Emergency Room Care Research Articles

Position paper of DGKL and DIVI on requirements for laboratory services in intensive care and emergency medicine

The timely determination and evaluation of laboratory parameters in patients with acute life- or organ-threatening diseases and disease states in the emergency room or intensive care units can be essential for diagnosis, initiation of therapy, and outcome. The aim of the position paper is to define the time requirements for the provision of laboratory results in emergency and intensive care medicine. Requirements for point-of-care testing (POCT) and the (central) laboratory can be derived from the urgency. Expert groups from the DGKL (Deutsche Gesellschaft für Klinische Chemie und Laboratoriumsmedizin) and DIVI (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin) developed a classification about the urgency for the determination of laboratory parameters as well as recommendations on the necessary organizational framework and quality assurance measures using national and international guidelines, review articles, and original papers. Three levels of urgency are defined, based on the turnaround time of the most common laboratory parameters: emergency 1, with a turnaround time of no more than 15 min; emergency 2, with a turnaround time of a maximum of 60 min; urgent case, with a turnaround time within 4 h. In addition, a recommendation is made when to provide the results for the main ward rounds in the intensive care unit and the emergency department. The recommendations allow the organizational and technical regulations for each hospital to be aligned with the urgency of the provision of the test results to the medical team based on the medical requirements.

Construction and validation of the Emergency Oncology Scale (EMOnco), a risk rating protocol for the triage of cancer patients in acute care settings.

Manfredini et al. demonstrate that the new rating protocol, EMOnco, can triage of cancer patients in acute care settings safely, considering their cancer type, stage and treatment histories and oncological emergencies, enabling the appropriate classification from high-risk patients to non-urgent patients. ■ EMOnco considers variables related to the cancer history and treatment. ■ Triages patients in the emergency care in less than three minutes. ■ Cancer patients need priority care regarding infection, and this protocol consider it. ■ EMOnco has shown to be a valid and reliable scale for the triage of oncological patients in the emergency room or acute care clinics. To validate a risk rating scale for triaging of cancer patients in emergency rooms that can identify individuals needing urgent care or in imminent worsening of the clinical condition. This is a health instrument validation study developed in the emergency care ward of a Brazilian hospital, a referral center for cancer and hematological diseases. We built the Emergency Oncology Scale (EMOnco) based on literature review and a Delphi survey with 20 experienced oncologists (physicians and nurses). We validated the scale by assessing its construct validity, interobserver agreement and reliability after applying them in a convenience sample of all consecutive patients with cancer who visited the ward between August 2017 and January 2018. We compared the EMOnco Scores with those from other scales, used by six trained nurses: the Emergency Severity Index, the Manchester Triage System, and the Karnofsky Performance Status. We also recorded socio-demographic and clinical features and the Sequential Organ Failure Assessment (SOFA) results in the intensive care unit. We included 250 patients with locally advanced or recurrent disease and undergoing chemotherapy. EMOnco screening took 2.24 (± 2.9) minutes in average. The interobserver correlation coefficient was 0.9. EMOnco was highly correlated with Emergency Severity Index (r=0.617) and also correlated with Karnofsky Performance Status (0.420) Manchester Triage System (0.491; p<0.001 for all). EMOnco in Portuguese considers variables related to the cancer history and treatment and has proven to be a valid and reliable for the risk classification of oncological patients in emergency care services.

The comprehensive geriatric assessment in emergency and intensive unit settings

This review discusses the challenges that hospitals face when caring for older patients in emergency departments and intensive care units. Beyond chronic diseases, the older person is often affected by acute events, which require, in addition to the typical knowledge of emergency medicine and anesthesia, the holistic and targeted approach of the comprehensive geriatric assessment in the emergency room and intensive care setting. With Italy’s health centers struggling to manage the increasing pressure of patients, the COVID-19 pandemic has highlighted the need for a geriatric approach to address this challenge. This review outlines the Geriatric 5Ms Model of Care, which addresses five domains, and the Domain Management Model, which provides acute medical management.

Current and Future Roles of Glycoprotein IIb-IIIa Inhibitors in Primary Angioplasty for ST-Segment Elevation Myocardial Infarction.

