Can cardiovascular reserve index (CVRI) on arrival to the trauma unit detects massive hemorrhage and predicts developing hemorrhage? observational prospective cohort study.

BACKGROUND: The detection of haemorrhage in trauma casualties may be delayed owing to compensatory mechanisms. This study aimed to evaluate whether the cardiovascular reserve index (CVRI) on arrival detects massive haemorrhage and predicts haemorrhage development in trauma casualties. METHODS: This was an observational prospective cohort study of adult casualties (≥18 years) who were brought to a single level-1 trauma centre, enroled upon arrival and followed until discharge. Vital signs were monitored on arrival, from which the CVRI and shock index were retrospectively calculated (blinded to the caregivers). The outcome measure was the eventual haemorrhage classification group: massive haemorrhage on arrival (MHOA) (defined by massive transfusion on arrival of ≥6 [O+] packed cells units), developing haemorrhage (DH) (defined by a decrease in haemoglobin >1 g/dl in consecutive tests), and no significant haemorrhage noted throughout the hospital stay. The means of each variable on arrival by haemorrhage group were evaluated using the analysis of variance. The authors evaluated the detection of MHOA in the entire population and the prediction of DH in the remainders (given that MHOA had already been detected and treated) by C-statistic predefined strong prediction by area under the curve (AUC) greater than or equal to 0.8, P less than or equal to 0.05. RESULTS: The study included 71 patients (after exclusion): males, 82%; average age 37.7 years. The leading cause of injuries was road accident (61%). Thirty-nine (54%) patients required hospital admission; distribution by haemorrhage classification: 5 (7%) MHOA, 5 (7%) DH, and 61 (86%) no significant haemorrhage. Detection of MHOA found a strong predictive model by CVRI and most variables (AUC 0.85-1.0). The prediction of DH on arrival showed that only lactate (AUC=0.88) and CVRI (0.82) showed strong predictive model. CONCLUSIONS: CVRI showed a strong predictive model for detection of MHOA (AUC>0.8) as were most other variables. CVRI also showed a strong predictive model for detection of DH (AUC=0.82), only serum lactate predicted DH (AUC=0.88), while all other variables were not found predictive. CVRI has advantages over lactate in that it is feasible in pre-hospital and mass casualty settings. Moreover, its repeatability enables detection of deteriorating trend. The authors conclude that CVRI may be a useful additional tool in the evaluation of haemorrhage.

Host test based on tumor necrosis factor-related apoptosis-inducing ligand, interferon gamma-induced protein-10 and C-reactive protein for differentiating bacterial and viral respiratory tract infections in adults: diagnostic accuracy study.

OBJECTIVES: To assess the performance of a test (called BV), integrating the blood levels of three immune proteins into a score, to differentiate bacterial from viral infection among adults with suspected lower respiratory tract infection (LRTI). METHODS: Prospective diagnostic accuracy study, enrolling febrile adults >18 years with LRTI signs or symptoms for less than 7 days presenting to several hospitals' emergency departments in Israel. The main exclusion criterion was immunodeficiency. Reference standard diagnosis (bacterial/viral/indeterminate) was based on three experts independently reviewing comprehensive patient data including follow-up data. BV generated three results: viral infection or other nonbacterial condition (0 ≤ score < 35), equivocal (35 ≤ score ≤ 65) and bacterial infection including co-infection (65 < score ≤ 100). BV performance was assessed against the reference standard with indeterminate reference standard and equivocal BV cases removed. RESULTS: Of 490 enrolled patients, 415 met eligibility criteria (median age 56 years, interquartile range 35). The reference standard classified 104 patients as bacterial, 210 as viral and 101 as indeterminate. BV was equivocal in 9.6% (30/314). Excluding indeterminate reference standard diagnoses and equivocal BV results, BV's sensitivity for bacterial infection was 98.1% (101/103; 95% confidence interval 95.4-100), specificity 88.4% (160/181; 83.7-93.1) and negative predictive value 98.8% (160/162; 97.1-100). DISCUSSION: BV exhibited high diagnostic performance for febrile adults with suspected LRTI among patients with reference standard diagnoses of bacterial or viral LRTI.

