Emergency medicine physician burnout before and during the COVID-19 pandemic.

BACKGROUND: Burnout is a common issue among physicians, and the rate among emergency medicine physicians (EPs) appears to be higher than those of other medical specialties. The COVID-19 pandemic presents unprecedented challenges to the medical community worldwide, but its effects on EP burnout has not yet been determined. METHODS: We conducted a three-stage nationwide study between July 2019 and June 2021. First, we evaluated the responses to burnout questionnaires that had been filled in by EP before the COVID-19 pandemic. We then re-sent the same questionnaires, with an addition of pandemic-specific questions. The third step involved a small group of EPs who participated in a burnout reduction workshop and re-took the questionnaires after a 3-month interval. The Maslach Burnout Inventory measured three burnout scales and a Work and Meaning Inventory predicts job satisfaction. Descriptive, univariate, and multivariate statistical tests were used to analyze the data. RESULTS: In the first stage, 240 questionnaires were sent by email to all Israeli EPs listed in emergency departments nationwide, and 84 out of 88 submitted questionnaires were completed in full before the pandemic. 393 questionnaires were sent in the second stage during the pandemic and 93 out of 101 submitted questionnaires were completed in full. Twenty EPs participated in the workshop and 13 out of 20 submitted questionnaires were completed in full. Burnout levels were high (Maslach) among EPs before the pandemic and increased during the pandemic. The feelings of personal accomplishment and work meaning-both protective factors from burnout-were significantly higher in the second (pandemic) stage. The pandemic-specific burnout factors were fear of infecting family members, lack of care centers for the physician's children, increased workload, and insufficient logistic support. The physician-oriented intervention had no significant impact on burnout levels (p < 0.412, Friedman test). CONCLUSIONS: Physician burnout is a major global problem, and it is now being aggravated by the challenges of the COVID-19 pandemic. Healthcare administrators should be alerted to pandemic-specific stress factors in order to help teams cope better and to prevent further worsening of the burnout. Further research is warranted to determine the lasting effect of the pandemic on EM physician burnout and the best means for reducing it.

Prospective examination of daily life traumatic stress symptom expression following motor vehicle collisions.

OBJECTIVE: Motor vehicle collisions (MVCs) are a common source of traumatic stress, which could lead to the development of posttraumatic stress disorder. However, the natural course of symptom development is still poorly understood. The current study aimed to prospectively examine the expression of traumatic stress symptoms in mild-moderate injured MVC survivors, using a novel daily life repeated measurement approach. METHOD: Participants (N = 70) were screened and recruited upon hospital arrival. Daily assessments of traumatic stress symptoms were conducted via mobile phones, and the data during days 2-6 (acute phase) and 27-31 (1-month phase) following the MVC were used for the current study. RESULTS: Latent growth curve analyses showed that at the acute phase, traumatic stress symptoms followed a reducing trajectory, with significant intercept and negative slope factors. At the 1-month phase, traumatic stress symptoms followed a low-stable trajectory, with a lower intercept and a nonsignificant slope factor. The acute-phase intercept and slope were both positively associated with 1-month symptomatology, such that higher initial symptoms and slower recovery rates were associated with greater traumatic stress symptoms at 1-month post-MVC. Trauma history and peritraumatic perceived life threat were indirectly associated with the 5-days end-of-the-month traumatic stress symptoms, through the mediation of the acute-phase intercept. CONCLUSIONS: An early screen of traumatic stress symptoms in the first few days following trauma exposure, together with trauma history and perceived peritraumatic life threat, may assist in identifying individuals at risk for subsequent posttraumatic psychopathology. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Pathophysiological profile of awake and anesthetized pigs following systemic exposure to the highly lethal ricin toxin.

Ricin, a plant-derived toxin originating from the seeds of Ricinus communis (castor bean plant), is one of the most lethal toxins known. To date, no in-depth study of systemic exposure to ricin in a standardized large animal model has been reported. This study details for the first time the pathophysiological hemodynamic profile following systemic/intramuscular exposure to the ricin toxin in a porcine model by comprehensive cardiorespiratory monitoring of awake and anesthetized pigs. Unlike respiratory exposure to ricin, which is characterized by the development of acute respiratory distress syndrome, following intramuscular exposure to ricin respiratory parameters were grossly unaffected, however the hemodynamics of both awake and anesthetize pigs were unsustainably compromised. We show that in the early phase until approximately 24 h post-exposure, cardiac output is not impaired although one of its components, stroke volume, is relatively low. This is due to compensatory increase in heart rate, which eventually becomes insufficient. Later, distributive shock develops, characterized by severe vasodilatation (decreased systemic vascular resistance), low central venous oxygen saturation and elevation of venous-to-arterial carbon dioxide difference indicating increase in tissue oxygen demand not met by cardiac supply. These findings serve as a basis for further studies to evaluate the ability of supportive treatments such as vasoactive and inotropic drugs, to postpone the hemodynamic deterioration and thus expand the therapeutic window for the anti-ricin treatment. Such studies are of crucial importance for judicious treatment of victims of acts of bioterrorism or of intentional self-poisoning.

