Pandemic phase-related racial and ethnic disparities in COVID-19 positivity and outcomes among patients presenting to emergency departments during the first two pandemic waves in the USA.

BACKGROUND: In many countries including the USA, the UK and Canada, the impact of COVID-19 on people of colour has been disproportionately high but examination of disparities in patients presenting to ED has been limited. We assessed racial and ethnic differences in COVID-19 positivity and outcomes in patients presenting to EDs in the USA, and the effect of the phase of the pandemic on these outcomes. METHODS: This is a retrospective cohort study of adult patients tested for COVID-19 during, or 14 days prior to, the index ED visit in 2020. Data were obtained from the National Registry of Suspected COVID-19 in Emergency Care network which has data from 155 EDs across 27 US states. Hierarchical models were used to account for clustering by hospital. The outcomes included COVID-19 diagnosis, hospitalisation at index visit, subsequent hospitalisation within 30 days and 30-day mortality. We further stratified the analysis by time period (early phase: March-June 2020; late phase: July-September 2020). RESULTS: Of the 26 111 adult patients, 38% were non-Hispanic White (NHW), 29% Black, 20% Hispanic/Latino, 3% Asian and 10% all others; half were female. The median age was 56 years (IQR 40-69), and 53% were diagnosed with COVID-19; of those, 59% were hospitalised at index visit. Of those discharged from ED, 47% had a subsequent hospitalisation in 30 days. Hispanic/Latino patients had twice (adjusted OR (aOR) 2.3; 95% CI 1.8 to 3.0) the odds of COVID-19 diagnosis than NHW patients, after adjusting for age, sex and comorbidities. Black, Asian and other minority groups also had higher odds of being diagnosed (compared with NHW patients). On stratification, this association was observed in both phases for Hispanic/Latino patients. Hispanic/Latino patients had lower odds of hospitalisation at index visit, but when stratified, this effect was only observed in early phase. Subsequent hospitalisation was more likely in Asian patients (aOR 3.1; 95% CI 1.1 to 8.7) in comparison with NHW patients. Subsequent ED visit was more likely in Blacks and Hispanic/Latino patients in late phase. CONCLUSION: We found significant differences in ED outcomes that are not explained by comorbidity burden. The gap decreased but persisted during the later phase in 2020.

Multi-center analysis of point-of-care ultrasound for small bowel obstruction: A systematic review and individual patient-level meta-analysis.

OBJECTIVE: The study aimed to assess the diagnostic accuracy of point-of-care ultrasound (POCUS) in identifying small bowel obstruction (SBO) and to investigate the impact of clinician experience level and body mass index (BMI) on POCUS performance for diagnosing SBO in the Emergency Department. METHODS: We systematically searched PubMed and Cochrane databases from January 2011-2022. We performed a meta-analysis using individual patient-level data from prospective diagnostic accuracy studies from which we obtained data from the corresponding authors. Overall test characteristics and subgroup analysis across clinician experience levels and a range of BMI were calculated. The primary outcome was SBO as the final diagnosis during hospitalization. RESULTS: We included Individual patient data from 433 patients from 5 prospective studies. Overall, 33% of patients had a final diagnosis of SBO. POCUS had 83.0% (95%CI 71.7%-90.4%) sensitivity and 93.0% (95%CI 55.3%-99.3%) specificity; LR+ was 11.9 (95%CI 1.2-114.9) and LR- was 0.2 (95%CI 0.1-0.3). Residents had exhibited a sensitivity of 73.0% (95%CI 56.6%-84.9%) and specificity of 88.2% (95%CI 58.8%-97.5%), whereas attendings had demonstrated a sensitivity of 87.7% (95%CI 71.1%-95.4%) and specificity of 91.4% (95%CI 57.4%-98.8%). Among those patients with BMI<30 kg/m2, POCUS showed a sensitivity of 88.6% (95%CI 79.5%-94.7%) and a specificity of 84.0% (95%CI 75.3%-90.6%), while patients with BMI ≥ 30 kg/m2 exhibited a sensitivity of 72.0% (95%CI 50.6%-87.9%) and specificity of 89.5% (95%CI 75.2%-97.1%). CONCLUSIONS: POCUS correctly identified those patients with SBO with high sensitivity and specificity. Diagnostic accuracy was slightly reduced when performed by resident physicians and among patients with a BMI ≥ 30 kg/m2. REGISTRATION: PROSPERO registration number: CRD42022303598.