Age as a Predictive Factor in Severity of Injuries in Riders of Electric Bikes and Powered Scooters: A Retrospective Cross-Sectional Study.

The growth in worldwide popularity of electric bikes (E-bikes) and powered scooters (P-scooters) has been accompanied by an increase in injuries associated with their use. The aim of this study was to evaluate the contribution of rider age to injury severity, represented by need for hospitalization. A retrospective review of the database of a tertiary medical center yielded 1234 patients (75.7% male) who attended the emergency department (ED) in 2014−2020 for injuries sustained while riding an E-bike or P-scooter. Mean age was 31.52 ± 14.77 years: 23% were aged <20 years; 33%, 21−30 years; 23%, 31−40 years; 10%, 41−50 years; 11%, >51 years. Ninety patients (7.3%) were hospitalized. Older age was significantly associated with the need for hospitalization on univariate analysis (p <.001), but significance was not maintained on binary logistic regression (OR = 1.02, 95%CI 0.99−1.06; p = 0.11). Patients who underwent imaging evaluation in the ED were at lower risk of hospitalization, and patients who had surgery or a relatively long operative procedure were at higher risk of hospitalization. The study shows that older age (>51 years) is not associated with a significantly increased probability of severe injury in E-bike and P-scooter riders. This finding has important implications for insurers and healthcare administrators.

Daily output measures of Emergency Department in association with seasonality and day of the week: A retrospective cohort observational study.

To evaluate the daily output measures of the emergency department (ED) in association with seasonality and the day of the week. A retrospective cohort of ED visits to tertiary medical centers between 2016 and 2020. The research unit was each day during the study period. The independent variables were season and day of the week. The dependent variables were ED visits, admission and dropout rates, and duration of ED discharge. The comparison of means was evaluated using ANOVA. Statistical significance was set at P < .05. There were 1826 days, 792 thousand visits, 58% were female. Admission rate 28%, duration to discharge 3.8 h, dropout rate 2%. The average daily visits by season ranged from 101% of the overall average in autumn to 97% in spring. Average daily visits by day of the week were significantly different, with the highest on Sunday (Israel's first working day of the week), 124% of the overall daily average, and the lowest on Saturday (weekly day off) with 70%. Saturdays had the highest admission rate of 30% and 28% of the overall rate. There was a moderate dependency between the ED duration and discharge, with a dropout rate of r2 = 0.19. The average daily visits were not affected by season but differed considerably by day of the week. Admission rates varied slightly by season but were similar by day of the week apart from Saturdays. This may be attributable to the case mix on Saturdays or less restriction to admit when the number of visits is low. We recommended each Emergency Department to evaluate its daily output measures dependency with seasonality and day of the week for operational optimization.

Trends in the Incidence and Severity of Injuries Sustained by Riders of Electric Bikes and Powered Scooters: A Retrospective Cross-Sectional Study.

Background and Objectives: The worldwide increase in electric bike (E-bike) and powered scooter (P-scooter) use in recent years has been accompanied by an increase in associated injuries to riders. The aim of this study was to evaluate trends in the incidence and types of E-bikes and P-scooter-related injuries in riders evacuated to a tertiary ED. Materials and Methods: A retrospective cross-sectional design was used. The cohort included 1234 patients referred to the emergency department (ED) of a tertiary medical center in 2014-2020 for injuries sustained while riding an E-bike or P-scooter. Demographic, clinical, and injury data were collected from the medical files, and injury rates were evaluated over time. Results: The results showed that the annual number of ED visits by injured E-bike and P-scooter riders increased steadily over the study period concomitant with an increase in ED referrals for hospitalization, indicating severe injury. The upper and lower extremities were the most frequent anatomic sites of injury in every year of the study, with variations among the different age groups. Conclusions: Our findings suggest a need for safety regulations for riders who operate two-wheel powered vehicles, such as licensing requirements and mandatory protective gear, especially for anatomic sites most at risk.

Impact of Drug and Alcohol Use on Hospitalization for Injuries in Riders of Electric Bikes or Powered Scooters: A Retrospective Cross-Sectional Study.

