The latest medical research on Emergency Medicine
The research magnet gathers the latest research from around the web, based on your specialty area. Below you will find a sample of some of the most recent articles from reputable medical journals about emergency medicine gathered by our medical AI research bot.
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Management of patients with chronic heart failure and type 2 diabetes mellitus: the SCODIAC-II study.Internal and emergency medicine
SCODIAC was a pilot study which revealed an increasing use of SGLT2i in 123 outpatients affected with Heart Failure (HF) and Type 2 Diabetes Mellit...
Anticoagulation in patients with advanced liver disease: an open issue.Internal and emergency medicine
Liver disease has been long considered as a risk factor for bleeding for the presence of prolongation of global tests of clotting activation and lo...
Diagnostic accuracy of the magnetocardiograph for patients with suspected acute coronary syndrome.Emergency Medicine Journal
We aimed to estimate the diagnostic accuracy of the VitalScan magnetocardiograph (MCG) for suspected acute coronary syndrome (ACS).
We undertook a prospective cohort study evaluating the diagnostic accuracy of the MCG in adults with suspected ACS. The reference standard of ACS was determined by an independent adjudication committee based on 30-day investigations and events. The cohort was split into a training sample, to derive the MCG algorithm and an algorithm combining MCG with a modified Manchester Acute Coronary Syndrome (MACS) clinical probability score, and a validation sample, to estimate diagnostic accuracy.
We recruited 756 participants and analysed data from 680 (293 training, 387 validation), of whom 96 (14%) had ACS. In the training sample, the respective area under the receiver operating characteristic (AUROC) curves were the following: MCG 0.66 (95% CI 0.58 to 0.74), MACS 0.64 (95% CI 0.54 to 0.73) and MCG+MACS 0.70 (95% CI 0.63 to 0.77). MCG specificity was 0.16 (95% CI 0.12 to 0.21) at the threshold achieving acceptable sensitivity for rule-out (>0.98). In the validation sample (n=387), the respective AUROCs were the following: MCG 0.56 (95% CI 0.48 to 0.64), MACS 0.69 (95% CI 0.61 to 0.77) and MCG+MACS 0.64 (95% CI 0.56 to 0.72). MCG sensitivity was 0.89 (95% CI 0.77 to 0.95) and specificity 0.15 (95% CI 0.12 to 0.20) at the rule-out threshold. MCG+MACS sensitivity was 0.85 (95% CI 0.73 to 0.92) and specificity 0.30 (95% CI 0.25 to 0.35).
The VitalScan MCG is currently unable to accurately rule out ACS and is not yet ready for use in clinical practice. Further developmental research is required.
Planning for success: overcoming challenges to recruitment and conduct of an open-label emergency department-led paediatric trial.Emergency Medicine Journal
Key challenges to the successful conduct of The Emergency treatment with Levetiracetam or Phenytoin in Status Epilepticus in children (EcLiPSE) trial were identified at the pre-trial stage. These included practitioner anxieties about conducting research without prior consent (RWPC), inexperience in conducting an ED-led trial and use of a medication that was not usual ED practice. As part of an embedded study, we explored parent and practitioner experiences of recruitment, RWPC and conduct of the trial to inform the design and conduct of future ED-led trials.
A mixed-methods study within a trial involving (1) questionnaires and interviews with parents of randomised children, (2) interviews and focus groups with EcLiPSE practitioners and (3) audio-recorded trial discussions. We analysed data using thematic analysis and descriptive statistics as appropriate.
A total of 143 parents (93 mothers, 39 fathers, 11 missing information) of randomised children completed a questionnaire and 30 (25 mothers, 5 fathers) were interviewed. We analysed 76 recorded trial recruitment discussions. Ten practitioners (4 medical, 6 nursing) were interviewed, 36 (16 medical, 20 nursing) participated in one of six focus groups. Challenges to the success of the trial were addressed by having a clinically relevant research question, pragmatic trial design, parent and practitioner support for EcLiPSE recruitment and research without prior consent processes, and practitioner motivation and strong leadership. Lack of leadership negatively affected practitioner engagement and recruitment. EcLiPSE completed on time, achieving its required sample size target.
Successful trial recruitment and conduct in a challenging ED-led trial was driven by trial design, recruitment experience, teamwork and leadership. Our study provides valuable insight from parents and practitioners to inform the design and conduct of future trials in this setting.
Liberal vs Restrictive Hemoglobin Levels as Thresholds for Blood Transfusions.Academic Emergency Medicine
Blood transfusion is a common treatment of anemia due to chronic disease or acute blood loss. However, there continues to be uncertainty concerning...
Management of liver trauma in urban university hospitals in India: an observational multicentre cohort study.World Journal of Emergency Surgery
Low- and middle-income countries (LMICs) contribute to 90% of injuries occurring in the world. The liver is one of the commonest organs injured in abdominal trauma. This study aims to highlight the demographic and management profile of liver injury patients, presenting to four urban Indian university hospitals in India.
