Outcomes Associated with Prehospital Epinephrine in Adult and Pediatric Anaphylaxis Patients.

BACKGROUND: Prompt epinephrine administration is important to improve outcomes in anaphylaxis. OBJECTIVE: The objective of our study was to assess the impact of prehospital epinephrine on clinical outcomes of hospital admission, biphasic reactions, and ED length of stay (LOS) in a cohort of ED anaphylaxis patients including both children and adults. METHODS: We conducted a single-center prospective and retrospective cohort study of anaphylaxis patients from April 2008 to December 2022. Associations between prehospital epinephrine administration with biphasic reactions and ED LOS were assessed with univariable models and the association with ED disposition was assessed with both univariable and multivariable logistic regression. RESULTS: A total of 1107 patient visits were included for analysis. The median patient age was 29 (IQR 14-50), 593 (53.6%) patients were female, 366 (33.1%) were under 18 years of age. Patients in the prehospital epinephrine group were also less likely to experience a biphasic reaction (5.4% vs 9.3%; OR 0.56, 95% CI 0.34-0.92) and had a decreased ED LOS (median 4.0 hours vs 4.7 hours). There was no difference in hospital admission between patients with and without prehospital epinephrine in both the univariable (19.5% vs 15.7%; OR 1.30, 95% CI: 0.94-1.79) and multivariable (aOR 1.08, 95% CI: 0.71-1.64) models. CONCLUSION: Prehospital epinephrine administration reduced the odds of a biphasic reaction and decreased ED LOS but did not reduce hospitalization in this cohort of ED anaphylaxis patients. Our findings suggest that timely administration of prehospital epinephrine is associated with improved patient outcomes.

Reproductive life factors and estro-progestin exposure in women with early-onset Parkinson's disease compared to late-onset disease and controls: A retrospective cohort study.

BACKGROUND: Parkinson's disease (PD) is more common in men than women. Although hormonal factors may partially explain this difference, there are no studies evaluating reproductive life factors and exogenous estroprogestin exposure in women with Early Onset Parkinson Disease (EOPD). OBJECTIVE: To compare reproductive life factors and exogenous estroprogestin exposure among female patients with EOPD, late-onset Parkinson's disease (LOPD), and EOPD-matched unaffected controls. METHODS: We identified female patients with EOPD from 1989 to 2021, defining EOPD as PD with motor-symptoms onset before age 50 and LOPD as PD with motor onset after 50. We paired EOPD patients to age-matched, unaffected controls. We reviewed medical records to determine demographic characteristics, clinical history, and reported reproductive menopausal history (reviewing medical records). RESULTS: We included 87 EOPD patients, 84 LOPD patients, and 91 unaffected controls with information about reproductive life factors and exogenous estroprogestin exposure in their medical records. There were no significant differences in race, ethnicity, or BMI between the three groups. EOPD patients were more likely to have used hormonal contraception than LOPD patients (23/49 (47 %) vs 0/84 (0 %), p < 0.001). LOPD patients had higher numbers of pelvic surgeries (48/84 [57 %] in LOPD, 23/87 [26 %] in EOPD, p < 0.001) and higher usage of perimenopausal hormonal therapy (52/84 [62 %] in LOPD, 10/87 [11 %] in EOPD, p < 0.001) in LOPD than EOPD. CONCLUSIONS: Our study reports no significant difference in reproductive life factors and exogenous estroprogestin exposure between controls and EOPD patients, except for higher exposure to hormonal contraception in EOPD. There was no apparent difference in reproductive life factors and exogenous estroprogestin exposure between EOPD and LOPD patients. Our findings therefore do not observe that hormonal exposure is different between earlier onset of female EOPD compared to female LOPD patients, or between female EOPD patients and unaffected female controls.

Providing Performance Feedback and Patient Outcome Follow-Up to Emergency Medical Services (EMS) is Associated with Subsequent Improved Clinical Performance.