The growing popularity of E-bikes and P-scooters has led to their increasing involvement in injuries. This study sought to evaluate the impact of drug and alcohol consumption on hospitalization rates for electric-vehicle-associated injuries. A retrospective cross-sectional study design was used, including patients evacuated to the emergency department (ED) of a tertiary medical center in 2014−2020 for injuries sustained while riding E-bikes or P-scooters. Data on clinical characteristics were collected from the medical files, including pre-accident usage of alcohol or drugs. Of the 1234 patients (75.7% male) who met the inclusion criteria, 90 (7.3%) were hospitalized. The mean (SD) number of admission days was 5.44 (±0.12). Alcohol consumption was associated with 2.2% of injuries and drug use with 0.6%. Patients who rode under the influence of alcohol were significantly more likely to be hospitalized than discharged (6.7% vs. 1.8%, χ2 (2) =19.25, p < 0.001); the odds ratio was 14.1. A similar association with hospitalization was found for drug use (χ2 (2) = 7.83, p = 0.02). Riding an E-bike or P-scooter under the influence of alcohol or drugs increases the probability of severe injury requiring hospital admission. These results should prompt the relevant authorities to initiate effective legislation of alcohol and drug use.

Impact of Comorbidities on Hospitalization for Injuries in Riders of Electric Bikes and Powered Scooters: A Retrospective Cross-Sectional Study.

Background and Objectives: Injuries associated with electric bikes (E-bikes) and powered scooters (P-scooters) have increased yearly worldwide. We aimed to evaluate the impact of pre-existing comorbidities on the probability of hospitalization for injuries in riders of E-bikes and P-scooters. Materials and Methods: A retrospective cross-sectional study design was used. The cohort included patients referred to the emergency department (ED) of a tertiary medical center in 2014-2020 for injuries sustained while riding an E-bike or P-scooter. Data were collected from the medical files on demographics, clinical characteristics including pre-existing comorbidities and permanent use of medications, and injury characteristics. Findings were compared between patients referred for hospitalization from the ED and patients discharged home. Results: Of the 1234 patients who met the inclusion criteria, 202 (16.4%) had a prior medical condition and 167 (13.5%) were taking medication on a permanent basis. A significant relationship was found between hospitalization and having a medical condition (𝜒2(1) = 9.20, p = 0.002) or taking medication on a permanent basis (𝜒2(1) = 6.24, p = 0.01). Hospitalization for injuries was more likely in patients with a comorbidity (27.8%) than those without a comorbidity (15.5%), and in patients who were on permanent drug therapy (22.2%) than in patients who were not (12.9%). Surprisingly, anticoagulant intake specifically had no effect on the probability of hospital admission. Conclusions: Patients with comorbidities have a higher incidence of hospitalization for E-bike- and P-scooter-associated injuries. Therefore, physicians may take into account comorbidities for the effective management of this patient group's injuries.

Specialized Emergency Department Assessment and Multidisciplinary Intervention After Discharge Improve Management of Patients With Inflammatory Bowel Diseases.

GOAL: The aim was to assess proactive specialized inflammatory bowel diseases (IBD) emergency department (ED) consultation and multidisciplinary IBD team (IBD-MDT) intervention on IBD-related patient outcomes after discharge. BACKGROUND: Despite advances in patient care, IBD-related ED visits have increased and substantially contribute to the IBD burden. METHODS: Consecutive patients with IBD (below 50 y) who visited the ED during November 2017 to April 2018 (intervention group) were compared with patients with IBD that visited the same ED during 2014 to 2017 (standard-care group). The primary outcomes were hospitalization and ED revisits at 30, 90, and 180 days. RESULTS: The intervention group (45 patients, mean age 32.43±8.6 y, 57.8% male) and the standard-care group (237 patients) had comparable baseline characteristics, including age, sex, and IBD type, and similar rates of hospital admissions from the ED (46.7% vs. 38.8%, P=0.32). The intervention group more frequently underwent computed tomography (40% vs. 8%, P<0.001) and surgical interventions (13.3% vs. 0.8%, P<0.001) within the same hospital admission, compared with the standard-care group. In the intervention group, 24 patients were discharged from the ED, of whom 17 patients visited the IBD clinic (median 5 d postdischarge) and the majority were referred to ambulatory IBD-MDT services (dietitian: 46.7%, psychologist: 6.7%, advanced endoscopist: 8.9%, and proctology services: 6.7%). The intervention group had significantly fewer ED revisits than the standard-care group (30 d: 4.4% vs. 19.8%, P=0.013; 90 d: 4.4% vs. 35.9%, P<0.001; 180 d: 6.7% vs. 43%, P<0.001). CONCLUSION: Proactive specialized ED assessments and IBD-MDT interventions after a hospital discharge were preferable; they significantly reduced the ED revisit rate for at least 6 months.