Guidelines for Reasonable and Appropriate Care in the Emergency Department 2 (GRACE-2): Low-risk, recurrent abdominal pain in the emergency department.

This second Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-2) from the Society for Academic Emergency Medicine is on the topic "low-risk, recurrent abdominal pain in the emergency department." The multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding four priority questions for adult emergency department patients with low-risk, recurrent, undifferentiated abdominal pain. The intended population includes adults with multiple similar presentations of abdominal signs and symptoms recurring over a period of months or years. The panel reached the following recommendations: (1) if a prior negative computed tomography of the abdomen and pelvis (CTAP) has been performed within 12 months, there is insufficient evidence to accurately identify populations in whom repeat CTAP imaging can be safely avoided or routinely recommended; (2) if CTAP with IV contrast is negative, we suggest against ultrasound unless there is concern for pelvic or biliary pathology; (3) we suggest that screening for depression and/or anxiety may be performed during the ED evaluation; and (4) we suggest an opioid-minimizing strategy for pain control. EXECUTIVE SUMMARY: The GRACE-2 writing group developed clinically relevant questions to address the care of adult patients with low-risk, recurrent, previously undifferentiated abdominal pain in the emergency department (ED). Four patient-intervention-comparison-outcome-time (PICOT) questions were developed by consensus of the writing group, who performed a systematic review of the literature and then synthesized direct and indirect evidence to formulate recommendations, following GRADE methodology. The writing group found that despite the commonality and relevance of these questions in emergency care, the quantity and quality of evidence were very limited, and even fundamental definitions of the population and outcomes of interest are lacking. Future research opportunities include developing precise and clinically relevant definitions of low-risk, recurrent, undifferentiated abdominal pain and determining the scope of the existing populations in terms of annual national ED visits for this complaint, costs of care, and patient and provider preferences.

A 2-week elective experience provides comparable training as longitudinal exposure during residency for pelvic sonography.

OBJECTIVES: The purpose of this study was to compare the accuracy of first-trimester pelvic sonography done by physicians after a 2-week emergency ultrasound elective to similarly numbered examinations done by physicians longitudinally over several years of residency training. METHODS: We conducted a secondary analysis of a previously reported prospective study of pelvic sonography for symptomatic first-trimester pregnancy. The 21st through 40th examinations were compared between those who completed an emergency ultrasound elective and those who did not. The reference standard was pelvic sonography done by the department of radiology. RESULTS: Eighty-six examinations (34%) were done by 12 operators who did not participate in an emergency ultrasound elective, and 171 examinations (67%) were done by 13 operators who completed an emergency ultrasound elective. There was no statistical difference between the groups with regard to identifying an intrauterine pregnancy, molar pregnancy, ectopic pregnancy, or adnexal mass. CONCLUSIONS: The accuracy of pelvic sonography for first-trimester pregnancy was comparable between physicians who participated in a 2-week emergency ultrasound elective and those who performed the same number of examinations over a longer period during residency training.

Hypokalemia in diabetic ketoacidosis is less common than previously reported.

