A Pressing Matter: Compressive Postoperative Hematoma Causing Acute Diastolic Heart Failure.

BACKGROUND: Cardiopulmonary complications in the postoperative period can lead to significant morbidity and mortality. Many of the complications in the postoperative period occur after discharge from the hospital, and up to 25% of patients will require readmission. In postoperative patients presenting to the emergency department (ED), it is important to consider that postoperative complications can affect a multitude of organ systems, including those that are adjacent to where the surgery was performed. CASE REPORT: We present the case of a 54-year-old woman presenting to the ED with shortness of breath in the setting of recent Nissen fundoplication revision. Pulmonary angiography was significant for a large hiatal hernia and negative for pulmonary embolism. She was discharged and returned to the ED a few days later due to worsening symptoms. Further diagnostic studies demonstrated an esophageal hematoma causing compression of the left atrium, leading to acute diastolic heart failure. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: It is important to consider alternative etiologies for common complaints in the postoperative patient presenting to the ED. Early involvement of the operative team in the patient's care can assist in directing diagnostic approach and management of the postoperative patient.

Identifying Cancer Screening Adherence in the Emergency Department Utilizing Research Associates.

BACKGROUND: Despite the demonstrated benefits of regular screening, a large proportion of the adult female population are out of compliance with recommendations from specialty societies regarding breast and cervical cancer. OBJECTIVE: The current study investigated whether research associates (RAs) in the emergency department (ED) can usefully assess patients' recent compliance with breast and cervical cancer screening (BCCS) recommendations and provide information regarding how patients may access any recommended screening when it is overdue. METHODS: RAs at 5 heterogeneous hospitals in the United States approached willing nonemergent female patients and visitors between the ages of 21 and 74 years. After obtaining verbal consent, the participant's compliance with U.S. Preventive Service Task Force recommendations for BCCS was assessed. Participants found overdue for screening were provided information on how to obtain these recommended screenings. RESULTS: A total of 5419 participants were between 50 and 74 years old and would be recommended to have breast cancer screening, and 11,667 participants were between 21 and 65 years old and would be recommended to have cervical cancer screening. Among women of age for either of these screenings, 3169 reported that they did not have a women's primary health care provider (i.e., doctor, nurse practitioner, or physician assistant who manages women's primary health care issues). A total of 786 women (15% of women 50-74 years old) were found to be out of compliance with breast cancer screening guidelines and 1208 women (12% of women 21 to 65 years with intact uteruses) were found to be out of compliance with cervical cancer screening guidelines. CONCLUSIONS: Our results indicate that RAs can identify large numbers of women who should undergo BCCS screening across a variety of emergency department settings.

Early Recognition and Treatment of Acute Disseminated Encephalomyelitis in Pediatrics: A Case Series.

OBJECTIVE: Our aim is to emphasize the varied presentation of acute disseminated encephalomyelitis (ADEM) to help health care professionals improve recognition of the disease in a timely manner, thereby allowing for the selection of an appropriate treatment regimen. Therefore, this may avoid neurocognitive consequences and the ultimate fatality of the patient. PATIENTS AND METHODS: This is a retrospective case series involving 7 cases of children presenting to the Pediatric Emergency Department of Hackensack University Medical Center who were ultimately diagnosed with ADEM. RESULTS: In many of the cases, a preceding viral-like illness with nonspecific symptomatology made it difficult to accurately establish an initial diagnosis. Ultimately, the neurologic symptoms spontaneously resolved or improved with administration of high-dose steroids. CONCLUSIONS: Children presenting to the emergency department with nonspecific symptoms associated with any neurological deficits should undergo further investigation using magnetic resonance imaging and lumbar puncture to rule out rare yet possibly fatal diseases such as ADEM.

Psychosocial risk factors for hypertension: an update of the literature.

