow for targeted treatment, discharge and prognosis. This study did not find an effect of such diagnoses on length of hospital stay nor in-hospital mortality.

A universal anti-Xa assay for rivaroxaban, apixaban, and edoxaban measurements: method validation, diagnostic accuracy and external validation.

A universal anti-Xa assay for the determination of rivaroxaban, apixaban and edoxaban drug concentrations would simplify laboratory procedures and facilitate widespread implementation. Following two pilot studies analysing spiked samples and material from 698 patients, we conducted a prospective multicentre cross-sectional study, including 867 patients treated with rivaroxaban, apixaban or edoxaban in clinical practice to comprehensively evaluate a simple, readily available anti-Xa assay that would accurately measure drug concentrations and correctly predict relevant levels in clinical practice. Anti-Xa activity was measured by an assay calibrated with low-molecular-weight heparin (LMWH) in addition to ultra-high performance liquid chromatography-tandem mass spectrometry (LC-MS/MS). As an external validation, LMWH-calibrated anti-Xa activity was also determined in nine external laboratories. The LMWH-calibrated anti-Xa activity correlated strongly with rivaroxaban, apixaban or edoxaban drug levels [rs  = 0·98, 95% confidence interval (CI) 0·98-0·98]. The sensitivity for the clinically relevant cut-off levels of 30, 50 and 100 µg/l was 96·2% (95% CI 94·4-97·4), 96·4% (95% CI 94·4-97·7) and 96·7% (95% CI 94·3-98·1) respectively. Concordant results were obtained in the external validation study. In conclusion, a universal, LMWH-calibrated anti-Xa assay accurately measured rivaroxaban, apixaban and edoxaban concentrations and correctly predicted relevant drug concentrations in clinical practice.

Bruns' nystagmus revisited: A sign of stroke in patients with the acute vestibular syndrome.

OBJECTIVE: Gaze-evoked nystagmus (GEN) is a central sign in patients with the acute vestibular syndrome (AVS); however, discriminating between a pathological and a physiologic GEN is a challenge. Here we evaluate GEN in patients with AVS. METHODS: In this prospective cross-sectional study, we used video-oculography (VOG) to compare GEN in the light (target at 15° eccentric) in 64 healthy subjects with 47 patients seen in the emergency department (ED) who had AVS; 35 with vestibular neuritis and 12 with stroke. All patients with an initial non-diagnostic MRI received a confirmatory, delayed MRI as a reference standard in detecting stroke. RESULTS: Healthy subjects with GEN had a time constant of centripetal drift >18 s. VOG identified pathologic GEN (time constant ≤ 18 s) in 33% of patients with vestibular strokes, specificity was 100%, accuracy was 83%. Results were equivalent to examination by a clinical expert. As expected, since all patients with GEN had a SN in straight-ahead position, they showed the pattern of a Bruns' nystagmus. CONCLUSIONS: One third of patients with AVS due to central vestibular strokes had a spontaneous SN in straight-ahead gaze and a pathological GEN, producing the pattern of a Bruns' nystagmus with a shift of the null position. The localization of the side of the lesion based on the null was not consistent, presumably because the circuits underlying gaze-holding are widespread in the brainstem and cerebellum. Nevertheless, automated quantification of GEN with VOG was specific, and accurately identified patients in the ED with AVS due to strokes.

Online forward triage during the COVID-19 outbreak.

Health systems face major challenges during the COVID-19 pandemic with new information and challenges emerging daily and frequently changing guidelines. Online forward triage tools (OFTTs) provide useful information, direct patients and free physician resources.We implemented an OFTT targeted at the current pandemic, adapted the content and goals and assessed its effects. The OFTT was implemented on 2 March 2020 and modified regularly based on the revised testing criteria issued by the Swiss Federal Office of Public Health. After testing criteria liberalised, a chatbot tool was set up on 9 April 2020 to assess urgency of testing, referral to available testing sites and need for emergency care.In the first 40 days of the OFTT, there were more than 17 300 visitors and 69.8% indicated they would have contacted the healthcare system if the online test had not been available. During the initial week of operation, using the conservative testing strategy, 9.1% of visitors received recommendations to be tested, which increased to 36.0% of visitors after a change in testing criteria on 9 March 2020. Overall, since the implementation of the tool, 26.27% of all users of the site have been directed to obtain testing. The Chatbot tool has had approximately 50 consults/day.Setting up an OFTT should be considered as part of local strategies to cope with the COVID-19 pandemic. It may ease the burden on the healthcare system, reassure patients and inform authorities. To account for the dynamic development of the pandemic, frequent adaptation of the tool is of great importance. Further research on clinical outcomes of OFTT is urgently needed.