Medical expertise as a critical influencing factor on the length of stay in the ED: A retrospective cohort study.

ABSTRACT: Overcrowding in the emergency departments (ED) is a significant issue associated with increased morbidity and mortality rates as well as decreased patient satisfaction. Length of stay (LOS) is both a cause and a result of overcrowding. In Israel, as there are few emergency medicine (EM) physicians, the ED team is supplemented with doctors from specialties including internal medicine, general surgery, orthopedics etc. Here we compare ED length of stay (ED-LOS), treatment time and decision time between EM physicians, internists and general surgeons.A retrospective cohort study was conducted examining the Emergency Department length of stay (ED-LOS) for all adult patients attending Sheba Medical Center ED, Israel, between January 1st, and December 31st, 2014. Using electronic medical records, data was gathered on patient age, sex, primary ED physician, diagnosis, eventual disposition, treatment time and disposition decision time. The primary outcome variable was ED-LOS relative to case physician specialty and level (ED, internal medicine or surgery; specialist or resident). Secondary analysis was conducted on time to treatment/ decision as well as ED-LOS relative to patient classification variables (internal medicine vs surgical diagnosis). Specialists were compared to specialists and residents to residents for all outcomes.Residents and specialists in either EM, internal medicine or general surgery attended 57,486 (51.50%) of 111,630 visits to Sheba Hospital's general ED. Mean ED-LOS was 4.12 ±â€Š3.18 hours. Mean treatment time and decision time were 1.79 ±â€Š1.82 hours, 2.84 ±â€Š2.17 hours respectively. Amongst specialists, ED-LOS was shorter for EM physicians than for internal medicine physicians (mean difference 0.28 hours, 95% CI 0.14-0.43) and general surgeons (mean difference 0.63 hours, 95% CI 0.43-0.83). There was no statistical significance between residents when comparing outcomes.Increasing the number of EM specialists in the ED may support efforts to decrease ED-LOS, overcrowding and medical errors whilst increasing patient satisfaction and outcomes.

The Impact of Personal Protection Equipment on Intubation Times.

INTRODUCTION: Hazardous material (HAZMAT) protocols require health care providers to wear personal protective equipment (PPE) when caring for contaminated patients. Multiple levels of PPE exist (level D - level A), providing progressively more protection. Emergent endotracheal intubation (ETI) of victims can become complicated by the cumbersome nature of PPE. STUDY OBJECTIVE: The null hypothesis was tested that there would be no difference in time to successful ETI between providers in different types of PPE. METHODS: This randomized controlled trial assessed time to ETI with differing levels of PPE. Participants included 18 senior US Emergency Medicine (EM) residents and attendings, and nine US senior Anesthesiology residents. Each individual performed ETI on a mannequin (Laerdal SimMan Essential; Stavanger, Sweden) wearing the following levels of PPE: universal precautions (UP) controls (nitrile gloves and facemask with shield); partial level C (PC; rubber gloves and a passive air-purifying respirator [APR]); and complete level C (CC; passive APR with an anti-chemical suit). Primary outcome measures were the time in seconds (s) to successful intubation: Time 1 (T1) = inflation of the endotracheal tube (ETT) balloon; Time 2 (T2) = first ventilation. Data were reported as medians with Interquartile Ranges (IQR, 25%-75%) or percentages with 95% Confidence Intervals (95%, CI). Group comparisons were analyzed by Fisher's Exact Test or Kruskal-Wallis, as appropriate (alpha = 0.017 [three groups], two-tails). Sample size analysis was based upon the power of 80% to detect a difference of 10 seconds between groups at a P = .017; 27 subjects per group would be needed. RESULTS: All 27 participants completed the study. At T1, there was no statistically significant difference (P = .27) among UP 18.0s (11.5s-19.0s), PC 21.0s (14.0s-23.5s), or CC 17.0s (13.5s-27.5s). For T2, there was also no significant (P = .25) differences among UP 24.0s (17.5s-27.0s), PC 26.0s (21.0s-32.0s), or CC 24.0s (19.5s-33.5s). CONCLUSION: There were no statistically significant differences in time to balloon inflation or ventilation. Higher levels of PPE do not appear to increase time to ETI.

