"I do not know the advantages of having a general practitioner" - a qualitative study exploring the views of low-acuity emergency patients without a regular general practitioner toward primary care.

BACKGROUND: Emergency departments (ED) worldwide have to cope with rising patient numbers. Low-acuity consulters who could receive a more suitable treatment in primary care (PC) increase caseloads, and lack of PC attachment has been discussed as a determinant. This qualitative study explores factors that contribute to non-utilization of general practitioner (GP) care among patients with no current attachment to a GP. METHOD: Qualitative semi-structured telephone interviews were conducted with 32 low-acuity ED consulters with no self-reported attachment to a GP. Participants were recruited from three EDs in the city center of Berlin, Germany. Data were analyzed by qualitative content analysis. RESULTS: Interviewed patients reported heterogeneous factors contributing to their PC utilization behavior and underlying views and experiences. Participants most prominently voiced a rare need for medical services, a distinct mobility behavior, and a lack of knowledge about the role of a GP and health care options. Views about and experiences with GP care that contribute to non-utilization were predominantly related to little confidence in GP care, preference for directly consulting medical specialists, and negative experiences with GP care in the past. Contrasting their reported utilization behavior, many interviewees still recognized the advantages of GP care continuity. CONCLUSION: Understanding reasons of low-acuity ED patients for GP non-utilization can play an important role in the design and implementation of patient-centered care interventions for PC integration. Increasing GP utilization, continuity of care and health literacy might have positive effects on patient decision-making in acute situations and in turn decrease ED burden. TRIAL REGISTRATION: German Clinical Trials Register: DRKS00023480; date: 2020/11/27.

Impact of Preferred Written Language in Patients Discharged With Bronchiolitis From a Children's Hospital.

OBJECTIVES: This study aimed to identify differences in length of stay and readmission in patients admitted with bronchiolitis based on preferred written language. A secondary aim was to assess adherence to providing written discharge instructions in patients' preferred language. METHODS: In this cross-sectional study, we included 384 patients aged 0 to 2 years discharged from 2 children's hospitals with bronchiolitis from May 1, 2021, through April 30, 2022; patients were excluded for history of prematurity, complex chronic condition, or ICU stay during the study period. A manual chart review was performed to determine preferred written language and language of written discharge instructions. RESULTS: Patients preferring a written language other than English had a longer length of stay compared with English-preferring patients (37.9 vs 34.3 hours, P < .05), but there was no significant difference in unplanned 7-day readmissions. All patients who preferred English and Spanish received written discharge instructions in their preferred written language; no patients with other preferred languages did. CONCLUSIONS: Patients who preferred a written language other than English had a longer length of stay than those preferring English but there was no difference in 7-day readmissions, though power for readmissions was limited. The study also identified significant disparities in the provision of written discharge instructions in languages other than English and Spanish.

Younger and Rural Children are More Likely to be Hospitalized for SARS-CoV-2 Infections.

Purpose: To identify characteristics of SARS-CoV-2 infection that are associated with hospitalization in children initially evaluated in a Pediatric Emergency Department (ED). Methods: We identified cases of SARS-CoV-2 positive patients seen in the Arkansas Children's Hospital (ACH) ED or hospitalized between May 27, 2020, and April 28, 2022 using ICD-10 codes within the Pediatric Hospital Information System (PHIS) Database. We compared infection waves for differences in patient characteristics, and used logistic regressions to examine which characteristics led to a higher chance of hospitalization. Findings: We included 681 pre-Delta cases, 673 Delta cases, and 970 Omicron cases. Almost 17% of patients were admitted to the hospital. Compared to Omicron infected children, pre-Delta and Delta infected children were twice as likely to be hospitalized (OR=2.2 and 2.0, respectively; p<0.0001). Infants less than 1 year of age were >3 times as likely to be hospitalized than children ages 5-14 years regardless of wave (OR=3.42; 95%CI=2.36-4.94). Rural children were almost 3 times as likely than urban children to be hospitalized across all waves (OR=2.73; 95%CI=1.97-3.78). Finally, those with a complex condition had nearly a 15-fold increase in odds of admission (OR=14.6; 95%CI=10.6-20.0). Conclusions: Children diagnosed during the pre-Delta or Delta waves were more likely to be hospitalized than those diagnosed during the Omicron wave. Younger and rural patients were more likely to be hospitalized regardless of wave. We suspect lower vaccination rates and larger distances from medical care influenced higher hospitalization rates.