Impaired kidney function at ED admission: a comparison of bleeding complications of patients with different oral anticoagulants.

BACKGROUND: Up to a fourth of patients at emergency department (ED) presentation suffer from acute deterioration of renal function, which is an important risk factor for bleeding events in patients on oral anticoagulation therapy. We hypothesized that outcomes of patients, bleeding characteristics, therapy, and outcome differ between direct oral anticoagulants (DOACs) and vitamin-K antagonists (VKAs). METHODS: All anticoagulated patients older than 17 years with an impaired kidney function treated for an acute haemorrhage in a large Swiss university ED from 01.06.2012 to 01.07.2017 were included in this retrospective cohort study. Patient, treatment, and bleeding characteristics as well as outcomes (length of stay ED, intensive care unit and in-hospital admission, ED resource consumption, in-hospital mortality) were compared between patients on DOAC or VKA anticoagulant. RESULTS: In total, 158 patients on DOAC and 419 patients on VKA with acute bleeding and impaired renal function were included. The renal function in patients on VKA was significantly worse compared to patients on DOAC (VKA: median 141 µmol/L vs. DOAC 132 µmol/L, p = 0.002). Patients on DOAC presented with a smaller number of intracranial bleeding compared to VKA (14.6% DOAC vs. 22.4% VKA, p = 0.036). DOAC patients needed more emergency endoscopies (15.8% DOAC vs, 9.1% VKA, p = 0.020) but less interventional emergency therapies to stop the bleeding (13.9% DOAC vs. 22.2% VKA, p = 0.027). Investigated outcomes did not differ significantly between the two groups. CONCLUSIONS: DOAC patients were found to have a smaller proportional incidence of intracranial bleedings, needed more emergency endoscopies but less often interventional therapy compared to patients on VKA. Adapted treatment algorithms are a potential target to improve care in patients with DOAC.

A dangerously underrated entity? Non-specific complaints at emergency department presentation are associated with utilisation of less diagnostic resources.

BACKGROUND: Patients presenting with non-specific complaints (NSC), such as generalised weakness, or feeling unwell, constitute about 20% of emergency care consultations. In contrast to patients presenting with specific symptoms, these patients experience more hospitalisations, longer stays in hospital and even higher mortality. However, little is known about the actual resources spent on patients with NSC in the emergency department (ED). METHODS: We have conducted a retrospective analysis from January 1st, 2013 until December 31st, 2017 in a Swiss tertiary care ED to assess the impact of NSC on the utilisation of diagnostic resources in adult patients with highlyurgent or urgent medical complaints. RESULTS: We randomly selected 1500 medical consultations from our electronic health record database: The majority of patients (n = 1310, 87.3%) presented with a specific complaint; n = 190 (12.7%) with a NSC. Univariate analysis showed no significant difference in the utilisation of total diagnostic resources in the ED [specific complaints: 844 (577-1313) vs. NSC: 778 (551-1183) tax points, p = 0.092, median (interquartile range)]. A backward selection logistic regression model was adjusted for the identified covariates (age, diabetes, cerebrovascular and liver disease, malignancy, past myocardial infarction, antihypertensive, antithrombotic or antidiabetic medication, night or weekend admission and triage category). This identified a significant association of NSC with lower utilisation of ED diagnostic resources [geometric mean ratio (GMR) 0.91, 95% CI: 0.84-0.99, p = 0.042]. CONCLUSIONS: Non-specific complaints (NSC) are a frequent reason for emergency medicine consultations and are associated with lower utilisation of diagnostic resources during ED diagnostic testing than with specific complaints.

An observational study of self-monitoring in ad hoc health care teams.

