Family history of venous thromboembolism predicts the diagnosis of acute pulmonary embolism in the emergency department.

BACKGROUND: Pulmonary embolism (PE) clinical decision rules do not consider a patient's family history of venous thromboembolism (VTE). We evaluated whether a family history of VTE predicts acute PE in the emergency department (ED). METHODS: Over a 5.5-year study period, we enrolled a prospective convenience sample of patients presenting to an academic emergency department with chest pain and/or shortness of breath. We defined a family history of VTE as a first-degree relative with previous PE or deep vein thrombosis (DVT). We noted outcomes of testing during the patient's ED stay, including the diagnosis of acute PE by either computed tomography (CT) or ventilation/perfusion (VQ) scan. RESULTS: Of the 3024 study patients, 19.4% reported a family history of VTE and 1.9% were diagnosed with an acute PE during the ED visit. Patients with a family history of VTE were more likely to be diagnosed with a PE: 3.2% vs. 1.6% (p = 0.009). 82.3% of patients were Pulmonary Embolism Rule-out Criteria (PERC) positive, and among PERC-positive patients, those with a family history of VTE were more likely to be diagnosed with a PE: 3.6% vs. 1.9% (p = 0.016). Of patients who underwent testing for PE (33.7%), patients with a family history of VTE were more likely to be diagnosed with a PE: 9.4% vs. 4.9% (p = 0.032). CONCLUSION: Patients with a self-reported family history of VTE in a first-degree relative are more likely to be diagnosed with an acute PE in the ED, even among those patients considered to have a higher likelihood of PE.

Characteristics of the first two years of applicants to a new emergency medicine residency program.

BACKGROUND: To the best of our knowledge, no study has compared the effect of using the Electronic Residency Application Service (ERAS) on applicant pool characteristics for a new emergency medicine (EM) residency program. OBJECTIVE: We sought to compare applicants in an EM residency program's first year, in which the ERAS is not typically used, to applicants in year 2 (using ERAS). METHODS: We reviewed the applications to the new University of Utah EM residency program for the entering classes of 2005 (year 1) and 2006 (year 2). RESULTS: In total, 130 and 458 prospective residents applied during year 1 and year 2, respectively. Applicants using and not using ERAS were similar in average Step 1 score (211.8 vs. 212.4, respectively; p = 0.791), previously failed Step 1 or Step 2 attempt (12.1% vs. 11.0%, respectively; p = 0.729), previous failure to match in a residency program (8.6% vs. 4.6%, respectively; p = 0.083), previous residency training (18.8% vs. 14.9%, respectively; p = 0.288), and the percent who had completed an EM clerkship (95.3% vs. 93.0%, respectively; p = 0.342). Applicants not using ERAS were more likely to have been remediated in medical school (13.2% vs. 4.2%; p < 0.001) and to have a Standardized Letter of Recommendation (SLOR) (87% vs. 78%; p = 0.024). Applicants using ERAS were more likely to have a SLOR match estimate of "very competitive" (38.2% vs. 54.1%; p = 0.004). Applicants were similar in having attended a "top tier" medical school (44.5% vs. 41.3%, p = 0.508). CONCLUSION: Despite significantly fewer applicants, those applying without the use of ERAS to a new EM residency program were generally comparable to the applicant pool that did permit the use of ERAS. The larger number of applicants the second year likely reflects the use of ERAS.

SARS-CoV-2 innate effector associations and viral load in early nasopharyngeal infection.

