Low back pain presentations to rural, regional, and metropolitan emergency departments.

OBJECTIVE: To describe the context of low back pain (LBP) presentations to emergency departments (EDs) by remoteness areas, hospital delineation level and staffing portfolios. DESIGN: A retrospective observational study using routinely captured ED and admission data over a 5-year period (July 2014-June 2019). SETTINGS: Thirty seven EDs across a large health district in NSW, Australia, covering major cities, inner regional areas and outer regional areas. PARTICIPANTS: Emergency department (ED) presentations with a principal or secondary diagnosis of LBP based on ICD-10 code (M54.5). MAIN OUTCOME MEASURES: ED presentation and associated admission measures, including presentation rate, referral source, time in ED, re-presentation rate, admission details and cost to the health system. RESULTS: There were 26 509 ED presentations for LBP across the 5 years. Time spent in ED was 206 min for EDs in major cities, 146 min for inner regional EDs and 89 min for outer regional EDs. Re-presentation rates were 6% in major cities, 8.8% in inner regional EDs and 11.8% in outer regional EDs. Admission rates were 20.4%, 15.8% and 18.8%, respectively. CONCLUSIONS: This study describes LBP presentations across 37 EDs, highlighting the potential burden these presentations place on hospitals. LBP presentations appear to follow different pathways depending on the ED remoteness area, delineation level and staff portfolio.

Association of vascular netosis with COVID-19 severity in asymptomatic and symptomatic patients.

We examined from a large exploratory study cohort of COVID-19 patients (N = 549) a validated panel of neutrophil extracellular traps (NETs) markers in different categories of disease severity. Neutrophil elastase (NE), myeloperoxidase (MPO), and circulating nuclear DNA (cir-nDNA) levels in plasma were seen to gradually and significantly (p < 0.0001) increase with the disease severity: mild (3.7, 48.9, and 15.8 ng/mL, respectively); moderate (9.8, 77.5, and 27.7 ng/mL, respectively); severe (11.7, 99.5, and 29.0 ng/mL, respectively); and critical (13.1, 110.2, and 46.0 ng/mL, respectively); and are also statistically different with healthy individuals (N = 140; p < 0.0001). All observations made in relation to the Delta variant-infected patients are in line with Omicron-infected patients. We unexpectedly observed significantly higher levels of NETs in asymptomatic individuals as compared to healthy subjects (p < 0.0001). Moreover, the balance of cir-nDNA and circulating mitochondrial DNA level was affected in COVID-19 infected patients attesting to mitochondrial dysfunction.

Takutsubo cardiomyopathy and flash pulmonary edema in a trauma patient.

BACKGROUND: First described in Japanese literature in 1991, Takotsubo cardiomyopathy (TCM), or "broken heart" syndrome, continues to be described in novel circumstances. Commonly mistaken for acute coronary syndrome (ACS) due to similar clinical symptoms and electrocardiogram changes, it usually affects postmenopausal women and those in acute emotional or physical stress. Named for the resemblance of apical ballooning and dyskinesis to the Japanese octopus trap, the pathogenesis is poorly understood. Believed to be associated with catecholamine surges during extreme stress, TCM has been reported with grieving, lightning strikes, burns, injuries, and anesthesia. We describe a unique case occurring after a significant motor-vehicle collision (MVC) without apparent injury. OBJECTIVE: Our aim was to discuss the presentation and management of a cardiac syndrome that can complicate the care of trauma patients by mimicking other life-threatening pathologies. CASE REPORT: A 59-year-old healthy female in a rollover MVC was found suspended upside down with her seatbelt across her neck. She was hypoxic, in respiratory distress, and had nonsustained ventricular tachycardia en route. She was dyspneic without pain and had no signs of external trauma. She was assessed with chest x-ray study, focused assessment with sonography in trauma, and electrocardiogram, which demonstrated inferior ST elevation. After negative trauma computed tomography scans, she underwent coronary angiography. Ventriculography revealed apical inferior and anterior ballooning without coronary artery occlusion. She rapidly improved and was discharged in stable condition 2 days later. CONCLUSIONS: TCM presents a diagnostic challenge to the emergency physician. In a patient of this age and mechanism, alternate intrathoracic pathologies, such as ACS, aortic injury, pulmonary contusion, and pneumothorax must be considered.

The Daalbirrwirr Gamambigu (Safe Children) Model: Embedding Cultural Safety in Child Protection Responses for Australian Aboriginal Children in Hospital Settings.

The aim of this paper is to describe the development of a model of care to embed cultural safety for Aboriginal children into paediatric hospital settings. The Daalbirrwirr Gamambigu (pronounced "Dahl-beer-weer gum-um-be-goo" in the Gumbaynggirr language means 'safe children') model encompasses child protection responses at clinical, managerial and organisational levels of health services. A review of scholarly articles and grey literature followed by qualitative interviews with Aboriginal health professionals formed the evidence base for the model, which then underwent rounds of consultation for cultural suitability and clinical utility. Culturally appropriate communication with children and their families using clinical yarning and a culturally adapted version of ISBAR (a mnemonic for Identify, Situation, Background, Assessment and Recommendation) for interprofessional communication is recommended. The model guides the development of a critical consciousness about cultural safety in health care settings, and privileges the cultural voices of many diverse Aboriginal peoples. When adapted appropriately for local clinical and cultural contexts, it will contribute to a patient journey experience of respect, dignity and empowerment.