Exploring the views of low-acuity emergency department consulters on an educational intervention and general practitioner appointment service: a qualitative study in Berlin, Germany.

OBJECTIVES: Low-acuity patients presenting to emergency departments (EDs) frequently have unmet ambulatory care needs. This qualitative study explores the patients' views of an intervention aimed at education about care options and promoting primary care (PC) attachment. DESIGN: Qualitative telephone interviews were conducted with a subsample of participants of an interventional pilot study, based on a semi-structured interview guide. The data were analysed through qualitative content analysis. SETTING: The study was carried out in three EDs in the city centre of Berlin, Germany. PARTICIPANTS: Thirty-two low-acuity ED consulters with no connection to a general practitioner (GP) who had participated in the pilot study were interviewed; (f/m: 15/17; mean age: 32.9 years). INTERVENTION: In the pilot intervention, ED patients with low-acuity complaints were provided with an information leaflet on appropriate ED usage and alternative care paths and they were offered an optional GP appointment scheduling service. Qualitative interviews explored the views of a subsample of the participants on the intervention. RESULTS: Interviewees perceived both parts of the intervention as valuable. Receiving a leaflet about appropriate ED use and alternatives to the ED was viewed as helpful, with participants expressing the desire for additional online information and a wider distribution of the content. The GP appointment service was positively assessed by the participants who had made use of this offer and seen as potentially helpful in establishing a long-term connection to GP care. The majority of patients declining a scheduled GP appointment expected no personal need for further medical care in the near future or preferred to choose a GP independently. CONCLUSIONS: Low-acuity ED patients seem receptive to information on alternative acute care options and prevailingly appreciate measures to encourage and facilitate attachment to a GP. Promoting PC integration could contribute to a change in future usage behaviour. TRIAL REGISTRATION NUMBER: DRKS00023480.

Fournier's Gangrene: A Rare Infectious Entity in an Adolescent with Type II Diabetes.

Fournier's gangrene is a rapidly progressive necrotizing fasciitis of the perineum and external genital organs that is uncommon in the pediatric age group. We present a case report of a 17-year-old obese male with comorbidities of type II diabetes, hypertension, and tobacco use, who presented to the hospital with vague systemic symptoms and pain in the gluteal area. On examination, he was febrile and had erythema and induration of his left scrotum, perineum, and gluteal region. Imaging obtained due to rapid progression of symptoms was consistent with a diagnosis of Fournier's gangrene. He was managed with broad-spectrum antibiotics, aggressive surgical debridement, and a diverting colostomy. This case brings to light to a classically adult diagnosis that should be considered in adolescents, especially given the rising numbers of risk factors in this population, such as diabetes, obesity, and smoking.

Demographic and clinical characteristics of pediatric COVID-19 in Arkansas: March-December 2020.

The COVID-19 pandemic reached the United States in early 2020 and spread rapidly across the country. This retrospective study describes the demographic and clinical characteristics of 308 children presenting to an Arkansas Children's emergency department (ED) or admitted to an Arkansas Children's hospital with COVID-19 in the first 10 months of the COVID-19 pandemic, prior to the emergence of clinically significant variants and available vaccinations. Adolescents aged 13 and older represented the largest proportion of this population. The most common presenting symptoms were fever, gastrointestinal symptoms, and upper respiratory symptoms. Patients with multisystem inflammatory syndrome in children (MIS-C) had a longer length of stay (LOS) than patients with acute COVID-19. Children from urban zip codes had lower odds of admission but were more likely to be readmitted after discharge. Nearly twenty percent of the study population incidentally tested positive for COVID-19. Despite lower mortality in children with COVID than in adults, morbidity and resource utilization are significant. With many Arkansas children living in rural areas and therefore far from pediatric hospitals, community hospitals should be prepared to evaluate children presenting with COVID-19 and to determine which children warrant transport to pediatric-specific facilities.

Redirecting emergency medical services patients with unmet primary care needs: the perspective of paramedics on feasibility and acceptance of an alternative care path in a qualitative investigation from Berlin, Germany.