The impact of helmet use on oral and maxillofacial injuries associated with electric-powered bikes or powered scooter: a retrospective cross-sectional study.

BACKGROUND: Electric bikes (E-bikes) and powered scooters (P-scooters) have become increasingly popular modes of public transportation, but they have been associated with injuries of all kinds, including dental trauma. Helmet use is promoted as a means of reducing injuries in accidents involving motorized and unmotorized vehicles. The aim of the study was to evaluate the impact of helmet use on the number and severity of oral and maxillofacial injuries caused by E-bikes and P-scooters. METHODS: A retrospective cross-sectional study design was used. The cohort included all patients referred to the emergency department of a tertiary medical center in 2014-2020 with oral and maxillofacial injuries involving E-bikes or P-scooters. Data were collected from the medical files on demographics, types of injuries, circumstances of occurrence, work-up, treatment, and outcome. Use of a helmet was recorded in each case. RESULTS: Of the total 1417 patients referred to the emergency department for E-bike and P-scooter-related trauma, 62 had oral and maxillofacial injuries, including 57 riders and 5 pedestrians. All had hard- or soft-tissue injuries; 20 (32.2%) had head injuries and 22 (35.5%) had dentoalveolar injuries. Eleven riders had worn a helmet at the time of injury (17.7%). Helmet use was associated with time of injury (weekday/weekend, daytime/night-time), type of motorized vehicle (E-bike or P-scooter), head injury, and number of bone fractures. Head injuries occurred more often on the weekend (57.9%) than during the week (20.9%) and were more likely to occur in riders who were not protected by a helmet (37.3% vs 18.2%). Patients who used helmets also had a lower rate of fractured bones (18.2%) and dentoalveolar injuries (23.7%) than patients who did not (68.8 and 37.3%, respectively). Interestingly, helmet use had no protective effect on soft-tissue injuries. CONCLUSIONS: Helmet use by E-bike and P-scooter riders decreased the probability of head injury and of hard tissue and dentoalveolar injuries. These results may provide guidance for effective legislation and regulation of helmet use and improved treatment protocols for general and dental physicians.

A Call for a Reconsideration of the Use of Fecal Occult Blood Testing in Emergency Medicine.

BACKGROUND: Fecal occult blood testing (FOBT) was developed to detect microscopic bleeding caused by colorectal neoplasms. The role of FOBT in the emergency department (ED) is typically used for 5 different clinical workups: trauma, anemia, syncope, hypotension, and before the administration of systemic anticoagulants or thrombolytics. OBJECTIVE: We scrutinized the literature to assess the utility of FOBT for its 5 most common applications in the emergent setting. DISCUSSION: Logic and clinical evidence advocating for FOBT usage in the aforementioned situations are lacking. The test itself requires specific drug and dietary restrictions that are often violated or never met when patients present to the ED with acute pathologies. In addition, the poor sensitivity and specificity of the test in these scenarios dictate that neither a negative nor positive FOBT should change the subsequent clinical workup of patients presenting to the ED. CONCLUSION: Clinical decision making should seldom be predicated on the results of a FOBT in the ED setting.

The accuracy of a diagnosis of pneumonia in the emergency department.