Acute myocardial infarction still represents the major cause of mortality in high-income countries. Therefore, considerable efforts have been focused on the treatment of myocardial infarctions in the acute and long-term phase, with special attention being paid to reperfusion strategies and adjunctive antithrombotic therapies. In fact, despite the successful mechanical recanalization of the epicardial conduit, a substantial percentage of patients still experience poor myocardial reperfusion or acute/subacute in-stent thrombosis. Due the delayed onset of action of currently available oral antiplatelet therapies, glycoprotein (GP) IIb-IIIa inhibitors could be expected to improve clinical outcomes, especially when administrated in the early phase of the infarction, due to the larger platelet composition of fresh thrombi, the dynamic nature of early thrombi, and the larger amount of viable myocardium existing in the early, as compared to a delayed, phase. Considerable evidence has accumulated regarding the benefits from GP IIb-IIIa inhibitors on mortality, especially among high-risk patients and when administered as an upstream strategy. Therefore, based on currently available data, GP IIb-IIIa inhibitors can be considered when the drug can be administered within the first 3 h of symptom onset and among high-risk patients (e.g., those with advanced Killip class or an anterior myocardial infarction). Even though it is not universally accepted, in our opinion, this strategy should be implemented in a pre-hospital setting (in an ambulance) or as soon as possible when arriving at the hospital (at the Emergency Room or Coronary Care Unit, irrespective of whether they are in spoke or hub hospitals). A new, second-generation GP IIb-IIIa inhibitor (zalunfiban) appears to be highly suitable as a pre-hospital pharmacological facilitation strategy at the time of first medical contact due to its favourable features, including its simple subcutaneous administration, rapid onset of action (15 min), and limited time of action (with a half-life of ~1 h), which is likely to minimize the risk of bleeding. The ongoing CELEBRATE trial, including 2499 STEMI patients, may potentially provide compelling data to support the upstream treatment of STEMI patients undergoing mechanical reperfusion. In fact, although the current therapeutic target of increased rates of timely reperfusion has been achieved, the future goal in myocardial infarction treatment should be to achieve the most rapid reperfusion prior to primary percutaneous coronary intervention, thus further minimizing myocardial damage, or, in some cases, even preventing it completely, and improving survival.

Indian Society of Critical Care Medicine Position Statement: Approach to a Patient with Poisoning in the Emergency Room and Intensive Care Unit.

Rungta N, Ray B, Bhalla A, DP Samaddar, Paul G, Prasad S, et al. Indian Society of Critical Care Medicine Position Statement: Approach to a Patient with Poisoning in the Emergency Room and Intensive Care Unit. Indian J Crit Care Med 2024;28(S2):S217-S232.

Disparate Patient Advocacy When Facing Unaffordable and Problematic Medical Bills

People in the US face high out-of-pocket medical expenses, yielding financial strain and debt. To understand how households respond to medical bills they disagree with or cannot afford. A retrospective cohort study was carried out using a survey fielded between August 14 and October 14, 2023. The study included a random sample of adult (aged ≥18 years) survey respondents from the Understanding America Study (UAS). Participant responses were weighted to be nationally representative. The analysis took place from November 3, 2023, through January 8, 2024. Respondents reported if their household received a medical bill that they could not afford or did not agree with in the prior 12 months, and if anyone contacted the billing office regarding their concerns. Those who did reach out were asked about their experience and those who did not were asked why. The survey was sent to 1233 UAS panelists, of which 1135 completed the survey, a 92.1% cooperation rate. Overall, 1 in 5 of the 1135 respondents received a medical bill that they disagreed with or could not afford. Leading bill sources were physician offices (66 [34.6%]), emergency room or urgent care (22 [19.9%]), and hospitals (31 [15.3%]), and 136 respondents (61.5%) contacted the billing office to address their concern. A more extroverted and less agreeable personality increased likelihood of reaching out. Respondents without a college degree, lower financial literacy, and the uninsured were less likely to contact a billing office. Among those who did not reach out, 55 (86.1%) reported that they did not think it would make a difference. Of those who reached out, 37 (25.7%) achieved bill corrections, better understanding (16 [18.2%]), payment plans (18 [15.5%]), price drop (17 [15.2%]), financial assistance (10 [8.1%]), and/or bill cancellation (6 [7.3%]), while 32 (21.8%) said that the issue was unresolved and 23.8% reported no change. These outcomes aligned well with respondents' billing concerns with financial relief for 75.8% of respondents reaching out about an unaffordable bill, bill corrections for 73.7% of those who thought there was mistake, and a price drop for 61.8% of those who negotiated. This cross-sectional survey of a representative sample of patients in the US found that most respondents who self-advocated achieved bill corrections and payment relief. Differences in self-advocacy may be exacerbating socioeconomic inequalities in medical debt burden, as those with less education, lower financial literacy, and the uninsured were less likely to self-advocate. Policies that streamline the administrative burden or shift it from patients to the billing clinician may counter these disparities.

