Management of atrial flutter and atrial fibrillation with rapid ventricular response in patients with acute decompensated heart failure: A systematic review.

OBJECTIVE: The objective was to evaluate the comparative effectiveness and safety of pharmacological and nonpharmacological management options for atrial fibrillation/atrial flutter with rapid ventricular response (AFRVR) in patients with acute decompensated heart failure (ADHF) in the acute care setting. METHODS: This study was a systematic review of observational studies or randomized clinical trials (RCT) of adult patients with AFRVR and concomitant ADHF in the emergency department (ED), intensive care unit, or step-down unit. The primary effectiveness outcome was successful rate or rhythm control. Safety outcomes were adverse events, such as symptomatic hypotension and venous thromboembolism. RESULTS: A total of 6577 unique articles were identified. Five studies met inclusion criteria: one RCT in the inpatient setting and four retrospective studies, two in the ED and the other three in the inpatient setting. In the RCT of diltiazem versus placebo, 22 patients (100%) in the treatment group had a therapeutic response compared to 0/15 (0%) in the placebo group, with no significant safety differences between the two groups. For three of the observational studies, data were limited. One observation study showed no difference between metoprolol and diltiazem for successful rate control, but worsening heart failure symptoms occurred more frequently in those receiving diltiazem compared to metoprolol (19 patients [33%] vs. 10 patients [15%], p = 0.019). A single study included electrical cardioversion (one patient exposed with failure to convert to sinus rhythm) as nonpharmacological management. The overall risk of bias for included studies ranged from serious to critical. Missing data and heterogeneity of definitions for effectiveness and safety outcomes precluded the combination of results for quantitative meta-analysis. CONCLUSIONS: High-level evidence to inform clinical decision making regarding effective and safe management of AFRVR in patients with ADHF in the acute care setting is lacking.

Critical Electrocardiogram Curriculum: Setting the Standard for Flipped-Classroom EKG Instruction.

INTRODUCTION: Electrocardiogram (EKG) interpretation is integral to emergency medicine (EM). In 2003 Ginde et al. found 48% of emergency medicine (EM) residency directors supported creating a national EKG curriculum. No formal national curriculum exists, and it is unknown whether residents gain sufficient skill from clinical exposure alone. METHODS: The authors sought to assess the value of this EKG curriculum, which provides exposure to critical EKG patterns, a framework for EKG interpretation when the diagnosis is not obvious, and implementation guidelines and open access to any interested residency. The Foundations of Emergency Medicine (FoEM) EKG I course launched in January 2016, followed by EKG II in July 2017; they are benchmarked to post-graduate year 1 (PGY) and PGY2 level learners, respectively. Selected topics included 15 published critical EKG diagnoses and 33 selected by the authors. Cases included presenting symptoms, EKGs, and Free Open Access Medical Education (FOAM) links. Full EKG interpretations and question answers were provided. RESULTS: Enrollment during 2017-2018 included 37 EM residencies with 663 learners in EKG I and 22 EM residencies with 438 learners in EKG II. Program leaders and learners were surveyed annually. Leaders indicated that content was appropriate for intended PGY levels. Leaders and learners indicated the curriculum improved the ability of learners to interpret EKGs while working in the emergency department (ED). CONCLUSION: There is an unmet need for standardization and improvement of EM resident EKG training. Leaders and learners exposed to FoEM EKG courses report improved ability of learners to interpret EKGs in the ED.

The severity of disparity: increasing injury intensity accentuates disparate outcomes following trauma.

OBJECTIVE: Studies have shown disparities in mortality among racial groups and among those with differing insurance coverage. Our goal was to determine if injury severity affects these disparities. METHODS: We classified patients from the 2003-2008 National Trauma Data Banks suffering moderate to severe injuries into six groups based on race/ethnicity and insurance, stratifying by injury severity. Logistic regression compared odds of death between races-ethnicities/insurance groups within these strata. We adjusted for age, gender, Injury Severity Score, Glasgow Coma Scale motor component, hypotension, and mechanism of injury. RESULTS: Patients meeting inclusion criteria numbered 760,598. Disparities between races-ethnicities/insurance groups increased as injury severity worsened. Odds of death for uninsured Black patients compared with insured Whites increased from 1.82 among moderately injured patients to 3.14 among severely injured, hypotensive patients. A similar pattern was seen among uninsured Hispanic patients. CONCLUSIONS: Disparities in trauma mortality suffered by minority and uninsured patients, when compared with non-minority and insured patients, worsen with increasing injury.

Do shade-grown coffee plantations pose a disease risk for wild birds?

Shade-grown coffee plantations are often promoted as a conservation strategy for wild birds. However, these agro-ecosystems are actively managed for food production, which may alter bird behaviors or interactions that could change bird health, compared to natural forest. To examine whether there is a difference between the health parameters of wild birds inhabiting shade-grown coffee plantations and natural forest, we evaluated birds in Costa Rica for (1) their general body condition, (2) antibodies to pathogens, (paramyxovirus and Mycoplasma spp.), and (3) the prevalence and diversity of endo-, ecto-, and hemoparasites. We measured exposure to Mycoplasma spp. and paramyxovirus because these are pathogens that could have been introduced with domestic poultry, one mechanism by which these landscapes could be detrimental to wild birds. We captured 1,561 birds representing 75 species. Although seasonal factors influenced body condition, we did not find bird general body condition to be different. A total of 556 birds of 31 species were tested for antibodies against paramyxovirus-1. Of these, five birds tested positive, four of which were from shade coffee. Out of 461 other tests for pathogens (for antibodies and nucleotide detection), none were positive. Pterolichus obtusus, the feather mite of chickens, was found on 15 birds representing two species and all were from shade-coffee plantations. Larvated eggs of Syngamus trachea, a nematode typically associated with chickens, were found in four birds captured in shade coffee and one captured in forest. For hemoparasites, a total of 1,121 blood smears from 68 bird species were examined, and only one species showed a higher prevalence of infection in shade coffee. Our results indicate that shade-coffee plantations do not pose a significant health risk to forest birds, but at least two groups of pathogens may deserve further attention: Haemoproteus spp. and the diversity and identity of endoparasites.