BACKGROUND: Achieving a high degree of diagnostic accuracy of infections in the emergency department (ED) is crucial since a delay in diagnosis can lead to increased mortality, whereas overdiagnosis can lead to antibiotic overprescription. Limited data are available as to ED diagnostic accuracy of infections. The aim of this study was to demonstrate the degree of discordance of an ED diagnosis of pneumonia in relation to an internal medicine ward's discharge diagnosis of hospitalized adults. METHODS: We reviewed the records of all adults hospitalized in internal wards from November 2017-January 2018 diagnosed with an acute infection by an ED physician. The primary outcome was the discordance degree of an ED pneumonia diagnosis compared to the internal ward discharge diagnosis. The influence comorbidities and clinical characteristics on the diagnostic discordance were also evaluated. RESULTS: The study included 875 adults; 434 were admitted with an ED diagnosis of a specific infection. Pneumonia was the most frequent ED diagnosis (n = 195, 45%), of them, 56 (29%) were discordant diagnosis in the internal ward. CONCLUSION: Interpretation of chest X-rays with the assistance of a radiologist might help in reducing overdiagnosis and minimize antibiotic overprescription, thus improving the ED diagnostic accuracy of pneumonia.

Gender differences in the comprehension of care plans in an emergency department setting.

BACKGROUND: Previous studies have shown that, in a variety of health care settings, patients often do not understand what health care professionals tell them about their diagnoses and care plans; this is particularly true among male patients. Emergency department (ED) settings present unique challenges to communication with patients due to the rapid pace of activity, substantial changes in personnel over the course of the day and the week, and the need for fast decision-making processes. The aim of our study was to investigate the extent to which patients in an Israeli ED comprehended their plan of care and whether there were gender differences in this regard. METHODS: We conducted a questionnaire-based prospective study, in which patients admitted to the ED at Rabin Medical Center were evaluated during the years 2014-2016. The primary outcome was patients' comprehension of their plan of care, stratified by gender of patients. Plan of care included information related to diagnosis, treatment and discharge instructions. The secondary outcome was patients' satisfaction with the instruction process. RESULTS: One hundred seventy seven ED patients met study criteria and were asked to participate in the study; 85% of them agreed to do so. Overall, 150 ED patients aged 18-80 were recruited [75 men (50%) and 75 women (50%)]. 80% of the respondents reported a satisfactory understanding of their plan of care. Overall, no gender-related differences were found. Differences between men and women concerning satisfaction with the instructions provided by nurses were found among non-Hebrew speakers, but not among Hebrew speakers. CONCLUSION: Contrary to most earlier studies, patients at our ED demonstrated a high degree of self-reported adequate comprehension concerning their plan of care, and overall no gender-related differences were found. These finding may be due in part to improved training of the medical staff to better communicate with the patients and to answer their questions. In addition, patients may feel more comfortable than in the past about asking the medical staff questions regarding their plan of care and diagnosis. The main implication of this study is that physician education programs should continue to emphasize patient-physician communications skills and improving methods for providing patients with information.

Knowledge Translation of the PERC Rule for Suspected Pulmonary Embolism: A Blueprint for Reducing the Number of CT Pulmonary Angiograms.

INTRODUCTION: Computerized decision support decreases the number of computed tomography pulmonary angiograms (CTPA) for pulmonary embolism (PE) ordered in emergency departments, but it is not always well accepted by emergency physicians. We studied a department-endorsed, evidence-based clinical protocol that included the PE rule-out criteria (PERC) rule, multi-modal education using principles of knowledge translation (KT), and clinical decision support embedded in our order entry system, to decrease the number of unnecessary CTPA ordered. METHODS: We performed a historically controlled observational before-after study for one year pre- and post-implementation of a departmentally-endorsed protocol. We included patients > 18 in whom providers suspected PE and who did not have a contraindication to CTPA. Providers entered clinical information into a diagnostic pathway via computerized order entry. Prior to protocol implementation, we provided education to ordering providers. The primary outcome measure was the number of CTPA ordered per 1,000 visits one year before vs. after implementation. RESULTS: CTPA declined from 1,033 scans for 98,028 annual visits (10.53 per 1,000 patient visits (95% CI [9.9-11.2]) to 892 scans for 101,172 annual visits (8.81 per 1,000 patient visits (95% CI [8.3-9.4]) p<0.001. The absolute reduction in PACT ordered was 1.72 per 1,000 visits (a 16% reduction). Patient characteristics were similar for both periods. CONCLUSION: Knowledge translation clinical decision support using the PERC rule significantly reduced the number of CTPA ordered.