BACKGROUND: Working in ad hoc teams in a health care environment is frequent but a challenging and complex undertaking. One way for teams to refine their teamwork could be through post-resuscitation reflection and debriefing. However, this would require that teams have insight into the quality of their teamwork. This study investigates (1) the accuracy of the self-monitoring of ad hoc resuscitation teams and their leaders relative to external observations of their teamwork and (2) the relationship of team self-monitoring and external observations to objective performance measures. METHODS: We conducted a quantitative observational study of real-world ad hoc interprofessional teams responding to a simulated cardiac arrest in an emergency room. Teams consisting of residents, consultants, and nurses were confronted with an unexpected, simulated, standardized cardiac arrest situation. Their teamwork was videotaped to allow for subsequent external evaluation on the team emergency assessment measure (TEAM) checklist. In addition, objective performance measures such as time to defibrillation were collected. All participants completed a demographic questionnaire prior to the simulation and a questionnaire tapping their perceptions of teamwork directly after it. RESULTS: 22 teams consisting of 115 health care professionals showed highly variable performance. All performance measures intercorrelated significantly, with the exception of team leaders' evaluations of teamwork, which were not related to any other measures. Neither team size nor cumulative experience were correlated with any measures, but teams led by younger leaders performed better than those led by older ones. CONCLUSION: Team members seem to have better insight into their team's teamwork than team leaders. As a practical consequence, the decision to debrief and the debriefing itself after a resuscitation should be informed by team members, not just leaders.

What determines diagnostic resource consumption in emergency medicine: patients, physicians or context?

OBJECTIVES: A major cause for concern about increasing ED visits is that ED care is expensive. Recent research suggests that ED resource consumption is affected by patients' health status, varies between physicians and is context dependent. The aim of this study is to determine the relative proportion of characteristics of the patient, the physician and the context that contribute to ED resource consumption. METHODS: Data on patients, physicians and the context were obtained in a prospective observational cohort study of patients hospitalised to an internal medicine ward through the ED of the University Hospital Bern, Switzerland, between August and December 2015. Diagnostic resource consumption in the ED was modelled through a multilevel mixed effects linear regression. RESULTS: In total, 473 eligible patients seen by one of 38 physicians were included in the study. Diagnostic resource consumption heavily depends on physicians' ratings of case difficulty (p<0.001, z-standardised regression coefficient: 147.5, 95% CI 87.3 to 207.7) and-less surprising-on patients' acuity (p<0.001, 126.0, 95% CI 65.5 to 186.6). Neither the physician per se, nor their experience, the patients' chronic health status or the context seems to have a measurable impact (all p>0.05). CONCLUSIONS: Diagnostic resource consumption in the ED is heavily affected by physicians' situational confidence. Whether we should aim at altering physician confidence ultimately depends on its calibration with accuracy.

Characteristics and resource needs in patients with vestibular symptoms: a comparison of patients with symptoms of unknown versus determined origin.

BACKGROUND: Vestibular symptoms are a frequent reason for presenting at the emergency department (ED). Underlying conditions range in severity from life-threatening to benign, but often remain undiagnosed despite extensive investigations. We aimed to identify clinical characteristics that are associated with ED consultations by patients with vestibular symptoms of unknown origin (VUO) and to quantify the ED resources consumed during the investigations. METHODS: This retrospective one-year, single-centre, cross-sectional study assessed ED consultations with patients whose chief complaint was 'vestibular symptoms'. Data on risk factors, clinical characteristics, management and ED resources were extracted from the administrative database and medical records. Consultations were grouped according to the discharge diagnosis as either VUO or non-VUO. We determined clinical factors associated with VUO and compared ED resource consumption by the two patient groups using multivariable analysis. RESULTS: A total of 1599 ED consultations were eligible. Of these, 14.3% (n = 229) were consultations with patients with VUO. Clinical characteristics included in the final multivariable model to determine associations with VUO were sensory disorders, aural fullness, improvement at rest, absence of situational provocation, pre-existing neurological conditions, and age < 65 years. Patients with VUO had higher total ED resource consumption in terms of physicians' work and radiology resources, as a result of more use of computed tomography and magnetic resonance imaging. CONCLUSION: One in seven emergency patients with vestibular symptoms is dismissed without a diagnosis. Clinical characteristics of VUO patients are distinct from patients in whom a diagnosis was made in the ED. VUO triggers higher ED resource consumption, which can be justified if appropriately indicated.