Statistical learning methodologies and admission prediction in an emergency department.

BACKGROUND: The quality of an emergency department (ED) is highly dependent on its ability to supply efficient, as well as high-quality treatment for all patients. Key performance indicators are important when measuring the performance of an emergency department. This study aimed to perform an exploratory data analysis and to develop an admission prediction model based on a dataset that was constructed from key performance indicators selected by a panel of expert physicians, nurses and hospital administrators. METHODS: A dataset of 172,695 records was retrospectively collected from an Emergency Department. The relationships within the dataset were analyzed and three machine learning algorithms were compared for an admission predictive model based on the initial patient information. RESULTS: The dataset showed that mean length of stay was similar in the different weekdays, there was a positive linear relationship between the length of stay and patient age and the admission predictive model yielded an AUC of 0.79. CONCLUSIONS: The selected indicators can be used to study whether emergency department allocates its resources properly to cope with overcrowding and the predictive model may be employed by Hospital and ED administrates to fill information gaps and support decision making for the improvement of the key performance indicators.

Mechanical Ventilation with Room Air is Feasible in a Moderate Acute Respiratory Distress Syndrome Pig Model - Implications for Disaster Situations and Low-Income Nations.

INTRODUCTION: Patients with respiratory failure are usually mechanically ventilated, mostly with fraction of inspired oxygen (FiO2) > 0.21. Minimizing FiO2 is increasingly an accepted standard. In underserved nations and disasters, salvageable patients requiring mechanical ventilation may outstrip oxygen supplies. STUDY OBJECTIVE: The hypothesis of the present study was that mechanical ventilation with FiO2 = 0.21 is feasible. This assumption was tested in an Acute Respiratory Distress Syndrome (ARDS) model in pigs. METHODS: Seventeen pigs were anesthetized, intubated, and mechanically ventilated with FiO2 = 0.4 and Positive End Expiratory Pressure (PEEP) of 5cmH2O. Acute Respiratory Distress Syndrome was induced by intravenous (IV) oleic acid (OA) infusion, and FiO2 was reduced to 0.21 after 45 minutes of stable moderate ARDS. If peripheral capillary oxygen saturation (SpO2) decreased below 80%, PEEP was increased gradually until maximum 20cmH2O, then inspiratory time elevated from one second to 1.4 seconds. RESULTS: Animals developed moderate ARDS (mean partial pressure of oxygen [PaO2]/FiO2 = 162.8, peak and mean inspiratory pressures doubled, and lung compliance decreased). The SpO2 decreased to <80% rapidly after FiO2 was decreased to 0.21. In 14/17 animals, increasing PEEP sufficed to maintain SpO2 > 80%. Only in 3/17 animals, elevation of FiO2 to 0.25 after PEEP reached 20cmH2O was needed to maintain SpO2 > 80%. Animals remained hemodynamically stable until euthanasia one hour later. CONCLUSIONS: In a pig model of moderate ARDS, mechanical ventilation with room air was feasible in 14/17 animals by elevating PEEP. These results in animal model support the potential feasibility of lowering FiO2 to 0.21 in some ARDS patients. The present study was conceived to address the ethical and practical paradigm of mechanical ventilation in disasters and underserved areas, which assumes that oxygen is mandatory in respiratory failure and is therefore a rate-limiting factor in care capacity allocation. Further studies are needed before paradigm changes are considered.

The potential benefit of a second C-reactive protein measurement in patients with gram-negative bacteraemia presenting to the emergency medicine department.

BACKGROUND: Low C-reactive protein in acute bacterial infections could convey the erroneous impression of a mild infection. We focussed on gram-negative bacteraemia, a phenomenon frequently seen at the emergency room. METHODS: Of 2200 patients with gram-negative bacteraemia, 460 patients with first C-reactive protein <30 mg/L and 460 patients with C-reactive protein >187 mg/L were reviewed. Following exclusions, we finally investigated 229 and 289 patients with low and high C-reactive protein concentrations, respectively. RESULTS: The cohort was divided into low and high C-reactive protein groups. Median first C-reactive protein was 13.6 and 219.9 mg/L, respectively (interquartile range 6.4-21.6 and 195-270.1). Compared to patients with first high C-reactive protein, patients with first low C-reactive protein concentrations had a significant five-fold higher C-reactive protein level with their second test. CONCLUSIONS: Patients with gram-negative bacteraemia can present with C-reactive protein within the range of apparently healthy individuals. A second C-reactive protein might help to avoid an erroneous decision regarding the severity of the infection.