Comparison of Weight-Based Dose vs. Standard Dose Diltiazem in Patients with Atrial Fibrillation Presenting to the Emergency Department.

BACKGROUND: Despite evidence-based recommended weight-based (WB) dosing of diltiazem for the initial treatment of atrial fibrillation (AF) with rapid ventricular response (RVR), many providers utilize lower initial doses of diltiazem. OBJECTIVE: We sought to determine whether a low, standard dose of diltiazem is noninferior to WB diltiazem as an initial bolus dose in the treatment of AF with RVR. METHODS: This retrospective review included patients who presented to the emergency department (ED) of an urban, academic tertiary medical center experiencing AF with RVR from November 2010 to August 2014. Adult patients were categorized by the dose of diltiazem received; 10 mg standard dose or 0.2-0.3 mg/kg WB dose. The primary outcome of successful treatment was defined as a composite of the following parameters 15 min after the initial bolus dose: heart rate (HR) < 100 beats/min, reduction of HR ≥ 20%, or a conversion to normal sinus rhythm. RESULTS: Four hundred and fifty-six patients who received diltiazem were included for study evaluation (standard dose: n = 255 patients, WB: n = 201 patients). Baseline characteristics, medical history, and medication use before ED presentation were similar between the groups. Significant differences at baseline between the groups included weight and HR at presentation. The primary outcome of successful treatment was attained in 60.8% of the standard dose patients and 68.7% of the WB patients (p = 0.082). CONCLUSIONS: In patients presenting to the ED, we found that standard dose diltiazem was noninferior to WB dosing in the initial treatment of AF with RVR.

A study of the workforce in emergency medicine in Israel 2012: what has changed in the last decade?

OBJECTIVE: In 2003, we published a study on the Israeli workforce in emergency medicine (EM). We repeated the study in 2012 to assess changes in the workforce that have occurred in the interval decade. METHODS: This is an observational cross-sectional study of the physician workforce in EM in Israel in 2012. An online survey was sent to the ED medical directors of all general hospitals in Israel querying the numbers of physicians working in the ED, as well as the specialty and level of training of those manning the ED at various times during the day. The workforce in 2012 was compared to that of 2003. RESULTS: Twenty-four of 28 (86 %) EDs responded. Certified EM specialists have increased from 59 to 164 since 2003. Disparities continue regarding their presence in the ED. Most EM specialists are scheduled during the day whereas they are virtually absent during the night. A total of 58 EM specialists were scheduled countrywide for the weekday day shift and only one overnight. The preponderance of EM specialists working during the day and the large number of supervised and unsupervised residents working at night has not changed substantially since 2003. Eleven departments reported having an EM specialist present during the evenings whereas in 2003, only two departments reported so. CONCLUSION: Since 2003, there are more certified EM specialists and more specialist coverage in the ED into the evening hours. Most ED providers are still not emergency physicians, and there is still a preponderance of EM specialist coverage during the day and a lack thereof overnight.

Can emergency medicine practitioners predict disposition of psychiatric patients based on a brief medical evaluation?