Characteristics, treatment and outcome of bleeding after tooth extraction in patients on DOAC and phenprocoumon compared to non-anticoagulated patients-a retrospective study of emergency department consultations.

OBJECTIVES: Bleeding after tooth extraction range from minor bleeding to life-threating haemorrhagic shock and are among the leading complications in patients under oral anticoagulation with direct oral anticoagulants (DOACs) or phenprocoumon. Little is known about how anticoagulation in patients under DOAC or phenprocoumon alters the characteristics, treatment or outcome of bleeding events, in comparison to non-anticoagulated patients. METHODS: Patients admitted to a tertiary ED in Bern, Switzerland, from June 1st 2012 to 31st May 2016 with bleeding related to tooth extraction under DOAC, phenprocoumon or without anticoagulation, were compared. RESULTS: Out of 161,458 emergency consultations, 64 patients with bleeding from tooth extraction were included in our study. In anticoagulation groups, we found significantly more delayed bleeding events than in patients without anticoagulation (9 (81.3%) DOAC, 19 (86.4%) phenprocoumon, 8 (30.8%) no anticoagulation, p < 0.001). Anticoagulated patients had to stay longer in the ED than non-anticoagulated patients, with no significant difference between DOAC or phenprocoumon (hours: 4.8 (3.2-7.6 IQR) DOAC, 3.0 (2.0-5.5 IQR) phenprocoumon, p = 0.133; 2.7 (1.6-4.6) no anticoagulation; p = 0.039). More patients with anticoagulation therapy needed surgery than patients without anticoagulant therapy (11 (68.8%) DOAC, 12 (54.6%) VKA, p = 0.506; 7(26.9%) no anticoagulation; p = 0.020). CONCLUSIONS: Delayed bleeding occur more often in anticoagulated patients with both DOAC and phenprocoumon compared to patients without anticoagulation. Bleeding events in anticoagulated patients with DOAC and phenprocoumon equally need longer ED treatment and more frequent surgical intervention. CLINICAL RELEVANCE: Caution with delayed bleeding in anticoagulated patients with DOACs and phenprocoumon is necessary and treatment of bleeding is resource-demanding.

Detection of pneumothoraces in patients with multiple blunt trauma: use and limitations of eFAST.

BACKGROUND: Extended focused assessment with sonography for trauma (eFAST) has been shown to have moderate sensitivity for detection of pneumothorax in trauma. Little is known about the location or size of missed pneumothoraces or clinical predictors of pneumothoraces in patients with false-negative eFAST. METHODS: This retrospective cross-sectional study includes all patients with multiple blunt trauma diagnosed with pneumothorax who underwent both eFAST and CT performed in the ED of a level 1 trauma centre in Switzerland between 1 June 2012 and 30 September 2014. Sensitivity of eFAST for pneumothorax was determined using CT as the gold standard. Demographic and clinical characteristics of those who had a pneumothorax detected by eFAST and those who did not were compared using the Mann-Whitney U or Pearson's χ2 tests. Univariate binary logistic regression models were used to identify predictors for pneumothoraces in patients with negative eFAST examination. RESULTS: The study included 109 patients. Overall sensitivity for pneumothorax on eFAST was 0.59 and 0.81 for pneumothoraces requiring treatment. Compared with those detected by eFAST, missed pneumothoraces were less likely to be ventral (30 (47.6%) vs 4 (9.3%), p <0.001) and more likely to be apical and basal (7 (11.1%) vs 15 (34.9%), p=0.003; 11 (17.5%) vs 18 (41.9%), p=0.008, respectively). The missed pneumothoraces were smaller than the detected pneumothoraces (left side: 30.7±17.4 vs 12.1±13.9 mm; right side: 30.2±10.1 vs 6.9±10.2 mm, both p <0.001). No clinical variables were identified which predicted pneumothoraces in falsely negative eFAST. Among those pneumothoraces missed by eFAST, 30% required tube thoracostomy compared with 88.9% of those detected with eFAST. CONCLUSION: In our study, pneumothoraces missed by eFAST were smaller and in atypical locations compared with those detected by eFAST and needed thoracic drainage less often.