A growing body of research demonstrates that psychosocial factors play an important role in the development of hypertension. Previous reviews have identified several key factors (i.e., occupational stress) that contribute to the onset of hypertension; however, they are now outdated. In this review, we provide an updated synthesis of the literature from 2010 to April 2014. We identified 21 articles for inclusion in the review, of which there were six categories of psychosocial stressors: occupational stress, personality, mental health, housing instability, social support/isolation, and sleep quality. Sixteen of the studies reported an association between the psychosocial stressor and blood pressure. While several findings were consistent with previous literature, new findings regarding mediating and moderating factors underlying the psychosocial-hypertension association help to untangle inconsistencies reported in the literature. Moreover, sleep quality is a novel additional factor that should undergo further exploration. Areas for future research based on these findings are discussed.

Educational Outcomes of Diversity Curricula in Graduate Medical Education.

Background: Education is an important step toward achieving equity in health care. However, there is little published literature examining the educational outcomes of curricula for resident physicians focused on diversity, equity, and inclusion (DEI). Objective: Our objective was to review the literature to assess the outcomes of curricula for resident physicians of all specialties focused on DEI in medical education and health care. Methods: We applied a structured approach to conducting a scoping review of the medical education literature. Studies were included for final analysis if they described a specific curricular intervention and educational outcomes. Outcomes were characterized using the Kirkpatrick Model. Results: Nineteen studies were included for final analysis. Publication dates ranged from 2000 to 2021. Internal medicine residents were the most studied. The number of learners ranged from 10 to 181. The majority of studies were from a single program. Educational methods ranged from online modules to single workshops to multiyear longitudinal curricula. Eight studies reported Level 1 outcomes, 7 studies reported Level 2 outcomes, 3 studies reported Level 3 outcomes, and only 1 study measured changes in patient perceptions due to the curricular intervention. Conclusions: We found a small number of studies of curricular interventions for resident physicians that directly address DEI in medical education and health care. These interventions employed a wide array of educational methods, demonstrated feasibility, and were positively received by learners.

AWAreness during REsuscitation - II: A multi-center study of consciousness and awareness in cardiac arrest.

INTRODUCTION: Cognitive activity and awareness during cardiac arrest (CA) are reported but ill understood. This first of a kind study examined consciousness and its underlying electrocortical biomarkers during cardiopulmonary resuscitation (CPR). METHODS: In a prospective 25-site in-hospital study, we incorporated a) independent audiovisual testing of awareness, including explicit and implicit learning using a computer and headphones, with b) continuous real-time electroencephalography(EEG) and cerebral oxygenation(rSO2) monitoring into CPR during in-hospital CA (IHCA). Survivors underwent interviews to examine for recall of awareness and cognitive experiences. A complementary cross-sectional community CA study provided added insights regarding survivors' experiences. RESULTS: Of 567 IHCA, 53(9.3%) survived, 28 of these (52.8%) completed interviews, and 11(39.3%) reported CA memories/perceptions suggestive of consciousness. Four categories of experiences emerged: 1) emergence from coma during CPR (CPR-induced consciousness [CPRIC]) 2/28(7.1%), or 2) in the post-resuscitation period 2/28(7.1%), 3) dream-like experiences 3/28(10.7%), 4) transcendent recalled experience of death (RED) 6/28(21.4%). In the cross-sectional arm, 126 community CA survivors' experiences reinforced these categories and identified another: delusions (misattribution of medical events). Low survival limited the ability to examine for implicit learning. Nobody identified the visual image, 1/28(3.5%) identified the auditory stimulus. Despite marked cerebral ischemia (Mean rSO2 = 43%) normal EEG activity (delta, theta and alpha) consistent with consciousness emerged as long as 35-60 minutes into CPR. CONCLUSIONS: Consciousness. awareness and cognitive processes may occur during CA. The emergence of normal EEG may reflect a resumption of a network-level of cognitive activity, and a biomarker of consciousness, lucidity and RED (authentic "near-death" experiences).

Development and evaluation of a novel, real time mobile telesonography system in management of patients with abdominal trauma: study protocol.