OBJECTIVE: Emergency medicine practitioners (EMPs) often provide 'medical clearance' before evaluation by a psychiatry practitioner (PP). We set out to determine the level of agreement between EMP impression and disposition as determined by PPs. PATIENTS AND METHODS: This was a prospective observational study in an urban tertiary teaching hospital emergency department. We collected data from February to April 2011. We used a convenience sample of patient encounters evaluated by EMPs and subsequent referral for psychiatric evaluation. We asked EMPs whether they thought the patients would be admitted or discharged following psychiatric evaluation, and if discharged, whether to outpatient psychiatric follow-up or to no follow-up. EMPs were asked to base their opinion upon their general impression following their brief medical evaluation. They were not given guidelines on which to base their decision. The EMPs were blind to PP decisions. The κ-statistic was used to calculate agreement between the EMP's impression and disposition decision by the PP. We excluded patients who were acutely intoxicated, in police custody, or lived in an extended care facility. RESULTS: We included 156 patient encounters over the study period and had complete data for 152 encounters. Of these, 86 (55%) were admitted, 46 (30%) were discharged with no specific psychiatric follow-up, and 20 (13%) were discharged with a follow-up plan. EMPs predicted the exact disposition in 77/152 (51%) cases (κ=0.264, 95% confidence interval 0.77-0.333). Agreement was higher for admitted patients, with EMPs predicting inpatient admission for 57/86 (66%) of these patients. Other factors associated with higher agreement scores were years in emergency medicine practice by the EMP and suicidal ideation by the patient. CONCLUSION: EMPs did not reliably predict psychiatric disposition decisions based on clinical 'gestalt'. Future research will focus on clinical guidelines to help EMPs better independently assess need for emergency psychiatric services.

Prophylactic etoricoxib is effective in preventing "first of Ramadan" headache: a placebo-controlled double-blind and randomized trial of prophylactic etoricoxib for ritual fasting headache.

BACKGROUND: Religious fasting is associated with headache. This has been documented as "Yom Kippur headache" and "first of Ramadan headache." Etoricoxib, a Cox-2 inhibitor with a 22-hour half-life, has been shown effective in preventing fasting headache when taken just prior to the 25-hour Yom Kippur fast. We hypothesized that etoricoxib would also be effective in preventing headache during Ramadan, despite the different characteristics of the fast. METHODS: We performed a double-blind randomized prospective crossover trial of etoricoxib 90mg vs placebo, taken just prior to the onset of fasting, during the first 2 weeks of Ramadan 2010. Healthy adults aged 18-65 years were enrolled. Demographics, headache history and a daily post-fast survey were collected. We compared incidence, time of onset, and intensity of headache on each day and side effects in control and treatment groups. RESULTS: We enrolled 222 patients and 189 completed the post-fast questionnaire (87%). Etoricoxib reduced the incidence of "first of Ramadan" headache by 54% (46% in placebo group [n=92] vs 21% [n=96] in etoricoxib group) (P<.0001, OR 3.19 [95% CI 1.68-6.06]). For days 1-6, the mean number of headache days for the placebo group was 1.60 (n=92) and for the treatment group the mean was 0.86 (n=99) headache days (P=.003). Median severity of headache in the treatment group was significantly lower. In the second week, there was no significant difference in incidence of headache between groups, and the incidence of headache in the placebo group dropped markedly over time. CONCLUSION: Etoricoxib 90mg taken prior to a 15-hour ritual fast decreases incidence of and attenuates headache during the first 5 days of the month of Ramadan.

Family history is a predictor for appendicitis in adults in the emergency department.

INTRODUCTION: A family history of appendicitis has been reported to increase the likelihood of the diagnosis in children and in a retrospective study of adults. We compare positive family history with the diagnosis of acute appendicitis in a prospective sample of adults. METHODS: We conducted a prospective observational study of a convenience sample of 428 patients. We compared patients with surgically proven appendicitis to a group without appendicitis. The latter were further grouped by their presenting symptoms: those presenting with a chief complaint of abdominal pain and those with other chief complaints. Participants answered questions regarding their family history of appendicitis. Family history was then compared for the appendicitis group versus the nonappendicitis group as a whole, and then versus the subgroup of patients without appendicitis but with abdominal pain. The primary analysis was a χ(2) test of proportions and the calculation of odds ratio (OR) for the relationship between final diagnosis of appendicitis and family history. RESULTS: Of 428 patients enrolled, 116 had appendicitis. Of those with other diagnoses, 158 had abdominal pain and 154 had other complaints. Of all patients with appendicitis, 37.9% (confidence interval [Cl] = 29.1-46.8) had positive family history. Of those without appendicitis, 23.7% (Cl = 19.0-28.4) had positive family history. In the subgroup without appendicitis but with abdominal pain, 25.9% (Cl = 19.1-32.8) had positive family history. Both comparisons were significant (P = 0.003; OR = 1.97; 95% Cl = 1.2-3.1; and P=0.034; OR = 1.74; 95% Cl = 1.04-2.9, respectively). By multivariate logistic regression analysis across the full sample, family history was a significant independent predictor (P = 0.011; OR = 1.883) of appendicitis. CONCLUSION: Adults presenting to the emergency department with a known family history of appendicitis are more likely to have this disease than those without.