Use of Diuretics is not associated with mortality in patients admitted to the emergency department: results from a cross-sectional study.

BACKGROUND: Patients with diuretic therapy are at risk for drug-induced adverse reactions. It is unknown if presence of diuretic therapy at hospital emergency room admission is associated with mortality. METHODS: In this cross sectional analysis, all emergency room patients 2010 and 2011 at the Inselspital Bern, Switzerland were included. A multivariable logistic regression model was performed to assess the association between pre-existing diuretic medication and 28 day mortality. RESULTS: Twenty-two thousand two hundred thirty-nine subjects were included in the analysis. A total of 8.5%, 2.5%, and 0.4% of patients used one, two, or three or more diuretics. In univariate analysis spironolactone, torasemide and chlortalidone use were associated with 28 day mortality (all p < 0.05). In a multivariate cox regression model no association with mortality was detectable (p > 0.05). No difference existed between patients with or without diuretic therapy (P > 0.05). Age and creatinine were independent risk factors for mortaliy (both p < 0.05). CONCLUSION: Use of diuretics is not associated with mortality in an unselected cohort of patients presenting in an emergency room.

Age is not associated with intracranial haemorrhage in patients with mild traumatic brain injury and oral anticoagulation.

BACKGROUND: Patients admitted to emergency departments with traumatic brain injury (TBI) are commonly being treated with oral anticoagulants. In contrast to patients without anticoagulant medication, no guidelines, scores or recommendations exist for the management of mild traumatic brain injury in these patients. We therefore tested whether age as one of the high risk factors of the Canadian head CT rule is applicable to a patient population on oral anticoagulants. METHODS: This cross-sectional analysis included all patients with mild TBI and concomitant oral anticoagulant therapy admitted to the Emergency Department, Inselspital Bern, Switzerland, from November 2009 to October 2014 (n = 200). Using a logistic regression model, two groups of patients with mild TBI on oral anticoagulant therapy were compared - those with and those without intracranial haemorrhage. RESULTS: There was no significant difference in age between the patient groups with (n = 86) and without (n = 114) intracranial haemorrhage (p = 0.078). In univariate logistic regression, GCS (OR = 0.419 (0.258; 0.680)) and thromboembolic event as reason for anticoagulant therapy (OR = 0.486 (0.257; 0.918)) were significantly associated with intracranial haemorrhage in patients with mild TBI and anticoagulation (all p < 0.05). However, there was no association with age (p = 0.078, OR = 1.024 (0.997; 1.051)), the type of accident or additional medication with acetylsalicylic acid or clopidogrel ((both p > 0.05; 0.552 (0.139; 2.202) and 0.256 (0.029; 2.237), respectively). CONCLUSION: Our study found no association between age and intracranial bleeding. Therefore, until further risk factors are identified, diagnostic imaging with CCT remains necessary for mild TBI patients on oral anticoagulation of all ages, especially those with therapeutic anticoagulation because of thromboembolic events.

[Medical extended reality in digital emergency medicine : From education to clinical application]. / Medical Extended Reality in der digitalen Notfallmedizin : Von der Ausbildung zur klinischen Anwendung.

BACKGROUND: Emergency medicine faces the challenge of providing optimal care with limited resources. Especially in rare but critical situations (high-acuity low occurrence [HALO] situations), sound expertise is essential. Previous training approaches are time-limited and resource-intensive. AIM OF THE WORK: Medical extended reality (MXR) offers promising solutions. This article gives insight into the different areas of MXR and shows the application of MXR in emergency medicine using the HALO-MXR concept as an example. RESULTS AND DISCUSSION: MXR encompasses augmented reality (AR), virtual reality (VR) and mixed reality (MR). AR overlays digital information on the real world, enhancing perception and enabling interactive elements. VR creates an artificial three-dimensional (3D) environment in which the user is immersed. MR combines real and virtual elements. MXR offers advantages such as location-independent learning, virtual mentoring and scalability. However, it cannot replace existing training formats, but should be embedded in an overall concept. The HALO-MXR concept at Inselspital Bern includes e­learning, simulation-based training in VR and on-site, and HALO-Assist support through augmented reality. HALO-Assist provides around-the-clock AR support for HALO procedures via audio and video communication as well as overlayed annotations, objects and flowcharts. CONCLUSION: The integration of MXR into emergency medicine promises more efficient use of resources and enhanced training opportunities. The HALO-MXR concept demonstrates how MXR effectively combines simulation-based training in VR and AR assist to enhance the application of HALO procedures.