COVID-19 causes severe disease with poor outcomes. We tested the hypothesis that early SARS-CoV-2 viral infection disrupts innate immune responses. These changes may be important for understanding subsequent clinical outcomes. We obtained residual nasopharyngeal swab samples from individuals who requested COVID-19 testing for symptoms at drive-through COVID-19 clinical testing sites operated by the University of Utah. We applied multiplex immunoassays, real-time polymerase chain reaction assays and quantitative proteomics to 20 virus-positive and 20 virus-negative samples. ACE-2 transcripts increased with infection (OR =17.4, 95% CI [CI] =4.78-63.8) and increasing viral N1 protein transcript load (OR =1.16, CI =1.10-1.23). Transcripts for two interferons (IFN) were elevated, IFN-λ1 (OR =71, CI =7.07-713) and IFN-λ2 (OR =40.2, CI =3.86-419), and closely associated with viral N1 transcripts (OR =1.35, CI =1.23-1.49 and OR =1.33 CI =1.20-1.47, respectively). Only transcripts for IP-10 were increased among systemic inflammatory cytokines that we examined (OR =131, CI =1.01-2620). We found widespread discrepancies between transcription and translation. IFN proteins were unchanged or decreased in infected samples (IFN-γ OR =0.90 CI =0.33-0.79, IFN-λ2,3 OR =0.60 CI =0.48-0.74) suggesting viral-induced shut-off of host antiviral protein responses. However, proteins for IP-10 (OR =3.74 CI =2.07-6.77) and several interferon-stimulated genes (ISG) increased with viral load (BST-1 OR =25.1, CI =3.33-188; IFIT1 OR =19.5, CI =4.25-89.2; IFIT3 OR =245, CI =15-4020; MX-1 OR =3.33, CI =1.44-7.70). Older age was associated with substantial modifications of some effects. Ambulatory symptomatic patients had an innate immune response with SARS-CoV-2 infection characterized by elevated IFN, proinflammatory cytokine and ISG transcripts, but there is evidence of a viral-induced host shut-off of antiviral responses. Our findings may characterize the disrupted immune landscape common in patients with early disease.

SARS-CoV-2 Innate Effector Associations and Viral Load in Early Nasopharyngeal Infection.

To examine innate immune responses in early SARS-CoV-2 infection that may change clinical outcomes, we compared nasopharyngeal swab data from 20 virus-positive and 20 virus-negative individuals. Multiple innate immune-related and ACE-2 transcripts increased with infection and were strongly associated with increasing viral load. We found widespread discrepancies between transcription and translation. Interferon proteins were unchanged or decreased in infected samples suggesting virally-induced shut-off of host anti-viral protein responses. However, IP-10 and several interferon-stimulated gene proteins increased with viral load. Older age was associated with modifications of some effects. Our findings may characterize the disrupted immune landscape of early disease.

Emergency Department Observation Unit Utilization Among Older Patients With Chest Pain.

BACKGROUND: Although some emergency department observation units (EDOUs) may exclude patients over 65 years old, our EDOU accepts patients up to 79 years old. We assessed the utilization of our EDOU by older patients (those 65-79 years old). METHODS: We prospectively enrolled emergency department (ED) patients with chest pain. We gathered baseline data at the time of ED presentation and tracked outcomes related to the ED stay, EDOU, and/or inpatient admission. Our primary outcome included EDOU placement among older patients. Our secondary outcome was the rate of major adverse cardiac events [MACE: myocardial infarction, stent, coronary artery bypass graft, and death]. RESULTS: Over the 5-year study period, we evaluated 2242 ED patients with chest pain, of whom 19.4% (95% confidence interval, 17.8%-21.1%) were 65-79 years old. Older patients were more likely to be placed in the EDOU after the ED visit (45.8% vs. 36.6%; P = 0.001) and more likely to be admitted to an inpatient unit from the ED (31.8% vs. 17.9%;P < 0.001) than those under 65 years old. The overall MACE rate was similar between admitted older patients and those in the EDOU: 5.9% versus 4.3% (P = 0.57). Of the admitted older patients, 30.4% (95% confidence interval, 22.3%-39.9%) were low risk and there were no cases of MACE in this group. CONCLUSIONS: In an EDOU that allows older patients, we noted substantial utilization by these patients for the evaluation of chest pain. The characteristics of admitted older patients suggest the potential for even greater EDOU utilization in this group.

The use of prehospital variables to predict acute coronary artery disease in failed resuscitation attempts for out-of-hospital cardiac arrest.