Six-Hour Manual Ventilation with a Bag-Valve-Tube Device by Briefly Trained Non-Medical Personnel is Feasible.

RATIONALE: Manual ventilation with a bag-valve device (BVD) is a Basic Life Support skill. Prolonged manual ventilation may be required in resource-poor locations and in severe disasters such as hurricanes, pandemics, and chemical events. In such circumstances, trained operators may not be available and lay persons may need to be quickly trained to do the job. OBJECTIVES: The current study investigated whether minimally trained operators were able to manually ventilate a simulated endotracheally intubated patient for six hours. METHODS: Two groups of 10 volunteers, previously unfamiliar with manual ventilation, received brief, structured BVD-tube ventilation training and performed six hours of manual ventilation on an electronic lung simulator. Operator cardiorespiratory variables and perceived effort, as well as the quality of the delivered ventilation, were recorded. Group One ventilated a "normal lung" (compliance 50cmH2O/L, resistance 5cmH2O/L/min). Group Two ventilated a "moderately injured lung" (compliance 20cmH2O/L, resistance 20cmH2O/L/min). RESULTS: Volunteers' blood pressure, heart rate (HR), respiratory rate (RR), and peripheral capillary oxygen saturation (SpO2) were stable throughout the study. Perceived effort was minimal. The two groups provided clinically adequate and similar RRs (13.3 [SD = 3.0] and 14.1 [SD = 2.5] breaths/minute, respectively) and minute volume (MV; 7.6 [SD = 2.1] and 7.7 [SD = 1.4] L/minute, respectively). CONCLUSIONS: The results indicate that minimally trained persons can effectively perform six hours of manual BVD-tube ventilation of normal and moderately injured lungs, without undue effort. Quality of delivered ventilation was clinically adequate.

Multi-domain potential biomarkers for post-traumatic stress disorder (PTSD) severity in recent trauma survivors.

Contemporary symptom-based diagnosis of post-traumatic stress disorder (PTSD) largely overlooks related neurobehavioral mechanisms and relies entirely on subjective interpersonal reporting. Previous studies associating biomarkers with PTSD have mostly used symptom-based diagnosis as the main outcome measure, disregarding the wide variability and richness of PTSD phenotypical features. Here, we aimed to computationally derive potential biomarkers that could efficiently differentiate PTSD subtypes among recent trauma survivors. A three-staged semi-unsupervised method ("3C") was used to firstly categorize individuals by current PTSD symptom severity, then derive clusters based on clinical features related to PTSD (e.g. anxiety and depression), and finally to classify participants' cluster membership using objective multi-domain features. A total of 256 features were extracted from psychometrics, cognitive functioning, and both structural and functional MRI data, obtained from 101 adult civilians (age = 34.80 ± 11.95; 51 females) evaluated within 1 month of trauma exposure. The features that best differentiated cluster membership were assessed by importance analysis, classification tree, and ANOVA. Results revealed that entorhinal and rostral anterior cingulate cortices volumes (structural MRI domain), in-task amygdala's functional connectivity with the insula and thalamus (functional MRI domain), executive function and cognitive flexibility (cognitive testing domain) best differentiated between two clusters associated with PTSD severity. Cross-validation established the results' robustness and consistency within this sample. The neural and cognitive potential biomarkers revealed by the 3C analytics offer objective classifiers of post-traumatic morbidity shortly following trauma. They also map onto previously documented neurobehavioral mechanisms associated with PTSD and demonstrate the usefulness of standardized and objective measurements as differentiating clinical sub-classes shortly after trauma.

Attention control therapy for acute stress disorder: A randomized controlled trial.

BACKGROUND: A subset of people exposed to traumatic events develop acute stress disorder (ASD), and approximately half of people with ASD develop posttraumatic stress disorder (PTSD). This randomized controlled trial examined the efficacy of internet-delivered attention control therapy (ACT), previously shown to reduce PTSD symptoms, as an adjuvant to treatment as usual in the community for patients with ASD. METHODS: About 119 participants with ASD were randomly assigned to ACT or treatment as usual in the community within the first month following their traumatic event. PTSD symptoms and attention patterns were measured. RESULTS: A significant reduction in stress-related symptoms was noted across participants with no difference between the two groups. Approximately half of the participants developed PTSD 2 months after the trauma. High attention bias variability was associated with elevated PTSD symptoms. However, attention bias variability did not change due to the therapy sessions. CONCLUSIONS: Internet-delivered ACT was no more effective in reducing risk for PTSD in participants with ASD than treatment as usual in the community. Although elevated attention bias variability was detected in the patients with ASD, ACT failed to engage this cognitive target. Finally, ACT-based prevention research should proceed with caution given the possibility that this intervention might be associated with symptom worsening as indexed by the Clinical Global Impression scale.