BACKGROUND: Against the backdrop of emergency department (ED) overcrowding, patients' potential redirection to outpatient care structures is a subject of current political debate in Germany. It was suggested in this context that suitable lower-urgency cases could be transported directly to primary care practices by emergency medical services (EMS), thus bypassing the ED. However, practicality is discussed controversially. This qualitative study aimed to capture the perspective of EMS personnel on potential patient redirection concepts. METHODS: We conducted qualitative, semi-structured phone interviews with 24 paramedics. Interviews were concluded after attainment of thematic saturation. Interviews were transcribed verbatim, and qualitative content analysis was performed. RESULTS: Technical and organizational feasibility of patients' redirection was predominantly seen as limited (theme: "feasible, but only under certain conditions") or even impossible (theme: "actually not feasible"), based on a wide spectrum of potential barriers. Prominently voiced reasons were restrictions in personnel resources in both EMS and ambulatory care, as well as concerns for patient safety ascribed to a restricted diagnostic scope. Concerning logistics, alternative transport options were assessed as preferable. Regarding acceptance by stakeholders, the potential for releasing ED caseload was described as a factor potentially promoting adoption, while doubt was raised regarding acceptance by EMS personnel, as their workload was expected to conversely increase. Paramedics predominantly did not consider transporting lower-urgency cases as their responsibility, or even as necessary. Participants were markedly concerned of EMS being misused for taxi services in this context and worried about negative impact for critically ill patients, as to vehicles and personnel being potentially tied up in unnecessary transports. As to acceptance on the patients' side, interview participants surmised a potential openness to redirection if this would be associated with benefits like shorter wait times and accompanied by proper explanation. CONCLUSIONS: Interviews with EMS staff highlighted considerable doubts about the general possibility of a direct redirection to primary care as to considerable logistic challenges in a situation of strained EMS resources, as well as patient safety concerns. Plans for redirection schemes should consider paramedics' perspective and ensure a provision of EMS with the resources required to function in a changing care environment.

Emergency department consultations for respiratory symptoms revisited: exploratory investigation of longitudinal trends in patients' perspective on care, health care utilization, and general and mental health, from a multicenter study in Berlin, Germany.

BACKGROUND: Only few studies of emergency department (ED) consulters include a longitudinal investigation. The EMACROSS study had surveyed 472 respiratory patients in eight inner-city EDs in Berlin in 2017/2018 for demographic, medical and consultation-related characteristics. This paper presents the results of a follow-up survey at a median of 95 days post-discharge. We aimed to explore the post hoc assessment of ED care and identify potential longitudinal trends. METHODS: The follow-up survey included items on satisfaction with care received, benefit from the ED visit, potential alternative care, health care utilization, mental and general health, and general life satisfaction. Univariable between-subject and within-subject statistical comparisons were conducted. Logistic regression was performed for multivariable investigations of determinants of dropout and of retrospectively rating the ED visit as beneficial. RESULTS: Follow-up data was available for 329 patients. Participants of lower education status, migrants, and tourists were more likely to drop out. Having a general practitioner (GP), multimorbidity, and higher general life satisfaction were determinants of response. Retrospective satisfaction ratings were high with no marked longitudinal changes and waiting times as the most frequent reason for dissatisfaction. Retrospective assessment of the visit as beneficial was positively associated with male sex, diagnoses of pneumonia and respiratory failure, and self-referral. Concerning primary care as a viable alternative, judgment at the time of the ED visit and at follow-up did not differ significantly. Health care utilization post-discharge increased for GPs and pulmonologists. Self-reported general health and PHQ-4 anxiety scores were significantly improved at follow-up, while general life satisfaction for the overall sample was unchanged. CONCLUSIONS: Most patients retrospectively assess the ED visit as satisfactory and beneficial. Possible sex differences in perception of care and its outcomes should be further investigated. Conceivable efforts at diversion of ED utilizers to primary care should consider patients' views regarding acceptable alternatives, which appear relatively independent of situational factors. Representativeness of results is restricted by the study focus on respiratory symptoms, the limited sample size, and the attrition rate. TRIAL REGISTRATION: German Clinical Trials Register ( DRKS00011930 ); date: 2017/04/25.

Hypokalemia Measurement and Management in Patients With Status Asthmaticus on Continuous Albuterol.