BACKGROUND: Despite the use of e-FAST in management of patients with abdominal trauma, its utility in prehospital setting is not widely adopted. The goal of this study is to develop a novel portable telesonography (TS) system and evaluate the comparability of the quality of images obtained via this system among healthy volunteers who undergo e-FAST abdominal examination in a moving ambulance and at the ED. We hypothesize that: (1) real-time ultrasound images of acute trauma patients in the pre-hospital setting can be obtained and transmitted to the ED via the novel TS system; and (2) Ultrasound images transmitted to the hospital from the real-time TS system will be comparable in quality to those obtained in the ED. METHODS: Study participants are three healthy volunteers (one each with normal, overweight and obese BMI category). The ultrasound images will be obtained by two ultrasound-trained physicians The TS is a portable sonogram (by Sonosite) interfaced with a portable broadcast unit (by Live-U). Two UTPs will conduct e-FAST examinations on healthy volunteers in moving ambulances and transmit the images via cellular network to the hospital server, where they are stored. Upon arrival in the ED, the same UTPs will obtain another set of images from the volunteers, which are then compared to those obtained in the moving ambulances by another set of blinded UTPs (evaluators) using a validated image quality scale, the Questionnaire for User Interaction Satisfaction (QUIS). DISCUSSION: Findings from this study will provide needed data on the validity of the novel TS in transmitting live images from moving ambulances to images obtained in the ED thus providing opportunity to facilitate medical care of a patient located in a remote or austere setting.

Obesity and the Other Independent Predictors in Elective Endotracheal Tube Intubations: A Narrative Review.

Obesity is one of the challenging elements in health care. Studies have shown that as the body mass index (BMI) increases, the risk of chronic conditions tends to increase due to altered physiologic and metabolic demands. In addition to underlying physiological changes, anatomical changes can lead to common procedural challenges, such as difficult intravenous (IV) cannulation, difficult airway, and difficult intubation, which makes their preoperative and postoperative care challenging for the anesthesiologists. According to previous studies, there is no single best predictor for difficult airway or intubations and no designed protocol for choosing an intubation technique in obese patients. Some of the preoperative risk factors and techniques such as the modified Mallampati class, sternomental distance, thyromental distance, neck circumference, indirect mirror laryngoscopy, BMI, and intraoperative risk factors such as inappropriate positioning of the patient, suboptimal medication dosing, inappropriate laryngoscopy device acted as independent predictors for difficult airway and difficult intubation. Analyzing each element's importance and making suitable decisions for the individual will reduce the complications and prepare for unplanned emergencies in the operating room. This review is convincing with previous studies that obesity itself is not an independent predictor. Instead, as a preoperative risk factor, and till date, sternomental distance and the number of intubation attempts were demonstrated as significant independent predictors for adverse events. All the other independent factors and considerations were discussed, which can help with further research.

Factors Associated With Repeat Emergency Department Visits for Low Back Pain.

Background Low back pain represents 2-3% of Emergency Department (ED) visits. In this study, we aimed to identify patient and treatment-related variables that contributed to repeat visits to the ED for low back pain within a 12-month period. Methodology We conducted a retrospective review of adult patients presenting to the ED of one hospital over a two-year period with the primary diagnosis of low back pain. The primary outcome included return to the ED within 12 months with the same complaint, and the secondary outcome included return to the ED within 30 days or six months. Results A total of 793 patients met the inclusion criteria. The rate of return to the ED with the same complaint within 30 days, six months, and 12 months of the first visit was 7%, 11%, and 14%, respectively. Patients who received opioids at discharge were more likely to return within 12 months (68% vs. 55%; p = 0.0075) and six months (68% vs. 56%; p = 0.0184) compared to those who did not receive opioids at discharge. Undergoing an X-ray decreased the odds of a 30-day return visit by 70% (p = 0.0067), and by 59% within 12 months (p = 0.0032). Receiving opioids at discharge also doubled the odds of return within 12 months (odds ratio = 2.030, p = 0.0183), while receiving nonsteroidal anti-inflammatory drugs (NSAIDs) reduced the odds by 60% (p = 0.0028). Conclusions Patients who received opioids at discharge were more likely to have a return visit for low back pain within six and 12 months. Patients who underwent X-rays at the index visit and were prescribed NSAIDs at discharge were less likely to return to the ED for low back pain.

Intervention during wait time: identification and referral of individuals non-adherent for colorectal cancer screening.