Neuroanatomical Risk Factors for Posttraumatic Stress Disorder in Recent Trauma Survivors.

BACKGROUND: Low hippocampal volume could serve as an early risk factor for posttraumatic stress disorder (PTSD) in interaction with other brain anomalies of developmental origin. One such anomaly may well be the presence of a large cavum septum pellucidum (CSP), which has been loosely associated with PTSD. We performed a longitudinal prospective study of recent trauma survivors. We hypothesized that at 1 month after trauma exposure the relation between hippocampal volume and PTSD symptom severity will be moderated by CSP volume, and that this early interaction will account for persistent PTSD symptoms at subsequent time points. METHODS: One hundred seventy-one adults (87 women, average age 34.22 years [range, 18-65 years of age]) who were admitted to a general hospital's emergency department after a traumatic event underwent clinical assessment and structural magnetic resonance imaging within 1 month after trauma. Follow-up clinical evaluations were conducted at 6 (n = 97) and 14 (n = 78) months after trauma. Hippocampal and CSP volumes were measured automatically by FreeSurfer software and verified manually by a neuroradiologist (D.N.). RESULTS: At 1 month after trauma, CSP volume significantly moderated the relation between hippocampal volume and PTSD severity (p = .026), and this interaction further predicted symptom severity at 14 months posttrauma (p = .018). Specifically, individuals with a smaller hippocampus and larger CSP at 1 month posttrauma showed more severe symptoms at 1 and 14 months after trauma exposure. CONCLUSIONS: Our study provides evidence for an early neuroanatomical risk factors for PTSD, which could also predict the progression of the disorder in the year after trauma exposure. Such a simple-to-acquire neuroanatomical signature for PTSD could guide early management as well as long-term monitoring.

Using the kinetics of C-reactive protein response to improve the differential diagnosis between acute bacterial and viral infections.

PURPOSE: Differential diagnosis between acute viral and bacterial infection is an emerging common challenge for a physician in the emergency department. Serum C-reactive protein (CRP) is used to support diagnosis of bacterial infection, but in patients admitted with low CRP, its ability to discriminate between viral and bacterial infections is limited. We aimed to use two consecutive CRP measurements in order to improve differential diagnosis between bacterial and viral infection. METHODS: A single-center retrospective cohort (n = 1629) study of adult patients admitted to the emergency department with a subsequent microbiological confirmation of either viral or bacterial infection. Trend of CRP was defined as the absolute difference between the first two measurements of CRP divided by the time between them, and we investigated the ability of this parameter to differentiate between viral and bacterial infection. RESULTS: In patients with relatively low initial CRP concentration (< 60 mg/L, n = 634 patients), where the uncertainty regarding the type of infection is the highest, the trend improved diagnosis accuracy (AUC 0.83 compared to 0.57 for the first CRP measurement). Trend values above 3.47 mg/L/h discriminated bacterial from viral infection with 93.8% specificity and 50% sensitivity. CONCLUSIONS: The proposed approach for using the kinetics of CRP in patients whose first CRP measurement is low can assist in differential diagnosis between acute bacterial and viral infection.

Neurobehavioral moderators of post-traumatic stress disorder (PTSD) trajectories: study protocol of a prospective MRI study of recent trauma survivors.

Background: Post-traumatic stress disorder (PTSD) is triggered by distinct events and is therefore amenable to studies of its early pathogenesis. Longitudinal studies during the year that follows trauma exposure revealed typical symptom trajectories leading to either recovery or protracted PTSD. Thezneurobehavioral correlates of early PTSD symptoms' trajectories have not been longitudinally explored. Objective: To present the rationale and design of a longitudinal study exploring the relationship between evolving PTSD symptoms and co-occurring cognitive functioning and structural and functional brain imaging parameters. Method: Adult civilians consecutively admitted to a general hospital emergency room (ER) for traumatic injury will be screened for early PTSD symptoms suggestive of chronic PTSD risk, and consecutively evaluated 1, 6 and 14 months following the traumatic event. Consecutive assessments will include structured clinical interviews for PTSD and comorbid disorders, self-reported depression and anxiety symptoms, a web-based assessment of cognitive domains previously linked with PTSD (e.g., memory, executive functions, cognitive flexibility), high-resolution structural MRI of both grey and white matter, functional resting-state connectivity, and fMRI tasks examining emotional reactivity and regulation, as well as motivation processing and sensitivity to risk and reward. Data analyses will explore putative cognitive predictors of non-remitting PTSD, and brain structural and functional correlates of PTSD persistence or recovery. Conclusion: This work will longitudinally document patterns of brain structures, connectivity, and functioning, predictive of (or associated with) emerging PTSD during the critical first year of after the traumatic event. It will thereby inform our understanding of the disorder's pathogenesis and underlying neuropathology. Challenges to longitudinal MRI studies of recent survivors, and methodological choices used to optimize the study's design are discussed.