OBJECTIVE: Emergency Medical Services (EMS) clinicians desire performance feedback (PF) and patient outcome follow-up (POF). Within our agency, both a peer-review and feedback/outcome (PF/POF) process exist. Our objective was to determine whether receiving feedback and outcome data improved future clinical care amongst EMS, based upon peer-review scores. METHODS: This retrospective cohort study took place between 1/1/2020 and 6/7/2023 within an EMS agency site with 22,000 average annual 9-1-1 calls. Requests for PF/POF were submitted on an individual basis beginning June 2020 and completed by a dedicated EMS nurse, EMS physician, or emergency medicine (EM) resident. Peer-review of select high-acuity cases were scored by two Quality Assurance (QA) specialists within the categories of assessment, treatment, disposition/outcome and process/administrative guidelines. Association between overall peer-review score and number of PF/POF requests at time of assessment was evaluated by linear regression. RESULTS: A total of 378 PF/POF requests were received, with the most common patient complaints being cardiac (n = 105; 27.8%, including 49 (13.0%) out of hospital cardiac arrests), altered mental status/neurologic (n = 103; 27.2%), trauma (n = 61; 16.1%, including 2 (0.5%) traumatic arrests); and respiratory distress (n = 47; 12.4%). A total of 378 runs meeting QA criteria were peer-reviewed post-PF/POF process implementation, including 337 (89.2%) cardiac/respiratory arrests, 27 (7.1%) with difficult airway management, and 14 (3.7%) major trauma/traumatic arrests. The number of prior PF/POF requests made by the team leader was associated with higher overall peer-review scores. Team leaders with >5 prior PF/POF requests had a peer-review score 0.39 points greater (95% CI: 0.16 - 0.62, p = 0.001) than those with <5 prior requests. The number of prior PF/POF requests amongst the entire crew was also associated with higher peer-review scores. Crews that collectively had >5 prior PF/POF requests had an increase in peer-review score 0.32 points greater (95% CI: 0.14 - 0.50, p < 0.001) than those with <5 prior requests. CONCLUSION: Providing performance feedback and patient outcome follow-up to EMS is associated with improved peer-review scores of clinical performance. Future studies should assess if those that are submitting cases for feedback/outcome are higher performers at baseline or if the process of receiving feedback/outcome improves their performance.

Improving emergency medicine resident pediatric lumbar puncture procedural performance through a brief just-in-time video intervention.

BACKGROUND: Emergency medicine (EM) trainee comfort level with lumbar puncture (LP) has decreased over time due to changing practice guidelines, particularly amongst pediatric patients. We implemented a "just in time" (JIT) brief educational video based on a previously published LP Performance Scoring Checklist to improve trainee efficiency and competence in LP performance. METHODS: Our pilot quasi-experimental study took place January-June 2022 within a large, academic Midwestern emergency department (ED) with an established 3-year EM residency program. All 9 interns performed a timed diagnostic LP on an infant LP model in January, scored according to the LP Performance Scoring Checklist. In June, interns repeated the timed LP procedure directly after watching a brief educational video based on major checklist steps. The study was deemed exempt by the Institutional Review Board. RESULTS: All interns completed both assessments. At baseline, interns had logged performance of median 2 (IQR 0-5) LPs and spent 12.9 (10.3-14.4) minutes performing the procedure. Post-intervention, interns had logged an additional median 2 (0-5) LPs and completed the procedure faster with an average time of 10.3 (9.7-11.3) minutes (p = 0.004). A median of 5 (4-7) major steps were missed at baseline, compared to 1 (1-2) at time of post-intervention assessment (p = 0.015). CONCLUSION: Development of a brief educational video improved efficiency and competency amongst our intern class in performing an infant LP when viewed Just-In-Time. Similar efforts may improve education and performance of other rare (or decreasing in frequency) procedures within EM training.

A Population-Based Approach to the Argument on Brain-First and Body-First Pathogenesis of Lewy Body Disease.

OBJECTIVE: To explore the clinical progression of the brain-/body-first categories within Lewy body disease (LBD): Parkinson's disease (PD), dementia with Lewy bodies (DLB), and PD dementia. METHODS: We used of the Rochester Epidemiology Project to establish a population-based cohort of clinically diagnosed LBD. We used two definitions for differentiating between brain- and body-first LBD: a previously hypothesized body-first presentation in patients with rapid eye movement sleep behavior onset before motor symptoms onset; and an expanded definition of body-first LBD when a patient had at least 2 premotor symptoms between constipation, erectile dysfunction, rapid eye movement sleep behavior, anosmia, or neurogenic bladder. RESULTS: Brain-first patients were more likely to be diagnosed with PD (RR = 1.43, p = 0.003), whereas body-first patients were more likely to be diagnosed with DLB (RR = 3.15, p < 0.001). Under the expanded definition, there was no difference in LBD diagnosis between brain-first and body-first patients (PD: RR = 1.03, p = 0.10; DLB: RR = 0.88, p = 0.58) There were no patterns between brain- or body-first presentation, PD dementia under either definition (original: p = 0.09, expanded: p = 0.97), and no significant difference in motor symptoms between brain-first and body-first. INTERPRETATION: Our findings do not support the dichotomous classification of body-first and brain-first LBD with the currently proposed definition. Biological exposures resulting in PD and DLB are unlikely to converge on a binary classification of top-down or bottom-up synuclein pathology. ANN NEUROL 2024;96:551-559.

Flexible endoscopic intubation in emergency medicine: A mixed-methods needs assessment.