Background: Despite unanimous recommendations from numerous specialty societies on regular colorectal cancer screening, a substantial proportion of eligible adults are non-adherent with screening. The current study investigated whether research associates (RAs) in the emergency department (ED) can adequately assess patients' adherence with colorectal cancer screening recommendations, outlined by the US Preventive Services Task Force (USPSTF), and provide referrals to individuals who are found to be non-adherent. Methods: RAs at seven heterogeneous hospitals in the USA queried non-emergent adult patients and visitors between the ages of 50 and 75. After obtaining verbal consent, the participant's adherence with USPSTF guidelines for colorectal cancer screening was assessed. Participants found due for screening were provided with referrals to obtain these recommended screenings. Results: A total of 8258 participants were surveyed on their colorectal cancer screening status, with RAs identifying 2063 participants who were not adherent with USPSTF guidelines for colorectal cancer screening and 67 for whom adherence could not be determined (total 27%). Conclusions: Our study demonstrates that RAs can identify a large volume of eligible adults who would benefit from colorectal cancer screening across a variety of emergency department settings.

Use of a Unique Mobile Medical Asset in COVID Monoclonal Antibody Treatment.

The COVID-19 pandemic and the subsequent surge of patients presented to emergency departments has forever changed the paradigm of delivering emergency care. The highly infectious nature of the 2019 Novel Coronavirus, or COVID-19, mandated strict environmental changes, novel patient care, and flexible strategies to continue to deliver efficient emergency care while maintaining appropriate physical distancing between suspect and non-suspect COVID-19 patients. The engagement of a unique rapidly deployable Mobile Satellite Emergency Department (MSED) with scalable capability from prompt care to resuscitation level allowed the emergency care team to optimize patient care and throughput. The MSED was strategically located adjacent to the ambulance entrance. While initially deployed to increase Emergency Department surge capacity, the MSED was repurposed to cohort and treat COVID patients with the monoclonal antibody, Bamlanivimab, who were expected to be discharged after treatment. This allowed for more efficient use of Emergency Department resources, including physical space and staffing.

Self-Inflicted Traumatic Bilateral Upper Extremity Amputation as a Suicidal Gesture?

Traumatic amputations are partial or complete dismemberment of part of the human body (usually one limb) due to an injury that involves a component of blunt force trauma. It is usually caused by accidental events and only very rarely due to suicidal events. A 37-year-old female with major depressive disorder attempted suicide by placing her forearms on a railroad track, resulting in traumatic bilateral upper extremity amputations. Emergency Department resuscitation was initiated as the patient was taken immediately to the operating room; however, restoration of the limbs was unfeasible, and the patient had successful debriding and fashioning a flap to the distal ends of the upper extremities after hemostasis was achieved. Depression may still be an undertreated clinical entity in our society, and many preventable causes of suicide are attempted each year. Evidence exists that suggests severe suicide attempts occur generally in men and minor suicide attempts, or so-called suicidal gestures, occur generally in women. This case questions this notion.

Feasibility and Effectiveness of Recruiting Latinos in Decídetexto-A Smoking Cessation Clinical Trial from an Emergency Department Patient Registry.

There is an underrepresentation of Latinos in smoking cessation clinical trials. This study describes the feasibility and effectiveness of recruiting Latino smokers in the U.S. from an emergency department (ED) patient registry into a randomized smoking cessation clinical trial. Recruitment occurred from the Hackensack University Medical Center ED. Potential participants were contacted from a patient registry. The primary outcome was whether the participant responded to a call or text. Secondary outcomes included the best day of the week, week of the month, and time of day to obtain a response. Of the 1680 potential participants, 1132 were called (67.5%), while 548 (32.5%) were texted. For calls, response rate was higher compared to text (26.4% vs 6.4%; p < 0.001). More participants were interested in the study when contacted by calls compared to text (11.4% vs. 1.8%) and more participants were enrolled in the study when contacted by calls compared to text (1.1% vs. 0.2%). Regression models showed that ethnicity, age, time of day, and week of the month were not significantly associated with response rates. Recruitment of Latinos from an ED patient registry into a smoking cessation clinical trial is feasible using call and text, although enrollment may be low.