Sex differences in early-onset atrial fibrillation in Norwegian primary care: a retrospective national database analysis

BackgroundIndividual variation in the need for healthcare constitutes knowledge gaps for young atrial fibrillation (AF) patients. We aimed to estimate the prevalence and primary care burden of early-onset AF in...

Rapid abdominopelvic MR imaging in the emergency department: establishing a program and addressing the challenges.

Utilization of magnetic resonance imaging (MRI) in the pediatric emergency room or urgent care setting for abdominopelvic indications has been increasing. The creation and implementation of rapid urgent MRI programs can have various challenges. The purpose of this article is to describe a framework for the creation of a rapid urgent abdominopelvic MRI program in the pediatric emergency room setting.

Implementation of standardized electronic documentation of goals of care discussions to improve cancer care.

11127 Background: Early documentation of physician-led goals of care (GOC) discussions is important to providing comprehensive and individualized quality care to cancer patients as it can provide all members of the patient care team with a context for the type of care each patient wishes to receive prior to and at end of life. The electronic medical record (EMR) should provide easy access to these conversations to seamlessly integrate outpatient, emergency room and inpatient care of cancer patients. Methods: The institution-wide initiative was introduced via presentations and emails between 8/2021 and 11/2021 to all Moores Cancer Center faculty at UC San Diego Health. A SmartPhrase was created in our EMR Epic as the intervention, including critical components of a GOC discussion: people present during discussion, goal of cancer-directed treatment, anticipated cancer trajectory shared with the patient, and patient’s health care agent. The SmartPhrase was radiolabeled to be easily searchable for any clinician accessing the patient’s chart. Physician documentation was tracked for the purposes of achieving a group goal with a target of greater than 50% documentation of GOC discussions within 30 days of the first day of the first cycle of chemotherapy. Prior to physician education, 4% of patients had a GOC note using a searchable SmartPhrase. In 12/2021, we began sending individual emails to physicians to remind them of eligible patients. Results: By 1/2022, after education, 50% of physicians ordering chemotherapy had used the GOC SmartPhrase and 29% of patients initiating chemotherapy had a GOC note using the SmartPhrase. After initiation of monthly reminder emails, documentation increased to 51% by 10/2022. An increased use of Advanced Care Planning billing codes was also noted. Conclusions: Implementation of an initiative to standardize electronic documentation of GOC conversations improved early documentation of these vital conversations. Radiolabeling of the SmartPhrase made it easily accessible to all members of a patient’s care team.

Clinical outcomes in patients with diabetes and stress hyperglycemia that developed SARS-CoV-2 infection

Diabetes and stress hyperglycemia have been related with poorer clinical outcomes in patients infected by SARS-CoV-2 and at risk for severe disease. To evaluate clinical outcomes in three groups of patients (with diabetes, without diabetes and with stress hyperglycemia) with SARS-CoV-2 infection. A retrospective cohort study was conducted in Cali (Colombia). We included patients 18 years old or older with a diagnosis of SARS-CoV-2 infection, managed in the emergency room, hospitalization, or intensive care unit between March 2020 and December 2021. Immunocompromised patients and pregnant women were excluded. Patients were classified into three groups: without diabetes, with diabetes, and with stress hyperglycemia. A comparison between the groups was performed. A total of 945 patients were included (59.6% without diabetes, 27% with diabetes, and 13.4% with stress hyperglycemia). Fifty-five-point three percent required intensive care unit management, with a higher need in patients with stress hyperglycemia (89.8%) and diabetes (67.1%), with no difference between these groups (p = 0.249). We identified a higher probability of death in the group with stress hyperglycemia versus the one without diabetes (adjusted OR = 8.12; 95% CI: 5.12-12.88; p < 0.01). Frequency of acute respiratory distress syndrome, need for invasive mechanical ventilation, use of vasopressors and inotropes, need for de novo renal replacement therapy, and mortality was higher in patients with metabolic alterations (diabetes and stress hyperglycemia). Diabetes and stress hyperglycemia were associated with worse clinical outcomes and mortality in patients with COVID-19. These patients should be identified early and considered them high risk at the COVID-19 diagnosis to mitigate adverse outcomes.