OBJECTIVE: Status asthmaticus is commonly treated in pediatric patients by using continuous albuterol, which can cause hypokalemia. The primary aim of this study was to determine if serial potassium monitoring is necessary by examining treatment frequency of hypokalemia. METHODS: This retrospective analysis was performed in 185 pediatric patients admitted with status asthmaticus requiring continuous albuterol between 2017 and 2019. All patients were placed on intravenous fluids containing potassium. The primary outcome measure was the treatment of hypokalemia in relation to the number of laboratory draws for potassium levels. The secondary outcome measure was hypokalemia frequency and relation to the duration and initial dose of continuous albuterol. RESULTS: Included were 156 patients with 420 laboratory draws (average, 2.7 per patient) for potassium levels. The median lowest potassium level was 3.40 mmol/L (interquartile range, 3.2-3.7). No correlation was found between initial albuterol dose and lowest potassium level (P = .52). Patients with hypokalemia had a mean albuterol time of 12.32 (SD, 15.76) hours, whereas patients without hypokalemia had a mean albuterol time of 11.50 (SD, 12.53) hours (P = .29). Potassium levels were treated 13 separate times. CONCLUSIONS: The number of laboratory draws for potassium levels was high in our cohort, with few patients receiving treatment for hypokalemia beyond the potassium routinely added to maintenance fluids. Length of time on albuterol and dose of albuterol were not shown to increase the risk of hypokalemia. Serial laboratory measurements may be decreased to potentially reduce health care costs, pain, and anxiety surrounding needlesticks.

[Am I an emergency patient? Emergency perception and decision-making competence in acute situations: a qualitative study of ED patients]. / Bin ich ein Notfall? Notfallempfinden und Entscheidungskompetenz in akuten Situationen: eine qualitative Erhebung bei Notaufnahmepatient*innen.

BACKGROUND: The number of patients visiting emergency departments (ED) due to acute but less than urgent treatment needs is increasing. A deeper understanding of emergency perception and decision-making competencies of patients is fundamentally important for developing strategies to reduce ED utilization. The aim of this study was to assess ED patients' subjective understanding of an emergency in general as well as relating to their own specific consultation. Additionally, the patients' perspective on the ability to make appropriate decisions in acute situations should be explored. METHODS: Seventeen qualitative semi-structured patient interviews were conducted and analyzed using qualitative content analysis. RESULTS: The majority of participants attributed their ED consultation to a subjectively perceived emergency situation. Interviewees mostly understood an emergency as a serious or life-threatening constellation associated with impending long-term health damage. They believed that uncertainty concerning the interpretation of their symptoms and associated anxiety may particularly promote situations in which referring to an ED appears to be the only alternative. Patients' health competencies were assessed negatively by a majority of interviewees with regard to assessment of complaints and decision-making in acute situations ("insecure patients"). In contrast, few patients, including those with chronic disease and experience in dealing with health problems, were considered to have a high level of competence ("confident patients"). CONCLUSION: Improving patients' health literacy skills to strengthen their assessment of acute situations and their decision-making is important in order to promote appropriate ED utilization.

Diverting less urgent utilizers of emergency medical services to primary care: is it feasible? Patient and morbidity characteristics from a cross-sectional multicenter study of self-referring respiratory emergency department consulters.

OBJECTIVE: Diversion of less urgent emergency medical services (EMS) callers to alternative primary care (PC) is much debated. Using data from the EMACROSS survey of respiratory ED patients, we aimed to characterize self-referred EMS patients, compare these with non-EMS patients, and assess scope and acceptability of a potential redirection to alternative PC. RESULTS: Of n = 292 self-referred patients, n = 99 were transported by EMS. Compared to non-EMS patients, these were older, triaged more urgently and arrived out-of-hours more frequently. The share of chronically and severely ill patients was greater. Out-of-hours ED visit, presence of a chronic pulmonary condition as well as a hospital diagnosis of respiratory failure were identified as determinants of EMS utilization in a logistic model, while consultation for access and quality motives as well as migrant status decreased the probability. EMS-transported lower urgency outpatients visiting during regular physicians' hours were defined as potential PC cases and evaluated descriptively (n = 9). As a third was medically complex and potentially less suitable for PC, redirection potential could be estimated at only 6% of EMS cases. This would be reduced to 2% if considering patients' judgment concerning the appropriate setting. Overall, the scope for PC diversion of respiratory EMS patients seems limited.

Barriers to Breastfeeding in Female Physicians.