Point-of-care testing for coagulation studies in a stroke protocol: a time-saving innovation.

STUDY OBJECTIVES: Time counts in thrombolytic therapy for stroke. An international normalized ratio (INR) greater than 1.7 may preclude its use. We studied whether the use of point-of-care testing (POCT) for INR in the emergency department (ED) may substitute for the same test done in the central hospital laboratory, thereby reducing time to treatment. METHODS: We performed a prospective observational study comparing a POCT analysis of INR (i-STAT-1; Abbott Inc, Abbott Park, Ill) with a simultaneously drawn sample sent to the central laboratory. We tested a convenience sample of adult patients taking warfarin who presented to the ED of a tertiary teaching hospital. RESULTS: Thirty-two patients were enrolled. A receiver operator curve analysis was performed. Sensitivity and specificity were calculated for laboratory INR cutoff of 1.7. The area under the curve was 0.979 (95% confidence interval [CI], 0.843-0.991). When POCT INR was 2.1, the sensitivity for laboratory INR being higher than 1.7 was 100% (CI, 62.9%-100.0%), and the specificity was 90.5 (CI, 69.6-98.5). When POCT INR was 1.8, the specificity for laboratory INR being lower than 1.7 was 100% (CI, 83.7%-100%), and the sensitivity was 62.5% (CI, 24.7%-91.0%). The regression coefficient (r) value was 0.9648. CONCLUSION: Correlation of POCT INR with that of the central laboratory and receiver operator curve characteristics are excellent. In general, POCT INR is about 0.3 higher than the laboratory INR. This is not generally of clinical importance, but when using cutoff of 1.7 (central laboratory), it may be. We describe a 3-tiered system for use of POCT INR in determining use of tissue-type plasminogen activator.

Prophylactic etoricoxib is effective in preventing Yom Kippur headache: a placebo-controlled double-blind and randomized trial of prophylaxis for ritual fasting headache.

BACKGROUND: Religious fasting is associated with headache. This has been documented as "Yom Kippur Headache" and "First-of-Ramadan Headache." Rofecoxib (Vioxx®), a cyclooxygenase-2 (Cox-2) inhibitor with a 17-hour half-life, has been shown to be effective in preventing fasting headache when taken just prior to the 25-hour Yom Kippur fast. Unfortunately for fasters rofecoxib is no longer available. We hypothesized that etoricoxib, another Cox-2 inhibitor with a longer half-life, would also be effective in preventing fasting headache. METHODS: We performed a double-blind randomized prospective trial of etoricoxib 120 mg vs placebo, taken just prior to the onset of fasting, Yom Kippur 2008. Healthy adults aged 18-65 years were enrolled from the community. Subjects completed a demographic data form and questions regarding headache history and a post-fast survey on headache during the fast. We compared incidence, time of onset and intensity of headache, general ease of fasting, and side effects in control and treatment groups. RESULTS: We enrolled 211 patients and 195 completed the post-fast questionnaire (92%). Of those subjects receiving etoricoxib (n=99), 36 or 36.4% vs 65 or 67.7% of the placebo group (n=96) developed any headache during the fast (P< .0001). Median severity of headache in the treatment group was significantly lower for the treatment group (3.0 vs 5.0 on a visual analog scale of 10; P= .024). Also, participants in the treatment group reported an easier fast than the placebo group, as compared with previous fasting experience (4.0 vs 3.5 on a scale of 1-5; P< .0001). CONCLUSION: Etoricoxib 120 mg taken prior to a 25-hour ritual fast decreases incidence of and attenuates fasting headache.