Antecedentes: Los trastornos de estrés postraumático (TEPT) son desencadenados por distintos eventos y son por lo tanto susceptibles para estudios de su patogénesis temprana. Los estudios longitudinales durante el año que sigue la exposición al trauma revelan trayectorias de síntomas típicos que llevan tanto a la recuperación como al TEPT prolongado. Los correlatos neuroconductuales de las trayectorias de los síntomas tempranos del TEPT no han sido explorados longitudinalmente.Objetivo: Se presenta la justificación y el diseño de un estudio longitudinal explorando la relación entre los síntomas del TEPT en evolución y la co-ocurrencia del funcionamiento cognitivo y los parámetros de las imágenes cerebrales estructurales y funcionales.Método: Los adultos civiles ingresados consecutivamente a una sala de emergencia (ER en su sigla en inglés) de un hospital general por lesión traumática serán tamizados por los síntomas tempranos del TEPT sugerentes de riesgo de TEPT crónico, y evaluados consecutivamente a los uno, seis, y catorce meses luego del evento traumático. Las evaluaciones consecutivas incluirán entrevistas clínicas estructuradas para el TEPT y los trastornos comórbidos, auto-reporte de los síntomas de depresión y ansiedad, una evaluación online de los dominios cognitivos vinculados previamente con el TEPT (por ej., memoria, funciones cognitivas, flexibilidad cognitiva), MRI estructural de alta definición para tanto la materia blanca como para la gris, conectividad en estado de descanso funcional, y tareas de MRI funcional (fMRI en su sigla en inglés) examinando la reactividad emocional y la regulación, como también el procesamiento de la motivación y la sensibilidad al riesgo y a la recompensa. Los análisis de los datos explorarán supuestos predictores cognitivos del TEPT no remitidos, y los correlatos estructurales y funcionales del cerebro de la persistencia o recuperación del TEPT.Conclusión: Este trabajo documentará longitudinalmente los patrones de las estructuras cerebrales, conectividad, y predicción funcional de, o asociado con TEPT emergente durante el primer año crítico, luego de un evento traumático. Así, informará nuestro entendimiento de la patogénesis del trastorno y la neuropatología de base. Se discuten los desafíos de los estudios longitudinales de MRI con sobrevivientes recientes, y las decisiones metodológicas usadas para optimizar el diseño del estudio.

Anemia measurements to distinguish between viral and bacterial infections in the emergency department.

The clinical diagnosis of acute infections in the emergency department is a challenging task due to the similarity in symptom presentation between virally and bacterially infected individuals, while the use of routine laboratory tests for pathogen identification is often time-consuming and may contain contaminants. We investigated the ability of various anemia-related parameters, including hemoglobin, red cell distribution width (RDW), and iron, to differentiate between viral and bacterial infection in a retrospective study of 3883 patients admitted to the emergency department with a confirmed viral (n = 1238) or bacterial (n = 2645) infection based on either laboratory tests or microbiological cultures. The ratio between hemoglobin to RDW was found to be significant in distinguishing between virally and bacterially infected patients and outperformed other anemia measurements. Moreover, the predictive value of the ratio was high even in patients presenting with low C-reactive protein values (< 21 mg/L). We followed the dynamics of hemoglobin, RDW, and the ratio between them up to 72 h post emergency department admission, and observed a consistent discrepancy between virally and bacterially infected patients over time. Additional analysis demonstrated higher levels of ferritin and lower levels of iron in bacterially infected compared with virally infected patients. The anemia measurements were associated with length of hospital stay, where all higher levels, except for RDW, corresponded to a shorter hospitalization period. We highlighted the importance of various anemia measurements as an additional host-biomarker to discern virally from bacterially infected patients.

Six Hours of Manual Ventilation With a Bag-Valve-Mask Device Is Feasible and Clinically Consistent.