AIM OF THE STUDY: To determine the ability of readily available prehospital variables to predict acute coronary artery disease (CAD) as the cause of arrest in failed out-of hospital cardiac arrest (OHCA) resuscitations. METHODS: Retrospective analysis of a prospectively collected database of all adult cases of OHCA who underwent resuscitation attempts and later post-mortem examination by the state Medical Examiner (ME) over a 6 year period. Multivariable logistic regression modeling was used to identify predictors. RESULTS: Among the 151 cases linked to ME reports, CAD was judged to be the cause of arrest in 65/151 (43%). In multivariable modeling, CAD was more likely to be found at autopsy among older victims (Odds ratio [OR] 2.3 per decade of life, 95% confidence interval [CI] 1.6-3.4), males (OR 7.3, 95% CI 1.9-27.4), and those with an initial shockable rhythm (OR 5.3, 95% CI 2.0-14.2). The combination of these three variables correctly classified 75% of victims with an area under the ROC curve (AUC) of 0.85. CONCLUSION: As hospital-based salvage therapies offer opportunities to extend survival for victims of OHCA who fail prehospital treatment, an ability to predict CAD may help guide protocols for appropriate use. In this derivation analysis, a simple set of variables available on scene can be used to predict CAD with good accuracy among OHCA victims who fail prehospital resuscitation attempts. An initial shockable rhythm should still be considered the result of acute coronary artery disease until proven otherwise.

Evaluating applicants to a new emergency medicine residency program: subjective assessment of applicant characteristics.

BACKGROUND: Because of the Accreditation Council for Graduate Medical Education (ACGME) and the Residency Review Committee (RRC) approval timelines, new residency programs cannot use Electronic Residency Application Service (ERAS) during their first year of applicants. AIM: We sought to identify differences between program directors' subjective ratings of applicants from an emergency medicine (EM) residency program's first year (in which ERAS was not used) to their ratings of applicants the following year in which ERAS was used. METHOD: The University of Utah Emergency Medicine Residency Program received approval from the ACGME in 2004. Applicants for the entering class of 2005 (year 1) did not use ERAS, submitting a separate application, while those applying for the following year (year 2) used ERAS. Residency program directors rated applicants using subjective components of their applications, assigning scores on scales from 0-10 or 0-5 (10 or 5 = highest score) for select components of the application. We retrospectively reviewed and compared these ratings between the 2 years of applicants. RESULTS: A total of 130 and 458 prospective residents applied during year 1 and year 2, respectively. Applicants were similar in average scores for research (1.65 vs. 1.81, scale 0-5, p = 0.329) and volunteer work (5.31 vs. 5.56, scale 0-10, p = 0.357). Year 1 applicants received higher scores for their personal statement (3.21 vs. 2.22, scale 0-5, p < 0.001), letters of recommendation (7.0 vs. 5.94, scale 0-10, p < 0.001), dean's letter (3.5 vs. 2.7, scale 1-5, p < 0.001), and in their potential contribution to class characteristics (4.64 vs. 3.34, scale 0-10, p < 0.001). CONCLUSION: While the number of applicants increased, the use of ERAS in a new residency program did not improve the overall subjective ratings of residency applicants. Year 1 applicants received higher scores for the written components of their applications and in their potential contributions to class characteristics.

Scene transport of pediatric patients injured at winter resorts.

OBJECTIVE: To examine the characteristics of pediatric patients (age =16 years) injured at winter resort scenes and transported by helicopter emergency medical services (HEMS) or ground EMS (GEMS) ambulance services to regional trauma centers. METHODS: Between 1997 and 2001, a total of 119 patients (GEMS = 69; HEMS = 50) were identified from trauma registries and HEMS transport records. Demographic data, initial vital signs, hospital interventions, and discharge status of the two groups were examined. RESULTS: The distributions of gender, initial vital signs, Injury Severity Score (ISS; either = or > 15), intensive care unit (ICU) length of stay (LOS), total hospital LOS, and home discharge status were similar between the two groups (p = 0.05). Patients transported by HEMS were older (14 +/- 2 vs. 10 +/- 4, p < 0.001), less likely to be admitted to the hospital (73% vs. 98.5%; p < 0.001), and more likely to have multiple injuries [13 (27%) vs. 8 (11.6%), p = 0.032]. The GEMS patients had a higher rate of isolated extremity [33 (80.5%) vs. 8 (19.5%)] and thoracoabdominal [11 (73.3%) vs. 4 (26.7%)] injuries. The high orthopedic injury rate in the GEMS patients contributed to a higher rate of surgery in this group (45% vs. 24%, p = 0.028). Regardless of transport mode, patients requiring immediate interventions (intubation, chest tube placement, or blood product administration) had either a depressed level of consciousness (GCS = 12) on emergency department arrival or thoracoabdominal injuries. No deaths were recorded. CONCLUSIONS: Patients transported by HEMS and GEMS had similar hospital characteristics but different injury patterns. A prospective study examining the initial triage of pediatric patients injured at winter resorts would help to determine which subset of patients are best served by HEMS transport.