Differences in mortality between patients with cardiogenic shock due to STEMI treated with PCI vs thrombolysis

Abstract Funding Acknowledgements None. Introduction STEMI is complicated with cardiogenic shock (CS) in approximately 5-10% of cases and mortality is about 40% at 30-day and 50% at 1 year worldwide. In Mexico the incidence of CS in STEMI that received revascularization therapy (PCI or thrombolysis) is between 4.4-4.8%. In our country, pharmacoinvasive strategy (PIs) is the preferred modality due to the lack of PCI centers and demographics. Purpose To demonstrate differences in total ischemia time and 30-day in-hospital mortality in patients treated with PIs or PCI. Methods This was a retrospective observational study of patients that arrived to the emergency room and coronary care unit of the National Institute of Cardiology from January 2018 to March 2023 with CS due to STEMI at presentation, who received reperfusion therapy (PCI or PIs) during the first 12 hours of symptom onset. Results We included 61 patients with CS due to STEMI at presentation, 60.7% received PIs and 39.3% underwent PCI. The prevalence of type 2 diabetes was 38%, hypertension was 28% and obesity was 10% with no significant differences between groups, however the presence of CKD differed significantly with approximately 3% in PCI group versus 0% in PIs group. 21% were smokers and 13% previous smokers. Only 8 patients (13.1%) had a previous MI, 5 patients (8.2%) had previous angioplasty and 4 patients (6.6%) had previous HF. The first medical contact (FMC) occurred at a median of 120 minutes (IQR 75-240 min) overall. For patients undergoing PIs, the FMC was 120 minutes (IQR 70-185 min), whereas for those undergoing PCI, it was 185 minutes (IQR 87-300 min). The total ischemia time was 270 minutes (IQR 180-470 min) overall, with a median of 229 minutes (IQR 163-405 min) for PIs and 396 minutes (IQR 267-592 min) for PCI. The 30-day in-hospital mortality rate was 27.9% overall, significantly lower at 18.9% in the PIs group compared to 41.7% in the PCI group (p=0.01). The average length of hospital stay was 8 days for the PIs population, slightly longer than the 6.5 days observed in the PCI group (p=0.09). Conclusion In this real-world retrospective analysis conducted in our center in a middle-income country showed that PIs impacted positively in 30-day in-hospital mortality of patients who arrived with CS due to STEMI at presentation compared to those that underwent PCI. This effect seems to be secondary to shorter ischemic times since symptom onset due to the use of a prompt reperfusion therapy.

The chain of survival and rehabilitation for sepsis: concepts and proposals for healthcare trajectory optimization.

This article describes the structures and processes involved in healthcare delivery for sepsis, from the prehospital setting until rehabilitation. Quality improvement initiatives in sepsis may reduce both morbidity and mortality. Positive outcomes are more likely when the following steps are optimized: early recognition, severity assessment, prehospital emergency medical system activation when available, early therapy (antimicrobials and hemodynamic optimization), early orientation to an adequate facility (emergency room, operating theater or intensive care unit), in-hospital organ failure resuscitation associated with source control, and finally a comprehensive rehabilitation program. Such a trajectory of care dedicated to sepsis amounts to a chain of survival and rehabilitation for sepsis. Implementation of this chain of survival and rehabilitation for sepsis requires full interconnection between each link. To date, despite regular international recommendations updates, the adherence to sepsis guidelines remains low leading to a considerable burden of the disease. Developing and optimizing such an integrated network could significantly reduce sepsis related mortality and morbidity.

COVID-19 Vaccination in Patients with Inborn Errors of Immunity Reduces Hospitalization and Critical Care Needs Related to COVID-19: a USIDNET Report