Objectives: This needs assessment aimed to improve understanding of flexible endoscopic intubation training and practice in emergency medicine (EM), providing insights to educators and practice leaders seeking to improve education and practices. Methods: We conducted a multicenter, mixed-methods needs assessment of emergency physicians (EPs) incorporating focus groups and a survey. Focus groups comprised community EPs, academic EPs, and resident EPs. We analyzed focus group transcripts using grounded theory, qualitatively describing EM endoscopic intubation. The qualitative analysis shaped our survey instrument, which we deployed in cross-sectional fashion. We report survey data with descriptive statistics. Results: Focus groups with 13 EPs identified three themes: indications for use of endoscopic intubation, factors impacting a physician's decision to endoscopically intubate, and attaining and maintaining endoscopic intubation competency. Of 257 surveyed EPs (33% response rate), 79% had received endoscopic intubation training during residency, though 82% had performed this procedure 10 or fewer times in their career. Despite 97% acknowledging the necessity of competency, only 23% felt highly confident in their ability to perform endoscopic intubation. Participants (93%) reported scarce opportunities to perform the procedure and identified factors believed to facilitate competency acquisition and maintenance, including opportunities to perform endoscopic intubation in practice (98%), local champions (93%), and performing nasopharyngoscopy (87%). Conclusions: While most EPs acknowledged the importance of competency in endoscopic intubation, they reported scarce procedural opportunities and commonly expressed low confidence. Further research is needed on this topic, and we propose avenues to enhance education and practices related to endoscopic intubation. These include development of robust procedural curricula, support of local champions, and incorporating nasopharyngoscopy into EM practice.

Payer Type and Emergency Department Visit Prices.

This cross-sectional study assesses list prices, cash prices, and negotiated rates for emergency department services.

Risk of falls is associated with 30-day mortality among older adults in the emergency department.

OBJECTIVE: Falls in older adults correlate with heightened morbidity and mortality. Assessing fall risk in the emergency department (ED) not only aids in identifying candidates for prevention interventions but may also offer insights into overall mortality risk. We sought to examine the link between fall risk and 30-day mortality in older ED adults. METHODS: Observational cohort study of adults aged ≥ 75years who presented to an academic ED and who were assessed for fall risk using the Memorial Emergency Department Fall Risk Assessment Tool (MEDFRAT), a validated, ED-specific screening tool. The fall risk was classified as low (0-2 points), moderate (3-4 points), or high (≥5) risk. The primary outcome was 30-day mortality. Hazard ratios (HR) with 95% confidence intervals (CIs) were calculated. RESULTS: A total of 941 patients whose fall risk was assessed in the ED were included in the study. Median age was 83.7 years; 45.6% were male, 75.6% lived in private residences, and 62.7% were admitted. Mortality at 30 days among the high fall risk group was four times that of the low fall risk group (11.8% vs 3.1%; HR 4.00, 95% CI 2.18 to 7.34, p < 0.001). Moderate fall risk individuals had nearly double the mortality rate of the low-risk group (6.0% vs 3.1%), but the difference was not statistically significant (HR 1.98, 95% CI 0.91 to 4.32, p = 0.087). CONCLUSION: ED fall risk assessments are linked to 30-day mortality. Screening may facilitate the stratification of older adults at risk for health deterioration.

Relationship between individual and country-level socio-economic background, USMLE step scores, and demographics of international medical graduates and residency match results.

PURPOSE: Twenty five percent of practicing physicians in the US are International Medical Graduates (IMGs) - physicians who completed their medical school training outside of the United States and Canada. There are multiple studies demonstrating higher socio-economic background is associated with medical school matriculation in the US. However, despite a substantial prevalence of IMGs in the American healthcare system, studies of the association between demographics, socio-economic background, and securing a residency position in the match are lacking. METHODS: We created a survey with questions on residency match-related data and information on personal socio-economic background. An invitation to participate in the study was sent to all IMGs that applied to the included residency programs after the conclusion of the 2022 residency match. We used multivariable logistic regression to compare survey responses to the odds of securing a residency match. RESULTS: The total number of survey respondents was 744 (response rate 15.1%). We found that younger age, higher United States Medical License Examination (USMLE) scores, higher-income country of origin (including the United States), fewer match attempts, applying to fewer specialties, having parents with college degree or higher, and coming from higher-than-average or lower-than-average family income were independently associated with increased odds of matching. Gender, personal income, and visa status did not demonstrate significant associations with residency match. CONCLUSIONS: Residency match is a significant expense for IMGs, especially for those from lower-income countries. International applicants from higher socio-economic backgrounds might have advantages in securing medical residency positions in the United States when controlling for other variables.

Association of Kidney Cysts With Progressive CKD After Radical Nephrectomy.