Perceptions and needs of an outpatient palliative care team regarding digital care conferences in palliative care: a mixed-method online survey.

BACKGROUND: Telemedicine in palliative care (PC) is increasingly being used, especially in outpatient settings with large geographic distances. Its proven benefits include improved communication, coordination quality and time savings. However, the effect on symptom control is less evident. Whether these benefits apply to the Swiss setting and the needs of healthcare professionals (HCPs) is unknown. OBJECTIVES: To identify the perceptions and needs of healthcare professionals (nurses and physicians) regarding telemedicine (generally and specifically for care conferences) in a Swiss outpatient palliative care network. METHODS: We conducted a cross-sectional, mixed-method online survey with purposefully sampled healthcare professionals from an outpatient palliative care team as baseline data during the planning phase of a quality improvement project (digital care conferences). FINDINGS/RESULTS: Of the 251 HCPs approached, 66 responded, including nurses (n = 37) and physicians (n = 29), with an overall response rate of 26.6%. These were distributed into two groups: general palliative care HCPs (n = 48, return rate 21.3%) and specialised palliative care HCPs (n = 18, return rate 69.2%). Generally, telemedicine was perceived as useful. Potential easy access to other HCPs and hence improved communication and coordination were perceived as advantages. Barriers included a lack of acceptance and physical contact, unsolved questions about potential data breaches and technical obstacles. Regarding digital care conferences, the perceived acceptance and feasibility were good; preferred participants were the specialised palliative care HCPs (nurses and physicians), primary physicians and home care nurses, as well as the leadership of a nurse. The needs of the HCPs were as follows: (a) clear and efficient planning, (b) usability and security and (c) visual contact with the patient. CONCLUSION: Digital care conferences are perceived as a feasible and useful tool by healthcare professionals in a local palliative care network in Switzerland. A pilot phase will be the next step towards systematic integration of this telemedicine modality into outpatient palliative care.

Effects of interacting with a large language model compared with a human coach on the clinical diagnostic process and outcomes among fourth-year medical students: study protocol for a prospective, randomised experiment using patient vignettes.

INTRODUCTION: Versatile large language models (LLMs) have the potential to augment diagnostic decision-making by assisting diagnosticians, thanks to their ability to engage in open-ended, natural conversations and their comprehensive knowledge access. Yet the novelty of LLMs in diagnostic decision-making introduces uncertainties regarding their impact. Clinicians unfamiliar with the use of LLMs in their professional context may rely on general attitudes towards LLMs more broadly, potentially hindering thoughtful use and critical evaluation of their input, leading to either over-reliance and lack of critical thinking or an unwillingness to use LLMs as diagnostic aids. To address these concerns, this study examines the influence on the diagnostic process and outcomes of interacting with an LLM compared with a human coach, and of prior training vs no training for interacting with either of these 'coaches'. Our findings aim to illuminate the potential benefits and risks of employing artificial intelligence (AI) in diagnostic decision-making. METHODS AND ANALYSIS: We are conducting a prospective, randomised experiment with N=158 fourth-year medical students from Charité Medical School, Berlin, Germany. Participants are asked to diagnose patient vignettes after being assigned to either a human coach or ChatGPT and after either training or no training (both between-subject factors). We are specifically collecting data on the effects of using either of these 'coaches' and of additional training on information search, number of hypotheses entertained, diagnostic accuracy and confidence. Statistical methods will include linear mixed effects models. Exploratory analyses of the interaction patterns and attitudes towards AI will also generate more generalisable knowledge about the role of AI in medicine. ETHICS AND DISSEMINATION: The Bern Cantonal Ethics Committee considered the study exempt from full ethical review (BASEC No: Req-2023-01396). All methods will be conducted in accordance with relevant guidelines and regulations. Participation is voluntary and informed consent will be obtained. Results will be published in peer-reviewed scientific medical journals. Authorship will be determined according to the International Committee of Medical Journal Editors guidelines.