OBJECTIVES: Manual ventilation of intubated patients is a common intervention. It requires skill as well as physical effort and is typically restricted to brief periods. Prolonged manual ventilation may be unavoidable in some scenarios, for example, extreme mass casualty incidents. The present study tested whether nurses are capable of appropriately manually ventilating patients for 6 hours. DESIGN: Volunteers performed ventilation on an electronic simulator for 6 hours while their own cardiorespiratory variables and the quality of the delivered ventilation were measured and recorded. The volunteers scored their perceived level of effort on a standard Borg Scale. SETTING: Research laboratory at the Emergency Department, Tel Aviv Medical Center. SUBJECTS: Ten nursing staff members of the Tel Aviv Sourasky Medical Center, 25-43 years old. INTERVENTIONS: Volunteers ventilated manually a lung simulator for 6 hours. MEASUREMENTS AND MAIN RESULTS: The subjects' physiologic states, including blood pressure, heart rate, respiratory rate, and oxygen saturation, showed no significant changes over time. The quality of delivered ventilation was somewhat variable, but it was stable on the average: average tidal volume ranged between 524.8 and 607.0 mL (p = 0.33). There was a slight but significant increase (7.3-10.9 L/min [p = 0.048]) in minute volume throughout the test period, reaching values consistent with mild hyperventilation. The subjects scored their perceived working effort as very light to fairly light, with a nonsignificant gradual increase in the Borg score as the study progressed. CONCLUSIONS: Manual ventilation of intubated patients can be performed continuously for 6 hours without excessive physical effort on the part of the operator. The quality of delivered ventilation was clinically adequate for all of them. There was a mild but significant trend toward hyperventilation, albeit within safe clinical levels, which was due to an increasing ventilatory rate rather than an increase in tidal volume.

Septic patients presenting with apparently normal C-reactive protein: A point of caution for the ER physician.

The presentation of septic patients with low C-reactive protein (CRP) concentrations to the emergency room (ER) might convey an erroneous impression regarding the severity of the disease.We analyzed a retrospective study of septic patients admitted to the internal medicine departments of a relatively large tertiary medical center, following admission to the ER. These patients had CRP concentrations of <31.9 mg/L, the determined cut-off for CRP concentrations in a large cohort of apparently healthy individuals in the community (n = 17,214, upper limit of mean + 3 standard deviations).By processing the electronic medical records, we found 2724 patients with a diagnosis of sepsis, 476 of whom had an admission CRP concentration of <31.9 mg/L. Following further analysis of these records, we found that 34 of the 175 patients (19.4%) who fulfilled the definition of sepsis, died within 1 week of hospitalization. Of special interest was the finding that within <24 h, a significant increment from a median CRP of 16.1 mg/L (IQR 7.9-22.5) to 58.6 mg/L (IQR 24.2-134.4), (P < .001) was noted, accompanied by a velocity change from 0.4 ±â€Š0.29 to 8.3 ±â€Š24.2 mg/L/h following antibiotic administration (P < .001).ER physicians should take into consideration that septic patients with a high in-hospital mortality rate can present with CRP concentrations that are within the range observed in apparently healthy individuals in the community. A second CRP test obtained within 24 h following antibiotic administration might influence attitudes regarding the severity of the disease.

Reduced hospitalization rates are not associated with increased mortality or readmission rates in an emergency department in Israel.