RATIONALE & OBJECTIVE: Simple kidney cysts, which are common and usually considered of limited clinical relevance, are associated with older age and lower glomerular filtration rate (GFR), but little has been known of their association with progressive chronic kidney disease (CKD). STUDY DESIGN: Observational cohort study. SETTING & PARTICIPANTS: Patients with presurgical computed tomography or magnetic resonance imaging who underwent a radical nephrectomy for a tumor; we reviewed the retained kidney images to characterize parenchymal cysts at least 5mm in diameter according to size and location. EXPOSURE: Parenchymal cysts at least 5mm in diameter in the retained kidney. Cyst characteristics were correlated with microstructural findings on kidney histology. OUTCOME: Progressive CKD defined by dialysis, kidney transplantation, a sustained≥40% decline in eGFR for at least 3 months, or an eGFR<10mL/min/1.73m2 that was at least 5mL/min/1.73m2 below the postnephrectomy baseline for at least 3 months. ANALYTICAL APPROACH: Cox models assessed the risk of progressive CKD. Models adjusted for baseline age, sex, body mass index, hypertension, diabetes, eGFR, proteinuria, and tumor volume. Nonparametric Spearman's correlations were used to examine the association of the number and size of the cysts with clinical characteristics, kidney function, and kidney volumes. RESULTS: There were 1,195 patients with 50 progressive CKD events over a median 4.4 years of follow-up evaluation. On baseline imaging, 38% had at least 1 cyst, 34% had at least 1 cortical cyst, and 8.7% had at least 1 medullary cyst. A higher number of cysts was associated with progressive CKD and was modestly correlated with larger nephrons and more nephrosclerosis on kidney histology. The number of medullary cysts was more strongly associated with progressive CKD than the number of cortical cysts. LIMITATIONS: Patients who undergo a radical nephrectomy may differ from the general population. A radical nephrectomy may accelerate the risk of progressive CKD. Genetic testing was not performed. CONCLUSIONS: Cysts in the kidney, particularly the medulla, should be further examined as a potentially useful imaging biomarker of progressive CKD beyond the current clinical evaluation of kidney function and common CKD risk factors. PLAIN-LANGUAGE SUMMARY: Kidney cysts are common and often are considered of limited clinical relevance despite being associated with lower glomerular filtration rate. We studied a large cohort of patients who had a kidney removed due to a tumor to determine whether cysts in the retained kidney were associated with kidney health in the future. We found that more cysts in the kidney and, in particular, cysts in the deepest tissue of the kidney (the medulla) were associated with progressive kidney disease, including kidney failure where dialysis or a kidney transplantation is needed. Patients with cysts in the kidney medulla may benefit from closer monitoring.

Characteristics and Outcomes of Patients in the Emergency Department with Left Ventricular Assist Devices.

Introduction: Left ventricular assist devices (LVAD) are increasingly common among patients with heart failure. The unique physiologic characteristics of patients with LVADs present a challenge to emergency clinicians making treatment and disposition decisions. Despite the increasing prevalence of LVADs, literature describing emergency department (ED) visits among this population is sparse. We aimed to describe clinical characteristics and outcomes among patients with LVADs seen in two quaternary-care EDs in a five-year period. Secondarily, we sought to evaluate mortality rates and ED return rates for bridge to transplant (BTT) and destination therapy (DT) patients. Methods: We conducted a retrospective cohort study of adult patients known to have an LVAD who were evaluated in two quaternary-care EDs from 2013-2017. Data were collected from the electronic health record and summarized with descriptive statistics. We assessed patient outcomes with mixed-effects logistic regression models including a random intercept to account for patients with multiple ED visits. Results: During the five-year study period, 290 ED visits among 107 patients met inclusion criteria. The median patient age was 61 years. The reason for LVAD implantation was BTT in 150 encounters (51.7%) and DT in 140 (48.3%). The most common presenting concerns were dyspnea (21.7%), bleeding (18.6%), and chest pain (11.4%). Visits directly related to the LVAD were infrequent (7.9%). Implantable cardioverter-defibrillator discharge was reported in 3.4% of visits. A majority of patients were dismissed home from the ED (53.8%), and 4.5% required intensive care unit admission. Among all patients, 37.9% returned to the ED within 30 days, with similar rates between DT and BTT patients (32.1 vs 43.3%; P = 0.055). The LVAD was replaced in three cases (1.0%) during hospitalization. No deaths occurred in the ED, and the mortality rate within 30 days was 2.1% among all patients. Conclusion: In this multicenter cohort study of ED visits among patients with an LVAD, dyspnea, bleeding, and chest pain were the most common presenting concerns. Visits directly related to the LVAD were uncommon. Approximately half of patients were dismissed home, although return ED visits were common.