Transport of winter resort injuries to regional trauma centers.

INTRODUCTION: This study examined the epidemiology of winter resort injuries presenting to regional trauma centers by helicopter (HEMS) or ground (GEMS) ambulance. METHODS: Five hundred seventy-five patients (GEMS 289; HEMS 286) were identified from trauma registries and HEMS transport records. Demographic data, hospital interventions, and discharge status were examined. RESULTS: HEMS patients had a significantly lower Glasgow coma score (GCS) and trauma score (TS), longer intensive care unit (ICU) length of stay (LOS), and more deaths than did GEMS patients (P < 0.05). Despite this, significantly more HEMS patients were discharged home from the emergency department (24.5% vs. 4.8%; P < 0.001). HEMS patients had more isolated head/facial injuries and multiple injuries, with less isolated extremity injuries than did GEMS patients (P < 0.05). Regardless of transport mode, patients with multiple injuries, thoracoabdominal injuries, or head injuries with a GCS < or = 13 were more likely to require immediate interventions (intubation, chest tube, blood products). Patients with isolated extremity injuries rarely needed immediate care. CONCLUSION: HEMS patients had a higher acuity and different injury pattern when compared to GEMS patients. Approximately 24.5% of HEMS patients were discharged home from the ED. This reflects significant overtriage of patients to HEMS. A prospective study examining the initial triage of patients injured at winter resorts would help to determine which subset of patients are best served by HEMS transport.

Evaluation of an electronic esophageal detector device in patients with morbid obesity and pulmonary failure.

OBJECTIVE: Undetected esophageal intubation can result in permanent injury or death. Clinical confirmation of tube location may be misleading. Adjunctive methods should be used to supplement clinical judgment. Unfortunately, end-tidal carbon dioxide may misidentify properly placed tracheal tubes in low perfusion situations, while esophageal detector devices (EDDs) may misidentify properly placed tracheal tubes in situations where little airway dead space exists (morbid obesity, pulmonary failure). This study evaluated a modified EDD (the electronic esophageal detector device, or EEDD) designed to eliminate the problem of misidentified tracheal intubations. METHODS: Intubated morbidly obese or pulmonary failure patients were eligible for study entry. All endotracheal tubes (ETTs) were confirmed to be tracheal by waveform capnography and clinical judgment prior to study entry. Following consent, all patients were attached to the EEDD and a "measurement" was made to determine the "location" of their ETTs. Probability of misidentifying a tracheal intubation in these high-risk populations was calculated using a log-normal distribution method. RESULTS: Twenty-seven morbidly obese patients and 37 pulmonary failure patients were entered. The EEDD correctly identified all tracheal intubations in these patients, giving a false-negative rate of zero. The probability of misidentifying a tracheal intubation in the combined group was 0.06%. CONCLUSION: This study demonstrates that the EEDD reliably identifies tracheal intubations in situations where standard EDDs may fail. However, future studies must determine the reliability of this device for identification of esophageal intubations and the reliability of this device in the less controlled emergency department and prehospital settings.

The 2003 Air Medical Leadership Congress: findings and recommendations.

To address important concerns facing the air medical community, 149 air medical transport leaders, providers, consultants, and experts met September 4-6, 2003, in Salt Lake City, Utah, for a 3-day summit-the Air Medical Leadership Congress: Setting the Health Care Agenda for the Air Medical Community. Using data from a Web-based survey, top air medical transport issues were identified in four core areas: safety, medical care, cost/benefit, and regulatory/compliance. This report reviews the findings of previous congresses and summarizes the discussions, findings, recommendations, and proposed industry actions to address these issues as set forth by the 2003 congress participants.