A Comparison of SARS-COV-2 Neutralizing Antibody Therapies in High-Risk Patients with Mild to Moderate COVID-19 Disease at a Single Academic Hospital.

BACKGROUND: Bamlanivimab and casirivimab/imdevimab are recombinant neutralizing monoclonal antibodies that decrease viral load in patients with coronavirus disease 2019 (COVID-19) and can decrease hospitalizations. Few data exist comparing these two therapies. OBJECTIVE: Our aim was to compare the efficacy and safety of bamlanivimab and casirivimab/imdevimab in emergency department (ED) patients with COVID-19 who met criteria for monoclonal antibody therapy. METHODS: We performed a single-center, open-label, prospective study in adult ED patients with confirmed COVID-19 and high-risk features for hospitalization. Enrolled patients received bamlanivimab or casirivimab/imdevimab, depending on the day of the week that they arrived. We observed patients for post-infusion-related reactions and contacted them on days 5, 10, and 30. The primary outcome was the number of hospitalizations through day 30. In addition, we compared groups with regard to return visits to the ED, symptom improvement, antibody-induced adverse events, and deaths. RESULTS: Between December 17, 2020 and January 17, 2021, 321 patients completed the study. We found no statistically significant difference in the rate of subsequent hospitalization between groups (bamlanivimab: n = 18 of 201 [8.9%] and casirivimab/imdevimab: n = 13 of 120 [10.8%]; p = 0.57). In addition, we found no statistically significant differences between groups regarding return visits to the ED or symptom improvement. One patient had a possible adverse reaction to the treatment, and 1 patient died. Both of these events occurred in the bamlanivimab group. CONCLUSIONS: We found no statistically significant differences in rates of subsequent hospitalization or other outcomes for ED patients with COVID-19 when they received bamlanivimab as opposed to casirivimab/imdevimab. Adverse events were rare in both groups.

A Culinary Misadventure: A Case Report of Shiitake Dermatitis.

Shiitake dermatitis is a rare cutaneous reaction that can occur after consumption of shiitake mushrooms. It is characterized by highly pruritic lesions with a distinct whip lash appearance. Management of this condition includes reassurance and providing symptomatic relief. Although most reported cases have occurred in Asia, this rash has made appearances in the Western world. Here, we report a case of a 23-year-old female in the United States who experienced this itchy ailment. A diagnosis was made based on the presence of the recognizable lesions and dietary history. She was discharged with advice to continue symptomatic care and given reassurance about her condition. Her symptoms resolved within a few weeks. As the use of shiitake mushrooms become more widespread, it is important for clinicians to be familiar with this rash and remember to take a detailed dietary history. Topics: Rash, dermatology, toxicology, shiitake mushrooms.

Does a Standardized Discharge Communication Tool Improve Resident Performance and Overall Patient Satisfaction?

INTRODUCTION: The discharge conversation is a critical component of the emergency department encounter. Studies suggest that emergency medicine (EM) residency education is deficient in formally training residents on the patient discharge conversation. Our goal was to assess the proficiency of EM residents in addressing essential elements of a comprehensive discharge conversation; identify which components of the discharge conversation are omitted; introduce "DC HOME," a standardized discharge mnemonic; and determine whether its implementation improved resident performance and patient satisfaction. METHODS: This was a prospective observational pre- and post-intervention study done by convenience sampling of 400 resident discharge encounters. Resident physicians were observed by attending physicians who completed an evaluation, answering "yes" or "no" as to whether residents addressed six components of a comprehensive discharge. The six components include the following: diagnosis; care rendered; health and lifestyle modifications; obstacles after discharge; medications; and expectations - or "DC HOME." Didactics introducing the mnemonic "DC HOME" was provided to resident physicians. Patient feedback and satisfaction were collected after each encounter, and we recorded differences between pre-intervention and post-intervention encounters. RESULTS: Resident physicians improved significantly in all six components of "DC HOME" from pre-and-post intervention: discharge diagnosis (P = 0.0036) and the remaining five components (P<0.0001). There was a statistically significant improvement in patients' perception for health and lifestyle modifications, obstacles after discharge, medications, expectations after discharge (P<0.0001), and discharge diagnosis (P = 0.0029). Patient satisfaction scores improved significantly (P = 0.005). Time spent with patients during discharge increased from 2 minutes and 42 seconds to 4 minutes and 4 seconds (P<0.0001). CONCLUSION: EM residents frequently omit key components of the discharge conversation. The implementation of the "DC HOME" discharge mnemonic improves resident discharge performance, patient perception, and overall patient satisfaction.

Point-of-Care Ultrasound Identifies Decompensated Heart Failure in a Young Male with Methamphetamine-Associated Cardiomyopathy Presenting in Severe Sepsis to the Emergency Department.