This is a retrospective registry-based study. Data of patients with liver injury either isolated or concomitant with other injuries was used using the ICD-10 code S36.1 for liver injury. The severity of injury was graded based on the World Society of Emergency Surgery (WSES) grading for liver injuries.
A total of 368 liver injury patients were analysed. Eighty-nine percent were males, with road traffic injuries being the commonest mechanism. As per WSES liver injury grade, there were 127 (34.5%) grade I, 96 (26.1%) grade II, 70 (19.0%) grade III and 66 (17.9%) grade IV injuries. The overall mortality was 16.6%. Two hundred sixty-two patients (71.2%) were managed non-operatively (NOM), and 106 (38.8%) were operated. 90.1% of those managed non-operatively survived.
In this multicentre cohort of liver injury patients from urban university hospitals in India, the commonest profile of patient was a young male, with a blunt injury to the abdomen due to a road traffic accident. Success rate of non-operative management of liver injury is comparable to other countries.
Does the Emergency Surgery Score (ESS) Predict Failure to Discharge the Patient Home? A Nationwide Analysis.Journal of Trauma and Acute Care Surgery
The Emergency Surgery Score (ESS) is a point-based scoring system validated to predict mortality and morbidity in Emergency General Surgery (EGS). In addition to demographics and comorbidities, ESS accounts for the acuity of disease at presentation. We sought to examine whether ESS can predict the destination of discharge of EGS patients, as a proxy for quality of life at discharge.
Prognostic and epidemiological, Level III, retrospective study.
Out of 6,485,915 patients, 84,694 were included. The mean age was 57 years, 51% were female, and 79.6% were discharged home. The mean ESS was 5. ESS accurately and reliably predicted the discharge destination with a c-statistic of 0.83. For example, ESS of 1, 10 and 20 were associated with 0.9%, 56.5%, and 100% rates of discharge to a rehabilitation or nursing facility instead of home.
ESS accurately predicts which EGS patients require discharge to rehabilitation or nursing facilities and can thus be used for preoperatively counseling patients and families, and for improving early discharge preparations, when appropriate.
Antiplatelet and Anticoagulant Agents have Minimal Impact on TBI Incidence, Surgery and Mortality in Geriatric Ground Level Falls: A Multi-institutional Analysis of 33,710 Patients.Journal of Trauma and Acute Care Surgery
Falls are the leading cause of TBI and TBI-related deaths for older persons (age>65). Antiplatelet and/or anticoagulant therapy (antithrombotics, ATs) is generally felt to increase this risk, but the literature is inconsistent. The purpose of this study was to determine the impact of AT use on the rate, severity and outcomes of TBI in older patients following GLFs.
Level II (therapeutic/care management).
There were 33 710 patients (35% male, mean age 80.5, mean GCS 14.6), with 47.6% on single or combination AT therapy. The proportion of patients with TBI diagnoses did not differ between those on No AT (21.25%) vs AT (21.61%; P=.418). Apixaban (15.7%; P<.001) and Rivaroxaban (13.19%; P=.011) were associated with lower rates of TBI, and ASA + Clopidogrel was associated with a higher TBI rate (24.34%; P=.002) vs. No AT. ASA + Clopidogrel was associated with a higher cranial surgery rate (2.9%; P=.006) vs No AT (1.96%), but surgery rates were similar for all other regimens. No regimen was associated with higher mortality.
In this large, multicenter study, the intake of ATs in older patients with GLFs was associated with inconsistent effects on risk of TBI and no significant increases in mortality, indicating AT use may have negligible impact on patient clinical management. A large, confirmatory, prospective study is needed, as the commonly held belief that ATs uniformly increase the risk of traumatic intracranial bleeding and mortality is not supported.
Freeze dried platelets promote clot formation, rescue thrombin induced endothelial cell permeability, and decrease pulmonary vascular leak in a murine model of hemorrhagic shock.Journal of Trauma and Acute Care Surgery
Hemorrhagic shock (HS) and trauma induce endothelial barrier compromise, inflammation, and aberrant clotting. We have shown that fresh human platelets (Plts) and platelet extracellular vesicles mitigate vascular leak in murine models of injury. Here, we investigate the potential of freeze-dried platelets (FDPlts) to attenuate pulmonary vascular permeability, decrease inflammation and promote clotting in a murine model of HS.
FDPlts expressed platelet specific markers and retained functionality similar to fresh Plts. In in vitro assays of platelet aggregation differences were noted. In vivo, FDPlts and Plts were found to incorporate into clots in post capillary venules in the mouse cremaster. HS mice resuscitated with LR displayed increased pulmonary vascular permeability compared to sham (sham, 686.6±359.7; shock+LR, 2637±954.7; p=0.001), treatment with FDPlts or WB attenuated permeability compared to shock: (shock+FDPlts, 1328±462.6; p=0.05), and (shock+WB, 1024±370.5; p=0.0108). However, Plts (Day 1-3) did not attenuate vascular leak in HS mice compared to shock (shock+Plts, 3601±1581; p=0.33).