BackgroundThe CDC and ACIP recommend COVID-19 vaccination for patients with inborn errors of immunity (IEI). Not much is known about vaccine safety in IEI, and whether vaccination attenuates infection severity in IEI.ObjectiveTo estimate COVID-19 vaccination safety and examine effect on outcomes in patients with IEI.MethodsWe built a secure registry database in conjunction with the US Immunodeficiency Network to examine vaccination frequency and indicators of safety and effectiveness in IEI patients. The registry opened on January 1, 2022, and closed on August 19, 2022.ResultsPhysicians entered data on 1245 patients from 24 countries. The most common diagnoses were antibody deficiencies (63.7%). At least one COVID-19 vaccine was administered to 806 patients (64.7%), and 216 patients received vaccination prior to the development of COVID-19. The most common vaccines administered were mRNA-based (84.0%). Seventeen patients were reported to seek outpatient clinic or emergency room care for a vaccine-related complication, and one patient was hospitalized for symptomatic anemia. Eight hundred twenty-three patients (66.1%) experienced COVID-19 infection. Of these, 156 patients required hospitalization (19.0%), 47 required ICU care (5.7%), and 28 died (3.4%). Rates of hospitalization (9.3% versus 24.4%, p < 0.001), ICU admission (2.8% versus 7.6%, p = 0.013), and death (2.3% versus 4.3%, p = 0.202) in patients who had COVID-19 were lower in patients who received vaccination prior to infection. In adjusted logistic regression analysis, not having at least one COVID-19 vaccine significantly increased the odds of hospitalization and ICU admission.ConclusionVaccination for COVID-19 in the IEI population appears safe and attenuates COVID-19 severity.

Fluid therapy in ICU – A review

The most common indications of fluid resuscitation in critical care settings are severe hypovolemia, sepsis, trauma, burns, and perioperative fluid loss. Evaluation of intravascular volume status and the ability for identifying patients who might profit from volume expansion is vital. Traditional markers such as central venous pressure and pulmonary capillary wedge pressure have poor predictive value for fluid responsiveness. Dynamic indices such as pulse pressure variation, stroke volume variation, tidal volume challenge, and passive leg raise test are recommended to predict fluid responsiveness over static markers. The next perplexing part of fluid therapy is the choice of fluid resuscitation. The simplest answer is to provide crystalloids and avoid synthetic colloids (hydroxyethyl startch, gelatin, and dextran). Among the colloids, albumin has a role in certain clinical conditions in critical care settings. Between normal saline and buffered solutions, buffered solutions have the advantage of reducing acid–base disturbances, and chloride burden, and are likely to prevent renal failure. However, the advantage of buffered solutions did not consistently show up in large randomized controlled trials. Although administering fluids is a common therapeutic approach in critical care settings, administering fluids excessively has been linked to fatal outcomes. The resuscitation, optimization, stabilization, and evacuation concept describes the use of a dynamic fluid strategy to optimize benefits and prevent the negative effects of fluid overload. After receiving a patient in an emergency room or intensive care unit with hemodynamic instability, the first thing that comes to mind is whether or not the patient would benefit from fluid administration. How to predict fluid responsiveness? What type of fluids should be administered? When to stop administering fluids and start evacuation are vital questions confronted in day-to-day practice. In this article, we would like to discuss these issues and provide recommendations for current practices.

A Path to High-Value Gastric Cancer Surgery Care Delivery.

To evaluate the feasibility, safety, and effectiveness of a comprehensive regional program, including the Minimally Invasive Recovery and Empowerment Care (MIREC) pathway, that can significantly reduce hospital stays after laparoscopic gastrectomy without increasing adverse events. Cost-effectiveness and improving patient outcomes are crucial in providing quality gastric cancer care worldwide. To compare the outcomes of gastric cancer surgery using 2 different models of care within an integrated healthcare system from February 2012 to March 2023. The primary endpoint was the length of hospital stay. The secondary endpoints were the need for intensive care unit care, emergency room (ER) visits, readmission, reoperation, and death within 30 days after surgery. There were 553 patients, 167 in the pre-(February 2012-April 2016) and 386 in the post-MIREC period (May 2016-March 2023). Perioperative chemotherapy utilization increased from 31.7% to 76.4% (P < 0.0001). Laparoscopic gastrectomy increased from 17.4% to 97.7% (P < 0.0001). Length of hospitalization decreased from 7 to 2 days (P < 0.0001), with 32.1% and 88% of patients discharged home on postoperative day 1 and postoperative day 2, respectively. When comparing pre- and post-MIREC, intensive care unit utilization (10.8% vs. 2.9%, P < 0.0001), ER visits (34.7% vs. 19.7%, P = 0.0002), and readmission (18.6% vs. 11.1%, P = 0.019) at 30 days were also considerably lower. In addition, more patients received postoperative adjuvant chemotherapy (31.4% to 63.5%, P < 0.0001), and the time between gastrectomy and starting adjuvant chemotherapy was also less (49-41 days; P = 0.002). This comprehensive regional program, which encompasses regionalization care, laparoscopic approach, modern oncologic care, surgical subspecialization, and the MIREC pathway, can potentially improve gastric cancer surgery outcomes. These benefits include reduced hospital stays and lower complication rates. As such, this program can revolutionize how gastric cancer surgery is delivered, leading to a higher quality of care and increased value to patients.