Influenza in the emergency department: 2020 update

Emergency clinicians must be aware of the current diagnostic and therapeutic recommendations for influenza and the available resources to guide management. This comprehensive review outlines the classification of influenza viruses, influenza pathophysiology, the identification of high-risk patients, and the importance of vaccination, with an update on the 2019-2020 influenza season. Seasonal variations of influenza are discussed, as well as the rationale for limiting testing during periods of high prevalence. Differences between strains of influenza are discussed, as well as the challenges in achieving optimal vaccine effectiveness. Recommendations for use of the currently available oral, intranasal, and intravenous antiviral treatments are provided, as well as utilizing shared decision-making with patients regarding risks and benefits of treatment.

IgA Monoclonal Gammopathy of Undetermined Significance and Complication of Streptococcus mitis Bacteremia.

This case presents a patient with bacteremia of an unusual organism with a history of monoclonal gammopathy of undetermined significance (MGUS). MGUS is typically thought to be asymptomatic until potential progression of the disease. This case reports a patient with a history of MGUS who does not show disease progression, however, may be showing symptoms, such as immunodeficiency. This case displays bacteremia with Streptococcus mitis within a two-week period of an invasive procedure. Recent studies parallel this case by showing MGUS patients may have two times the risk of infections compared to the unaffected population. This report brings up the question of taking prophylactic measures for this patient population to prevent future complications.

Should I Stay or Should I Go? A Bioethical Analysis of Healthcare Professionals' and Healthcare Institutions' Moral Obligations During Active Shooter Incidents in Hospitals - A Narrative Review of the Literature.

Active shooter incidents (ASI) have unfortunately become a common occurrence the world over. There is no country, city, or venue that is safe from these tragedies, and healthcare institutions are no exception. Healthcare facilities have been the targets of active shooters over the last several decades, with increasing incidents occurring over the last decade. People who work in healthcare have a professional and moral obligation to help patients. As concerns about the possibility of such incidents increase, how should healthcare institutions and healthcare professionals understand their responsibilities in preparation for and during ASI?

Decídetexto: Mobile cessation support for Latino smokers. Study protocol for a randomized clinical trial.

INTRODUCTION: Latinos, the largest minority group in the U.S., experience tobacco-related disparities, including limited access to cessation resources. Evidence supports the efficacy of mobile interventions for smoking cessation, which may be greater among Latinos, the highest users of text messaging. OBJECTIVES: To describe the methodology of a randomized clinical trial to evaluate the impact of Decídetexto, a culturally appropriate mobile smoking cessation intervention versus standard care on smoking abstinence (cotinine-verified 7-day point prevalence abstinence) at Month 6 among Latino smokers. METHODS: Latino smokers (N = 618) will be randomized to one of two conditions: 1) Decídetexto or 2) standard of care. Decídetexto is a mobile smoking cessation intervention (available in English and Spanish) that incorporates three integrated components: 1) a tablet-based software that collects smoking-related information to develop an individualized quit plan, 2) a 24-week text messaging counseling program with interactive capabilities, and 3) pharmacotherapy support. Decídetexto follows the Social Cognitive Theory as theoretical framework. Standard of care consists of printed smoking cessation materials along with referral to telephone quitline. Participants in both groups are given access to free pharmacotherapy (nicotine patches or gum) by calling study phone number. Promotores de Salud will rely on community-based approaches and clinical settings to recruit smokers into the study. All participants will complete follow-up assessments at Week 12 and Month 6. DISCUSSION: If successful, Decídetexto will be ready to be implemented in different community- and clinic-based settings to reduce tobacco-related disparities.

Persistence of symptoms and quality of life at 35 days after hospitalization for COVID-19 infection.

