Clinical presentation and assessment of older patients presenting with headache to emergency departments: A multicentre observational study.

OBJECTIVE: To describe the characteristics, assessment and management of older emergency department (ED) patients with non-traumatic headache. METHODS: Planned sub-study of a prospective, multicentre, international, observational study, which included adult patients presenting to ED with non-traumatic headache. Patients aged ≥75 years were compared to those aged <75 years. Outcomes of interest were epidemiology, investigations, serious headache diagnosis and outcome. RESULTS: A total of 298 patients (7%) in the parent study were aged ≥75 years. Older patients were less likely to report severe headache pain or subjective fever (both P < 0.001). On examination, older patients were more likely to be confused, have lower Glasgow Coma Scores and to have new neurological deficits (all P < 0.001). Serious secondary headache disorder (composite of headache due to subarachnoid haemorrhage (SAH), intracranial haemorrhage, meningitis, encephalitis, cerebral abscess, neoplasm, hydrocephalus, vascular dissection, stroke, hypertensive crisis, temporal arteritis, idiopathic intracranial hypertension or ventriculoperitoneal shunt complications) was diagnosed in 18% of older patients compared to 6% of younger patients (P < 0.001). Computed tomography brain imaging was performed in 66% of patients ≥75 years compared to 35% of younger patients (P < 0.001). Older patients were less likely to be discharged (43% vs 63%, P < 0.001). CONCLUSIONS: Older patients with headache had different clinical features to the younger cohort and were more likely to have a serious secondary cause of headache than younger adults. There should be a low threshold for investigation in older patients attending ED with non-traumatic headache.

Bicycle-Related Injuries of the Upper Extremity.

Background: In recent years, the increasing popularity of cycling for commuting and leisure has led to a corresponding increase in bicycle-related injuries. However, there is a lack of extensive analysis of bicycle-related injuries to the upper limb in the literature. Methods: A retrospective review of all patients with conventional bicycle-related injuries of the upper limb was performed. Data on demographics, mechanisms of injury, region of injury, fracture type, management type, and length of hospital stay were extracted and analyzed. Results: A total of 177 of 733(24%) patients with bicycle-related upper limb injuries were identified. The most common mechanism of injury was a collision with another vehicle (60%). Frequently affected regions were the shoulder (48%), hand (19%), and wrist (19%). Eighty-eight (50%) patients sustained bony injuries, while the remainder (50%) had isolated soft tissue injuries. Fifty-three (30%) patients required a mean of 3.9 days of hospitalization, whereas 13 (25%) patients required high dependency or intensive care unit treatment. Surgical interventions were required in 47 (27%) patients. Conclusion: Bicycle-related injuries to the upper limb are common and result in significant morbidity. The most common regions affected are the shoulder, wrist, and hand. Most of the injuries were caused by collisions with other vehicles. A third of affected patients required hospitalization, and a quarter required surgical intervention.

Validation of "Care of the Dying Evaluation" in Emergency Medicine (CODE-EM): pilot phase of end-of-life management protocol offered within emergency room (EMPOWER) study.

BACKGROUND: An increasing number of patients who present to emergency departments are at their end-of-life phase and have significant palliative care needs such as in symptom control for pain and dyspnoea. Evaluating quality of care provided is imperative, yet there is no suitable tool validated in the emergency and Asian settings. We aim to examine the face and construct validity, and reliability of a newly developed questionnaire, Care of the Dying Evaluation - Emergency Medicine, for measuring the quality of end-of-life care in an Asian emergency context. METHODS: A mixed methods pilot study was conducted. Participants composed of the next-of-kin to thirty dying patients who presented to the emergency departments of three public hospitals in Singapore. Qualitative evaluation, using cognitive "think-aloud" interviews, and quantitative analysis were employed. Percentage agreement and κ statistic were measured to evaluate temporal stability of the questionnaire. Cronbach's α and item-total correlations were used to assess internal consistency within the constructs. Confirmatory factor analysis was performed for construct validity. RESULTS: All participants reported clear understanding of the questionnaire with no ambiguity; a minority felt the questions caused emotional distress (7/30, 23.3%). The questions showed moderate to good test-retest reliability. Internal consistencies within the constructs were good for "ENVIRONMENT" and "CARE", and moderate for "COMMUNICATION". Factor loadings range from 0.40 to 0.99. CONCLUSIONS: The Care of the Dying Evaluation - Emergency Medicine questionnaire may be valid and reliable for use in an Asian emergency setting. Our prospective multicentre study using this evaluation tool may provide more insight on the quality of care rendered to dying patients and identify areas for improvement. TRIAL REGISTRATION: ClinicalTrials.gov (NCT03906747).

Assessment of dyspneic patients in the emergency department using point-of-care lung and cardiac ultrasonography-a prospective observational study.