We describe a case of a young male who presents to the emergency department with severe sepsis and decompensated heart failure with underlying Methamphetamine-Associated Cardiomyopathy that was previously undiagnosed. This presentation is unique because Methamphetamine-Associated Cardiomyopathy is an uncommonly reported condition that presented in a complex clinical scenario of severe sepsis and decompensated congestive heart failure. We discuss how we used point-of-care ultrasound (POCUS) in this case to identify an unsuspected disease process and how it changed our initial resuscitation strategy and management. Emergency physicians can utilize point-of-care ultrasound (POCUS) to help identify these high-risk patients in the emergency department and guide appropriate resuscitation. Methamphetamine-Associated Cardiomyopathy (MAC) is an infrequently described complication of methamphetamine abuse, most commonly presented as a nonischemic dilated cardiomyopathy. With the rise in methamphetamine abuse in the United States, complications from methamphetamine use are more commonly presenting to the emergency department. Proper education and rehabilitation, with a goal of abstinence from amphetamine use, may allow patients to potentially regain normal cardiac function. Since the majority of patients present late with severe cardiac dysfunction, early detection is essential amongst critically ill patients since recognition may significantly influence ED management.

How Much Time Do Residents Spend on Inpatient Clinical Computing?

OBJECTIVE: To evaluate the time that residents spend on clinical computing. METHODS: Our electronic health record system was used to record clinical computing time. Residents were unaware that we were tracking their time. Prior studies have reported computing times by watching the users. We evaluated residents in internal medicine, general surgery, and emergency medicine. The postgraduate year 1 (PGY1) and PGY3 residents were evaluated in July 2016 and January 2017. RESULTS: Emergency medicine residents spent approximately 3 hours/day and internal medicine and general surgery residents spent approximately 2 hours/day on clinical computing. For internal medicine and general surgery, there was a decrease in time spent on clinical computing from July to January and from PGY1 to PGY3. CONCLUSIONS: Residents in some specialties may decrease the time spent on clinical computing. There are many possible reasons for the changes. Our study serves as a computerized observation baseline for future assessments, interventions, and for developing improvements that increase the value of clinical computing.

Bilateral Phlegmasia Cerulea Dolens After Warfarin Reversal for Acute Rectal Bleeding: A Case Report.

BACKGROUND: Deep vein thrombosis (DVT) is a common disease that is diagnosed in approximately 1 in 1000 adults annually. Extensive DVT can lead to life- or limb-threatening diagnoses such as phlegmasia cerulea dolens (PCD), phlegmasia alba dolens, and venous gangrene. PCD, also known as massive iliofemoral venous thrombosis, is rare, and a severe complication of DVT. CASE REPORT: We report a case of a 94-year-old bedridden woman with past medical history of dementia, hypertension, pulmonary embolism, DVT, and atrial fibrillation. The patient was admitted to the hospital for bright red blood per rectum and an elevated international normalized ratio (INR) of 5.7. On admission, her dose of warfarin was suspended and she was given 4 units of fresh frozen plasma as well as 10 mg of i.v. vitamin K. She was discharged home with an INR normalized to 1.3 and cessation of her rectal bleeding. At discharge, she was not restarted on warfarin, nor was any bridging therapy used. The patient returned to the Emergency Department a week later for worsening pain and bluish discoloration of her bilateral lower extremities. An ultrasound (US) examination showed that she had developed bilateral PCD, after INR reversal. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians commonly care for patients who present with acute DVT or treat patients on anticoagulant therapy who require cessation of medications or administration of prothrombotic agents to reverse bleeding. Cases of extensive clot burden leading to PCD have been reported in the literature, however, reports of bilateral PCD secondary to cessation of warfarin have been scarce. PCD should be considered carefully as one of the complications in warfarin reversal, as it requires immediate attention and surgical intervention to prevent limb loss.

Pericardial Herniation of Small Bowel Post Minimally Invasive Hybrid Maze of Atrial Fibrillation.

BACKGROUND: Herniation of intraabdominal contents into the pericardial cavity is exceptionally rare, and when seen, it is most often the result of trauma, postsurgical complication, or genetic defect. There have been only a few case reports describing spontaneous bowel herniation into the pericardium in minimally invasive cardiac procedures like cardiac ablation, pacemaker placement, and minimally invasive coronary artery bypass graft. CASE REPORT: We report the case of a 65-year-old man who presented to an urgent care center complaining of abdominal and chest pain. This patient had recently undergone a laparoscopic hybrid maze procedure and ultimately had an incarcerated loop of small bowel herniate into the pericardial sac. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We present this case to increase awareness among emergency physicians of the diagnosis of a pericardial hernia in patients presenting with gastrointestinal or cardiorespiratory symptoms after surgical procedures involving the diaphragm.

Is serum lactate necessary in patients with normal anion gap and serum bicarbonate?

INTRODUCTION: There has been an increase in patients having serum lactate drawn in emergency situations. The objective of this study was to determine whether or not it was necessary to obtain a lactate level in patients with a normal serum bicarbonate level and anion gap. METHODS: This is a retrospective chart review evaluation of 304 patients who had serum lactate and electrolytes measured in an emergency setting in one academic medical center. RESULTS: In 66 patients who had elevated serum lactate (>2.2mmol/L), 45 (68%) patients had normal serum bicarbonate (SB) (greater than 21 mmol/L). Normal anion gap (AG) (normal range <16 mEq/l) was found in 51 of the 66 patients (77%). CONCLUSION: We found that among patients with elevated serum lactate, 77% had a normal anion gap and 68% had normal serum bicarbonate. We conclude serum lactate should be drawn based on clinical suspicion of anaerobic tissue metabolism independent of serum bicarbonate or anion gap values.