BACKGROUND: Characterizing the prevalence and persistence of symptoms associated with COVID-19 infection following hospitalization and their impact is essential to planning post-acute community-based clinical services. This study seeks to identify persistent COVID-19 symptoms in patients 35 days post-hospitalization and their impact on quality of life, health, physical, mental, and psychosocial function. METHODS AND FINDINGS: This prospective cohort study used the PROMIS® Instruments to identify symptoms and quality of life parameters in consecutively enrolled patients between March 22 and April 16, 2020, in New Jersey. The 183 patients (median age 57 years; 61.5% male, 54.1% white) reported persistent symptoms at 35 days, including fatigue (55.0%), dyspnea (45.3%), muscular pain (51%), associated with a lower odds rating general health (41.5%, OR 0.093 [95% CI: 0.026, 0.329], p = 0.0002), quality of life (39.8%; OR 0.116 [95% CI: 0.038, 0.364], p = 0.0002), physical health (38.7%, OR 0.055 [95% CI: 0.016, 0.193], p <0.0001), mental health (43.7%, OR 0.093 [95% CI: 0.021, 0.418], p = 0.0019) and social active role (38.7%, OR 0.095 [95% CI: 0.031, 0.291], p<0.0001), as very good/excellent, particularly adults aged 65 to 75 years (OR 8·666 [95% CI: 2·216, 33·884], p = 0·0019). CONCLUSIONS: COVID-19 symptoms commonly persist to 35 days, impacting quality of life, health, physical and mental function. Early post-acute evaluation of symptoms and their impact on function is necessary to plan community-based services.

Severe anemia may not be a contraindication to debridement in a Jehovah's witness patient with necrotizng fasciitis of the lower extremity - A case report.

INTRODUCTION: Necrotizing fasciitis is a severe soft tissue infection characterized by rapidly progressing necrosis involving the fascia and subcutaneous tissue. Necrotizing fasciitis of the lower extremity in a Jehovah's Witness patient in the setting of severe anemia and systemic sepsis is uncommon. CASE PRESENTATION: A 62-year-old man of Jehovah's Witness faith with a history of alcohol use disorder and uncontrolled diabetes mellitus initially presented with a non-healing diabetic foot ulcer, subsequently developed sepsis and necrotizing fasciitis. He underwent an above the knee amputation and was transferred to our institution's Surgical Intensive Care Unit for further management. The patient presented in critical condition with a hemoglobin of 4.7 g/dL and progression of necrotizing fasciitis of the lower extremity stump. He underwent revision amputation and numerous excisional debridements along with IV antibiotics, epoetin alfa, and iron sucrose. He successfully recovered with minimal blood loss and was discharged with a hemoglobin of 8 g/dL. DISCUSSION: This case highlights some of the challenges involved in managing necrotizing fasciitis. The conversation with the Jehovah's Witness patient in a life-threatening condition must be held with the upmost respect. Surgical decision making and operative technique is critical in determining the boundary of excisional debridement to perform in the absence of the ability to transfuse blood. The medical management was focused on resuscitation for sepsis, severe anemia, hyperglycemia, and wound management. CONCLUSION: Severely anemic patients in critical condition can survive necrotizing fasciitis with a well-planned interdisciplinary approach without compromising patient autonomy.

Percutaneous Cholecystostomy Tube Leading to a "Floating" Gallbladder: A Case Report.

In patients with significant comorbid conditions, acute cholecystitis is managed through surgical intervention or with cholecystostomy tube placement (CTP). The literature is not definitive in its recommendations for cholecystectomy versus cholecystostomy. This case report describes a presentation of acute calculous cholecystitis managed with CTP. Over a 10-week period, due to complications with the tube, the decision was made to perform a cholecystectomy. Upon open surgical exploration, an atraumatic, ruptured, and chronically inflamed gallbladder was found without attachment to the subhepatic plate and, in essence, free "floating" in the peritoneum. To our knowledge, this is the first-known documented case report in the English medical literature. An elderly woman, with significant co-morbidities, following two months of antibiotic treatment for acute cholecystitis and subsequent percutaneous cholecystostomy tube placement and re-placements, underwent elective laparoscopic cholecystectomy, which was converted to open surgery. Upon exploration, a detached, "floating" gallbladder was found posterior to the transverse colon and removed after lysing extensive peritoneal adhesions. Subsequent to the cholecystectomy, the patient had uncomplicated recovery. The literature does not present a clear consensus on CTP use vs early cholecystectomy in high-risk patients with acute cholecystitis. This management decision is based primarily on the surgeon's clinical judgment and the use of evidence-based risk assessment indices. The "floating gallbladder" is a rare, benign complication that affirms the importance of extensively assessing the risks and benefits of CTP as compared to cholecystectomy in the elderly and/or comorbid patient.