BACKGROUND: Breast milk is considered the normative nutrition for human infants, and exclusive breastfeeding for the first 6 months of life is recommended by several national and global societies. Female physicians are a high-risk group for early unintended weaning. We aimed to assess and compare the most common barriers to successful breastfeeding perceived by female physicians in various stages of training and practice. MATERIALS AND METHODS: Female faculty physicians and trainees (medical students, resident physicians, and fellows) affiliated with a large medical university in 2016 were surveyed via an anonymous web-based survey distributed through institutional e-mail lists. The three-item survey assessed role, breastfeeding experience, and perceived barriers to successful breastfeeding. Comparisons between groups were performed using Wilcoxon rank-sum tests or Fisher's exact tests. RESULTS: The survey was distributed to 1,301 women with 223 responses included in analysis. The majority (57%) of respondents had never breastfed; of those, 87% reported plans to breastfeed in the future. Ninety-seven percent of women with breastfeeding experience reported at least one perceived barrier to successful breastfeeding. Trainees identified more barriers compared with faculty physicians (median count 5 versus 3, p = 0.014). No individual barrier reached statistical significance when comparing between faculty and trainees. The most frequently identified barriers to breastfeeding were lack of time and appropriate place to pump breast milk, unpredictable schedule, short maternity leave, and long working hours. CONCLUSIONS: Physicians and medical students who breastfeed face occupation-related barriers that could lead to early unintended weaning. Trainees and faculty report similar barriers. Institutional support may help improve some barriers to successful breastfeeding in female physicians.

A boy unable to move his arm.

An 11-year-old boy presented with inability to move his right arm, back and neck pain, and fever. He had a history of recurrent vesicular rash on his face three times over the past two years. Magnetic resonance imaging (MRI) showed diffuse expansile cervical cord, leading to a diagnosis of transverse myelitis. After 3 days of intravenous solumedrol, the patient was discharged, but returned the following day with a vesicular rash to the right arm, as well as vomiting, malaise and diffuse pruritus.Wright-Giemsa stain of the vesicles revealed herpes group virus and culture was positive for herpes simplex type 1.

Dynamic developmental elaboration of N-linked glycan complexity in the Drosophila melanogaster embryo.

The structural diversity of glycoprotein N-linked oligosaccharides is determined by the expression and regulation of glycosyltransferase activities and by the availability of the appropriate acceptor/donor substrates. Cells in different tissues and in different developmental stages utilize these control points to manifest unique glycan expression patterns in response to their surroundings. The activity of a Toll-like receptor, called Tollo/Toll-8, induces a pattern of incompletely defined, but neural specific, glycan expression in the Drosophila embryo. Understanding the full extent of the changes in glycan expression that result from altered Tollo/Toll-8 signaling requires characterization of the complete N-linked glycan profile of both wild-type and mutant embryos. N-Linked glycans harvested from wild-type or mutant embryos were subjected to direct structural analysis by analytic and preparative high pressure liquid chromatography, by multidimensional mass spectrometry, and by exoglycosidase digestion, revealing a predominance of high mannose and paucimannose glycans. Di-, mono-, and nonfucosylated forms of hybrid, complex biantennary, and triantennary glycans account for 12% of the total wild-type glycan profile. Two sialylated glycans bearing N-acetylneuraminic acid were detected, the first direct demonstration of this modification in Drosophila. Glycan profiles change during normal development consistent with increasing alpha-mannosidase II and core fucosyl-transferase enzyme activities, and with decreasing activity of the Fused lobes processing hexosaminidase. In tollo/toll-8 mutants, a dramatic, expected loss of difucosylated glycans is accompanied by unexpected decreases in monofucosylated and nonfucosylated hybrid glycans and increases in some nonfucosylated paucimannose and biantennary glycans. Therefore, tollo/toll-8 signaling influences flux through several processing steps that affect the maturation of N-linked glycans.

Estradiol's effects on learning and neuronal morphology vary with route of administration.

Estrogen's effects on performance and neuronal morphology are variable, and the reasons for this variability are not yet understood. In this study, the authors compared the effects of 2 delivery routes of 17 beta-estradiol on spatial learning and dendritic spine densities in young ovariectomized rats; estradiol was administered by implanted capsules or by daily oral gavage. Estradiol treatment via capsules improved performance in the radial-arm water maze and increased spine densities on dendrites of CA1 pyramidal neurons in the hippocampal formation. In contrast, daily oral administration of estradiol did not affect either measure. These data demonstrate that estradiol delivery is a critical variable in animal studies and that clinical studies comparing the effects of different estradiol treatment routes on cognition are warranted.