Are radiographs overutilized in pediatric orthopaedic emergency room care?

BackgroundIt is estimated that $12.8 billion to $28.6 billion is wasted annually on unnecessary imaging studies and treatment in the United States. This is especially important to the pediatric population, which is unable to make decisions for themselves and vulnerable to radiation exposure. We hypothesized that a significant number of unnecessary radiographs are performed in the pediatric emergency department, leading to excessive time, cost, and radiation exposure to pediatric patients. MethodsWe retrospectively reviewed 406 patients who were evaluated in a pediatric emergency department (ED) for possible fracture at a single institution during the 2020 calendar year. Records were reviewed for demographics, history and physical exams, as well as the sequential order that radiographs were performed. All radiographs were evaluated by the senior author to determine if they resulted in a change in management. All data was recorded and analyzed by the senior author and our statistician using Student’s t-test. Results406 patient encounters were included. 2807 radiographs were deemed unnecessary, with an average of 6.9 radiographs per patient. $454,734 were spent on radiographs that ultimately did not change management. A total of 216 hours and 43 minutes were spent in the x-ray suite alone, for an average of 32 minutes per patient. The estimated amount of radiation exposure that did not change management was potentially as high as 69 millirem per patient. ConclusionsThere is an excessive amount of monetary waste, radiation exposure, and encounter time spent in pediatric orthopedic patients in the ED. There are several potential strategies to alleviate this problem, which we hope can be taken into consideration to help address this widespread healthcare issue.

Abstract P361: Health Behaviors, Healthcare Utilization and Social Determinants of Health Among Afro-Latin and Non-Hispanic Black Men at Risk for Hypertension: The CLIP Study

Background: Non-Hispanic Black (NHB) men experience cardiovascular disparities, including high prevalence of hypertension and high morbidity and mortality due to cardiovascular disease (CVD). Less is known about CVD risk among Afro-Latin (AL) men, who are an understudied population overall. The Hispanic/Latin population is the largest and fastest growing ethnic minority group in the United States, as well as one of the most heterogeneous. However, CVD in this population is often examined in aggregate, or by country of origin, and is most often compared to Non-Hispanic White individuals, not only limiting understanding of CVD risk but also potential avenues for intervention. Objective: To describe CVD risk, healthcare utilization and social determinants of health among a sample of AL and NHB men. Methods and Results: We present preliminary data from the Community-to-Clinic Linkage Program (CLIP) study, a community-based cluster randomized trial testing barbershop facilitation to prevent hypertension in normotensive Black men. The study is set in Staten Island (SI), New York City. Approximately 10% of SI residents identify as Black, of which ~ 90% live in 6 zip codes with the highest prevalence of hypertension in the borough. Within the cohort (N=243), AL men (N=88) and NHB men (N=155) had similar blood pressure, but AL men were younger and had lower BMI compared to NHB men, age mean (SD), 35.1 (11.8) years versus 39.2 (12.1) years, p=0.007, BMI 25.6 (4.2) versus 27.2 (5.2) BMI, p=0.01. While diet was similar, AL men had higher levels of weekly physical activity, 5662 (4927) minutes versus 3461 (2453) minutes among NHB men, p&lt;0.001. Both groups had a similar rate of smoking tobacco and there were no differences related to sleep quality or sleep duration. AL men were more likely to have seen a healthcare provider in the last 5 years compared to NHB men and used the emergency room for care more than NHB men, 70.5% versus 47.6%, p=0.02, and 20.4% versus 9.2%, p=0.02, respectively. More AL men delayed medical care because of costs in the last year than NHB men, 8.2% versus 2.3%, p=0.03. Fewer AL men reported having a primary care provider, 19.4% versus 29.3%, p=0.03 compared to NHB men. Both groups reported similar rates of depressive symptoms and social support, but NHB men had higher perceives stress (PSS-4 scores), 6.0 (2.9) versus 4.4 (3.4), p&lt;0.001 than AL men. More AL men were born abroad, 69.4% versus 96.6%, p&lt;0.001 than NHB men. Education attainment was similar between both groups; AL men were more likely to be employed full-time than NHB men, 57.1% versus 51.7%, p=0.04. Income data was limited as approximately a third of men declined to respond. Conclusion: Understanding CVD risk and patterns of healthcare utilization among Afro-Latin and Non-Hispanic Black men will help inform strategies for intervention to improve cardiovascular health and reduce CVD disparities.