[K+] < 3.5 mmol/L is reported to occur in approximately 4 % of patients with diabetic ketoacidosis (DKA.) Therefore, the American Diabetes Association (ADA) and Joint British Diabetes Societies (JBDS) recommend the assessment of [K+] before the initiation of insulin treatment to avoid the precipitation of morbid hypokalemia. The purpose of this study was to assess the incidence of hypokalemia in patients presenting to the emergency department (ED) with DKA. This was a multicenter retrospective, cross-sectional study at EDs with a combined annual adult census of 155,000. Adult patients diagnosed with DKA in the ED, or who were admitted from the ED and subsequently diagnosed with DKA as determined from the hospital electronic database between January 2008 and December 2008, were included for analysis if they had the following initial laboratory values: (1) serum glucose >13.9 mmol/L (250 mg/dL), (2) serum bicarbonate <18 mmol/L (18 mEq/L) or anion gap >15, and (3) evidence of ketonaemia or ketonuria. 537 patients were diagnosed with DKA in the ED at the participating institutions during the reference period. The median [K+] was 4.9 mmol/L (IQR 4.3, 5.5). There were a total of seven patients with an initial 3.3 < [K+] < 3.5 mmol/L, but none with a [K+] < 3.3 mmol/L. Thus, no patients in our study sample required potassium supplementation before the initiation of insulin treatment. The incidence of hypokalemia in our sample of patients with DKA was much less than previously reported, with no cases requiring potassium supplementation before insulin administration.

Emergency ultrasound of the gall bladder: comparison of a concentrated elective experience vs. longitudinal exposure during residency.

BACKGROUND: It is unknown how an intensive emergency ultrasound (EUS) experience compares with comparable exposure done over the course of residency training. OBJECTIVE: Our objective was to compare the accuracy of EUS of the gall bladder done by physicians after a 2-week EUS elective with similarly numbered examinations done by physicians longitudinally over several years of residency training. METHODS: This was a secondary analysis of a previously reported prospective study of EUS for biliary disease. The 21(st)-40(th) examinations were compared between those who participated in an EUS elective and those who did not. The gold standard was ultrasound done by the Department of Radiology. RESULTS: Mean time to complete 40 EUS examinations for biliary disease was 14 months for those participating in an EUS elective compared with 29 months for those who did not. One hundred and ninety-one examinations (49%) were done by 19 operators who did not participate in an EUS elective and 202 examinations (51%) were done by 23 operators who completed an EUS elective. There was no statistical difference between the two groups with regard to detecting the presence of gall stones, gall bladder wall thickening, pericholecystic free fluid, ductal dilation, or sludge. CONCLUSIONS: Physicians who participated in a 2-week, semi-structured EUS elective demonstrated EUS accuracy for biliary disease that was comparable with those who performed the same number of examinations over a longer period of time.

Predictive value of signs and symptoms for small bowel obstruction in patients with prior surgery.

BACKGROUND: The aim of this study was to determine the predictive value of various signs and symptoms for small bowel obstruction (SBO) in patients with prior abdominal surgery. METHODS: This was a secondary analysis of a previously reported prospective study of ultrasonography for SBO. Patients with prior abdominal surgery were identified and presenting signs and symptoms were compared to the CT diagnosis of SBO. RESULTS: No signs or symptoms were predictive of SBO. CONCLUSION: No constellation of signs and symptoms can be used to reliably exclude a SBO in patients with prior abdominal surgery.

The predictive value of physical examination findings in patients with suspected acute heart failure syndrome.

It can be difficult to differentiate acute heart failure syndrome (AHFS) from other causes of acute dyspnea, especially when patients present in extremis. The objective of the study was to determine the predictive value of physical examination findings for pulmonary edema and elevated B-type natriuretic peptide (BNP) levels in patients with suspected AHFS. This was a secondary analysis of a previously reported prospective study of jugular vein ultrasonography in patients with suspected AHFS. Charts were reviewed for physical examination findings, which were then compared to pulmonary edema on chest radiography (CXR) read by radiologists blinded to clinical information and BNP levels measured at presentation. The predictive value of every sign and combination of signs for pulmonary edema on CXR or an elevated BNP was poor. Since physical examination findings alone are not predictive of pulmonary edema or an elevated BNP, clinicians should have a low threshold for using CXR or BNP in clinical evaluation. This brief research report suggests that no physical examination finding or constellation of findings can be used to reliably predict pulmonary edema or an elevated BNP in patients with suspected AHFS.