FDPlts contribute to clot formation similar to fresh human Plts. FDPlts also attenuated vascular permeability in vitro and in vivo. Mouse WB resuscitation but not fresh Plts attenuated vascular permeability after HS. These data suggest that the effect of FDPlts may be a suitable alternative to fresh Plts in modulating hemostasis and the endotheliopathy associated with injury.
Baseline well-being, perceptions of critical incidents, and openness to debriefing in community hospital emergency department clinical staff before COVID-19, a cross-sectional study.BMC Emergency Medicine
Emergency department personnel routinely bear witness to traumatic experiences and critical incidents that can affect their own well-being. Peer support through debriefing has demonstrated positive impacts on clinicians' well-being following critical incidents. This study explored community hospital emergency department staff's perceptions of critical incidents, assessed openness to debriefing and measured baseline well-being. Our analysis provides a baseline of provider well-being immediately prior to the local onset of COVID-19. The potential need for additional resources to support frontline providers during the pandemic can be evaluated.
We conducted a cross-sectional study for 4-weeks prior to the first COVID-19 case in Connecticut using a survey offered to an interprofessional group of emergency department clinical staff. The main outcome measures were the Hospital Anxiety and Depression Scale (HADS) and the Professional Quality of Life (ProQOL) scale. Pearson's chi-square test was used to identify significant differences in perceptions of critical incidents and debriefings between professional categories. One-way ANOVA and Tukey's test were used to analyze significant differences in well-being between professional categories.
Thirty-nine clinical personnel from St. Vincent's Emergency Department responded to the survey. Events frequently selected as critical incidents were caring for critically ill children (89.7%), mass casualty events (84.6%), and death of a patient (69.2%). Critical incidents were commonly reported (81.6%) as occurring once per week. Additionally, 76.2% of participants reported wanting to discuss a critical incident with their team. Across all respondents, 45.7% scored borderline or abnormal for anxiety, 55.9% scored moderate for burnout, and 55.8% scored moderate to high for secondary traumatic stress.
At baseline, providers reported caring for critically ill children, mass casualty events, and death of a patient as critical incidents, which typically occurred once per week. Death of a patient occurs at increased frequency during the protracted mass casualty experience of COVID-19 and threatens provider well-being. Receptiveness to post-event debriefing is high but the method is still underutilized. With nearly half of staff scoring borderline or abnormal for anxiety, burnout, and secondary traumatic stress at baseline, peer support measures should be implemented to protect frontline providers' well-being during and after the pandemic.
Policies Tackling the COVID-19 Pandemic: A Sociopolitical Perspective from Taiwan.Health Security
As people around the world anxiously watched the early development of the novel coronavirus disease 2019 (COVID-19) pandemic, they expected Taiwan ...
Improving the Safety of an Emergency Department-Based Direct Admission Process at a Children's Hospital.Pediatric Emergency Care
Direct admission refers to admitting a patient to a unit avoiding usual entry points such as the emergency department. Inappropriate placement of direct admissions can result in rapid response activations, codes and unanticipated pediatric intensive care unit (PICU) transfers, which correlate with higher mortality and longer lengths of stay. The objective of the project was to improve the safety of the direct admission process as evidenced by decreasing the transfer of direct admission patients to the PICU within 6 hours.
Utilizing the model for improvement, a multidisciplinary team was assembled to improve our screening process and reduce unanticipated direct admission-to-PICU transfers within 6 hours of arrival. Our emergency department-based direct admission process includes screening vital signs (temperature, heart rate, respiratory rate, blood pressure, and pulse oximetry) and a Pediatric Early Warning Score. Five Plan-Do-Study-Act cycles focused on role definition, improved documentation, referring facility and family awareness, improved visual management within the ED, and education of partner EMS and transport providers. The primary outcome was PICU transfer within 6 hours of direct admission arrival. Compliance with full screening was a process measure and number of direct admissions a balancing measure. Statistical process control charts and run charts were used to follow the measures.
The total number of direct admissions from January 2014 to the end of data collection, June 2018, was 3070 patients. Screening protocol compliance improved from 56% to over 80% for the entire hospital. Unanticipated direct admission-to-PICU transfers decreased from a baseline of 1 every 98 patients to a special cause of 1 in 1126 patients.
By utilizing QI methodology our team was able to implement and sustain a direct admission process that was more consistent, easier to document and improved the safety of our patients. Our study demonstrates that screening direct admissions reliably and consistently can decrease the rate of unanticipated transfer to a higher level of care.