Complications of Bacterial Keratitis Impacted by Social Determinants of Health: A Case Report.

Introduction: The emergency department commonly evaluates eye pain and vision loss. Typically, these conditions can be managed outpatient; however, delays can lead to advanced pathology. Case Report: A 48-year-old homeless male presented with left-eye vision loss and pain. His exam revealed monocular decreased visual acuity, corneal ulcer, and hypopyon. The patient was diagnosed with bacterial keratitis and admitted for treatment but left against medical advice. He returned and was admitted for further treatment but was lost to follow-up thereafter. Conclusion: Our case features complicated bacterial keratitis with several treatment interruptions, demonstrating how healthcare disparities contribute to potentially preventable advanced pathology.

The Emergency Medicine Milestones 2.0: Setting the stage for 2025 and beyond.

INTRODUCTION: Beginning in 1999, residents in emergency medicine have been expected to demonstrate competence in the six Accreditation Council on Graduate Medical Education (ACGME) Core Competencies. Expectations were further refined and clarified through the introduction of the Milestones in 2013. Emerging research and data from milestone reporting has illustrated the need for modification of the original milestones. Against this backdrop, the ACGME convened a committee to review and revise the original milestones. METHODS: The working group was convened in December 2018 and consisted of representatives from the American Board of Emergency Medicine, American Osteopathic Association, Council of Residency Directors in Emergency Medicine, Association of American Medical Colleges, ACGME-Emergency Medicine Review Committee, three community members, a resident member, and a public member. This group also included members from both academic and community emergency medicine programs. The group was overseen by the ACGME vice president for milestones development and met in person one time followed by four virtual sessions to revise and draft the Emergency Medicine Milestones and Supplemental Guide as part of the ACGME Milestones 2.0 Project. RESULTS: Using data from milestones reporting, needs assessment data, stakeholder interviews, and community commentary, the working group engaged in revisions and updates for the Emergency Medicine Milestones and created a supplemental guide to aid programs in the design of programmatic assessment for the milestones. CONCLUSION: The Emergency Medicine Milestones 2.0 provide updated specialty-specific, competency-based behavioral anchors to guide the assessment of residents, the design of curricula, and the advancement of emergency medicine training programs.

A rare life-threatening complication of acute mastoiditis: Case report and literature review.

Severe complications may not always present with "classic" signs and symptoms. In the setting of recent mastoiditis, complications including cerebral venous sinus thrombosis, skull base osteomyelitis, and retropharyngeal abscess should be considered, particularly with persistent or worsening symptoms. A broad differential can lead to prompt diagnosis and treatment, thereby reducing the likelihood of morbidity and mortality.

Delirium in Older Patients With COVID-19 Presenting to the Emergency Department.

Importance: Delirium is common among older emergency department (ED) patients, is associated with high morbidity and mortality, and frequently goes unrecognized. Anecdotal evidence has described atypical presentations of coronavirus disease 2019 (COVID-19) in older adults; however, the frequency of and outcomes associated with delirium in older ED patients with COVID-19 infection have not been well described. Objective: To determine how frequently older adults with COVID-19 present to the ED with delirium and their associated hospital outcomes. Design, Setting, and Participants: This multicenter cohort study was conducted at 7 sites in the US. Participants included consecutive older adults with COVID-19 presenting to the ED on or after March 13, 2020. Exposure: COVID-19 was diagnosed by positive nasal swab for severe acute respiratory syndrome coronavirus 2 (99% of cases) or classic radiological findings (1% of cases). Main Outcomes and Measures: The primary outcome was delirium as identified from the medical record according to a validated record review approach. Results: A total of 817 older patients with COVID-19 were included, of whom 386 (47%) were male, 493 (62%) were White, 215 (27%) were Black, and 54 (7%) were Hispanic or Latinx. The mean (SD) age of patients was 77.7 (8.2) years. Of included patients, 226 (28%) had delirium at presentation, and delirium was the sixth most common of all presenting symptoms and signs. Among the patients with delirium, 37 (16%) had delirium as a primary symptom and 84 (37%) had no typical COVID-19 symptoms or signs, such as fever or shortness of breath. Factors associated with delirium were age older than 75 years (adjusted relative risk [aRR], 1.51; 95% CI, 1.17-1.95), living in a nursing home or assisted living (aRR, 1.23; 95% CI, 0.98-1.55), prior use of psychoactive medication (aRR, 1.42; 95% CI, 1.11-1.81), vision impairment (aRR, 1.98; 95% CI, 1.54-2.54), hearing impairment (aRR, 1.10; 95% CI 0.78-1.55), stroke (aRR, 1.47; 95% CI, 1.15-1.88), and Parkinson disease (aRR, 1.88; 95% CI, 1.30-2.58). Delirium was associated with intensive care unit stay (aRR, 1.67; 95% CI, 1.30-2.15) and death (aRR, 1.24; 95% CI, 1.00-1.55). Conclusions and Relevance: In this cohort study of 817 older adults with COVID-19 presenting to US emergency departments, delirium was common and often was seen without other typical symptoms or signs. In addition, delirium was associated with poor hospital outcomes and death. These findings suggest the clinical importance of including delirium on checklists of presenting signs and symptoms of COVID-19 that guide screening, testing, and evaluation.

Comparison of admission rates among patients treated by male and female emergency physicians: a multicenter study.

BACKGROUND: No study to date has looked at the gender of emergency medicine (EM) physicians in the United States in relation to admission rates. This study seeks to investigate admission rates of adult patients treated by female vs male EM physicians, to identify whether a practice pattern bias exists. METHODS: This was a multicenter retrospective study of four community hospitals. POPULATION: All patient encounters between July 1, 2016 and June 30, 2017. OUTCOME: We compared multiple benchmarks, including admission rates, patient acuity, length of stay, return visits, patient age, and years of practice using descriptive statistics and Pearson Correlation Coefficients. RESULTS: 171,762 encounters by 71 EM physicians; 29 females, 42 males. Average admission rates: female 30.1%, male 28.0%, p = .188. Average encounters: female 2456, male 2394, p = 0.77. Acuity: female 149.3, male 146.9, p = .227. Average length of stay (minutes): female 294.4, male 277.4, p = .137. Average patient age: female 50.9, male 50.2, p = .457. Median time of encounter: female 12.8, male 12.7, p = .964. Years of practice: female 16.2, male 19.1, p = .274. Average return visits per one thousand: female 8.5, male 8.5, p = .864. Secondary analysis of Pearson Correlation Coefficient of Significance; admission rate and length of stay: female 0.53, p = .0026; male 0.76, p < .0001. Admission rate and acuity: female 0.56, p = .0012; male 0.76, p < .0001. Admission rate and patient age: female 0.54, p = 0.0018; male 0.50, p = 0.0003. CONCLUSION: No statistically significant difference exists between the admission rates of male and female emergency medicine physicians. The admission rate in both groups had the highest correlation with patients' age, acuity, and length of stay.