BACKGROUND AND AIM: In 2011 the Israeli Ministry of Health (MOH) instructed hospitals to limit occupancy in the internal medicine wards to 120%, which was followed by a nationwide reduction in hospitalization rates. We examined how readmission and mortality rates changed in the five years following the changes in occupancy rates and hospitalization rates. METHODS: All visits to the Tel Aviv Medical Center internal Emergency Medicine Department (ED) in 2010, 2014 and 2016 were captured, with exclusion of visits by patients below 16 of age and patients with incomplete or faulty data. The main outcomes were one-week readmission rates and one-month death rates. The secondary outcomes were admission rate, ED visit length & admission-delay time (minutes), and rates of admission-delayed patients. RESULTS: After exclusion, a total of 168,891 internal medicine ED patients were included in the analysis. Mean age was 58.0 and 49% were males. During the relevant period (2010-2016), total medical ED visits increased by 11% - 53,327, 56,588 and 59,066 in 2010, 2014 and 2016 respectively. Hospitalization rates decreased from 46% in 2010 to 35% in 2015 (p < 0.001), with the most prominent reduction in the elderly population. One-week readmission rates were 6.5, 6.4 and 6.7% in 2010, 2014 and 2016 respectively (p = 0.347 and p = 0.21). One-month mortality was similar in 2010 and 2014 (4.4 and 4.5%, p = 0.388) and lower in 2016 (4.1%, p = 0.048 compared with 2010). Average ED visit length increased from 184 min in 2010 to 238 and 262 min in 2014 & 2016 (p < 0.001 for both) and average delay time to ward admission increased from 97 min in 2010 to 179 and 240 in 2014 & 2016 (p < 0.001 for both). In 2010 24% of the admitted patients were delayed in the ED more than 2 h, numbers that increased to 53% in 2014 and 66% in 2016 (p < 0.001 for both). CONCLUSION: Following the 2011 MOH's decision to establish a 120% occupancy limit for internal medicine wards along with natural growth in population volume, significant changes were noted in the work of a large, presumably representative emergency department in Israel. Although a steady increase in total ED visits along with a steady reduction in hospitalization rates were observed, the readmission and mortality rates remained low. The increase in the average length of ED visits and in the delay from ED admission to a ward reflects higher burden on the ED. The study was not able to establish a causal connection between the MOH directive and the subsequent changes in ED activity. Nonetheless, the study has significant potential implications for policy makers, including the presence of senior ED physicians during afterhours, creation of short-stay diagnostic units and proper adjustments in ED size and personnel.

Cognitive Flexibility Predicts PTSD Symptoms: Observational and Interventional Studies.

Introduction: Post-Traumatic Stress Disorder (PTSD) is a prevalent, severe and tenacious psychopathological consequence of traumatic events. Neurobehavioral mechanisms underlying PTSD pathogenesis have been identified, and may serve as risk-resilience factors during the early aftermath of trauma exposure. Longitudinally documenting the neurobehavioral dimensions of early responses to trauma may help characterize survivors at risk and inform mechanism-based interventions. We present two independent longitudinal studies that repeatedly probed clinical symptoms and neurocognitive domains in recent trauma survivors. We hypothesized that better neurocognitive functioning shortly after trauma will be associated with less severe PTSD symptoms a year later, and that an early neurocognitive intervention will improve cognitive functioning and reduce PTSD symptoms. Methods: Participants in both studies were adult survivors of traumatic events admitted to two general hospitals' emergency departments (EDs) in Israel. The studies used identical clinical and neurocognitive tools, which included assessment of PTSD symptoms and diagnosis, and a battery of neurocognitive tests. The first study evaluated 181 trauma-exposed individuals one-, six-, and 14 months following trauma exposure. The second study evaluated 97 trauma survivors 1 month after trauma exposure, randomly allocated to 30 days of web-based neurocognitive intervention (n = 50) or control tasks (n = 47), and re-evaluated all subjects three- and 6 months after trauma exposure. Results: In the first study, individuals with better cognitive flexibility at 1 month post-trauma showed significantly less severe PTSD symptoms after 13 months (p = 0.002). In the second study, the neurocognitive training group showed more improvement in cognitive flexibility post-intervention (p = 0.019), and lower PTSD symptoms 6 months post-trauma (p = 0.017), compared with controls. Intervention- induced improvement in cognitive flexibility positively correlated with clinical improvement (p = 0.002). Discussion: Cognitive flexibility, shortly after trauma exposure, emerged as a significant predictor of PTSD symptom severity. It was also ameliorated by a neurocognitive intervention and associated with a better treatment outcome. These findings support further research into the implementation of mechanism-driven neurocognitive preventive interventions for PTSD.

C-reactive protein and emergency department seven days revisit.

BACKGROUND: Emergency department (ED) revisit might be partially preventable. C-reactive protein (CRP) is an inflammatory biomarker which is commonly used as screening tool in the ED. We sought to evaluate the association between CRP level in patients visiting emergency department and 7 days revisit after discharge. METHODS: A historical cohort study of all patients who visited the internal division of the emergency department between June 2007 and July 2017 and had a CRP test. New ED visit was defined when neither any emergency department visit nor any hospital admission was recorded in our files during the previous 90 days. Univariate and multivariate models were used to evaluate the association between CRP and 7 days ED revisit. RESULTS: The study included 135,476 patients with 173,443 new visits. In 101,181 (58.3%) visits the patients were released and 7077 (7%) of them were revisited in 7 days. Even mild elevated CRP (5-25 mg/L) was independently associated with significant risk for revisit (OR 1.27, 95% CI 1.20-1.35). CONCLUSION: CRP is an independent predictor for 7 days ED revisit and should be considered at the time of discharge. Prediction models for ED revisit should include CRP as a potential predictor in their models.