BACKGROUND: Lung ultrasonography is increasingly used in the emergency department (ED) as a standard adjunct in the evaluation of the breathless patient. The study objective was to ascertain the diagnostic accuracy of lung and cardiac ultrasound in undifferentiated dyspneic ED patients. METHODS: We conducted this prospective observational study on patients presenting with dyspnea in the ED of a tertiary hospital. The sonographers who performed lung and cardiac ultrasound according to a locally-designed protocol were blinded to clinical and radiologic results. Ultrasonographic findings were subsequently compared with the final adjudicated diagnoses. RESULTS: Between February and August 2015, 231 patients were recruited. There was male predominance (63.2%) with a mean age of 67.8 years. Overall, lung ultrasonography yielded correct diagnoses in 68.3% of patients. Our protocol had likelihood ratios of 3.63 [95% confidence interval (CI): 2.44-5.40], 3.73 (95% CI: 2.50-5.57) and 6.31 (95% CI: 3.72-10.72) for positive findings; and 0.42 (95% CI: 0.29-0.63), 0.35 (95% CI: 0.25-0.50), and 0.40 (95% CI: 0.28-0.56) for negative findings in the diagnoses of pneumonia, pulmonary edema, and chronic obstructive pulmonary disease or asthma, respectively. Addition of bedside echocardiography was able to differentiate cardiogenic from nephrogenic pulmonary edema in 70% of patients. CONCLUSIONS: Lung ultrasonography, when complemented with other tools of investigation, aids evaluation, allows for earlier treatment and more accurate disposition of undifferentiated dyspneic patients in the ED. The addition of cardiac ultrasound was not able to reliably differentiate the causes of pulmonary edema.

AME evidence series 001-The Society for Translational Medicine: clinical practice guidelines for diagnosis and early identification of sepsis in the hospital.

Sepsis is a heterogeneous disease caused by an infection stimulus that triggers several complex local and systemic immuno-inflammatory reactions, which results in multiple organ dysfunction and significant morbidity and mortality. The diagnosis of sepsis is challenging because there is no gold standard for diagnosis. As a result, the clinical diagnosis of sepsis is ever changing to meet the clinical and research requirements. Moreover, although there are many novel biomarkers and screening tools for predicting the risk of sepsis, the diagnostic performance and effectiveness of these measures are less than satisfactory, and there is insufficient evidence to recommend clinical use of these new techniques. As a consequence, diagnostic criteria for sepsis need regular revision to cope with emerging evidence. This review aims to present the most updated information on diagnosis and early recognition of sepsis. Recommendations for clinical use of different diagnostic tools rely on the Grades of Recommendation Assessment, Development and Evaluation (GRADE) framework. Because most of the studies were observational and did not allow a reliable assessment of these tools, a two-step inference approach was employed. Future trials need to confirm or refute a particular index test and should directly explore relevant patient outcome parameters.

Extracellular Vesicle Proteins Associated with Systemic Vascular Events Correlate with Heart Failure: An Observational Study in a Dyspnoea Cohort.

BACKGROUND: SerpinF2, SerpinG1, CystatinC and CD14 are involved in inflammatory processes and plasma extracellular vesicle (EV) -levels of these proteins have been reported to be associated with systemic vascular events. Evidence is accumulating that inflammatory processes may play a pivotal role both in systemic vascular events and in heart failure. Therefore, we studied the association between plasma extracellular vesicle SerpinF2-, SerpinG1-, CystatinC and CD14-levels and the occurrence of acute heart failure in patients. METHODS AND RESULT: Extracellular vesicle protein levels of SerpinG1, SerpinF2, CystatinC and CD14 were measured in an observational study of 404 subjects presenting with dysponea at the emergency department (4B-cohort). Plasma extracellular vesicles were precipitated in a total extracellular vesicles (TEX)-fraction and in separate LDL- and HDL-subfractions. Extracellular vesicle protein levels were measured with a quantitative immune assay in all 3 precipitates. Out of 404 subjects, 141 (35%) were diagnosed with acutely decompensated heart failure. After correction for confounders (including comorbidities and medications), levels of CD14 in the HDL-fraction (OR 1.53, p = 0.01), SerpinF2 in the TEX-and LDL-fraction (ORs respectively 0.71 and 0.65, p<0.05) and SerpinG1 in the TEX-fraction (OR 1.55, p = 0.004) were statistically significantly related to heart failure. Furthermore, extracellular vesicle CD14- and SerpinF2-levels were significantly higher in heart failure patients with preserved ejection fraction than in those with reduced ejection fraction. CONCLUSION: Extracellular vesicle levels of CD14, SerpinG1 and SerpinF2 are associated with the occurrence of heart failure in subjects suspected for acute heart failure, suggesting common underlying pathophysiological mechanisms for heart failure and vascular events.