Role of point of care ultrasound in management of deteriorating respiratory intensive care unit patients and its impact on outcome

BackgroundPoint of care ultrasonography (POCUS) is a real time examination that can be used in the emergency room and intensive care unit (ICU). It can provide low-cost modality in short period of time that can help the clinician in better management the ICU patients. The aim of the current work was to evaluate the impact of POCUS (focused heart, lung, IVC and Doppler lower limb) in improving the outcome of deteriorating patients in the respiratory intensive care unit (RICU), via narrowing differential diagnosis and earlier start of target therapy.MethodsThis prospective study included 126 deteriorated patients in the RICU. The POCUS was performed to all included patients, together with the indicated laboratory and radiological investigations (Chest x-ray, computerized tomography, and conventional echocardiography) to detect the agreement between POCUS and the gold standard techniques to assess the POCUS effectiveness. The impact of applying POCUS on the outcome of the studied patients was evaluated regarding ICU and in hospital length of stay and the 30-day mortality.ResultsThe included patients were 51 males (40.5%) and 75 females (59.5%) with a mean ±SD of age 45.4 ± 15.7 years. POCUS showed a good agreement with the gold standard techniques. There was significant improvement in outcome of the studied patients as regard ICU and in hospital stay with early using of POCUS examination but no significant difference in 30 days mortality rate of the studied patients.ConclusionPOCUS is an effective modality in the management of deteriorating patients in the RICU with a good impact on the patient outcome.

Three-PointUltrasonography for Confirmation of Endotracheal Tube Position in Children (TRUCE Study).

To investigate the diagnostic accuracy of three-point ultrasonography for confirmation of endotracheal tube (ETT) position among children undergoing endotracheal intubation (ETI) with chest radiograph as reference standard. This prospective observational study was conducted from January 2021 through December 2021 (12 mo) in the pediatric emergency room (PER) and pediatric intensive care unit (PICU), Division of Pediatric Critical Care, Advanced Pediatrics Centre (APC), Post-Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India. Children aged 3 mo to 12 y, undergoing ETI in PER or PICU were included. Three-point ultrasonography (suprasternal notch and bilateral anterior chest) was done following ETI for confirmation of correct ETT position. Chest radiograph was used as a reference standard. Interobserver agreement between two investigators (IG and SKA) (kappa statistic) was determined for three-point ultrasonography to confirm the correct ETT position. One hundred fifty-five children with median (IQR) age of 4.5 (1-7) y were enrolled; 60% (n = 94) were males. On neck ultrasound, bilaminar sign was present in 100% of children. On lung ultrasound, bilateral and unilateral pleural sliding were present in 97.4% and 2.6% children, respectively. Three-point ultrasonography identified the correct position of ETT in 97.4% children as compared to 83.2% on chest radiograph. Sensitivity of three-point ultrasonography to identify the correct position of ETT was 98%. The interobserver agreement between two examiners was 96.8% (kappa of 0.53, p = 0.000). Three-point ultrasonography is an effective, sensitive, safe, and reproducible bedside method for identification of correct placement of ETT in children admitted to PER and PICU.

A longitudinal study of rotating shift type and attention performance of acute and critical care nurses with chronotype as moderator variable.

To investigate whether chronotype is a moderator variable that also interacts with shift type and whether they jointly influence the attention performance of nurses working in acute and critical care units. We adopted a longitudinal research design focusing on nurses working rotating shifts in the emergency room and intensive care units at a medical center. A total of 40 complete samples were obtained. Data analysis was conducted using the generalized estimating equations in SAS 9.4. The mean (SD) age of the participants was 26.35 (2.12) years. After controlling for age, gender, and sleep duration, an interaction effect was discovered between a specific chronotype and shift type; that is, the interaction effect between chronotype and shift type was only significant when comparing late-types working the night shift with early- and intermediate-types working the night shift (B = -18.81, P = .011). The least squares means of the mean reaction time of the interaction effects between the 2 chronotype groups and the 3 shift types found that the mean reaction time of late-types working the night shift was 11.31ms (P = .044) slower compared with working the day shift. The chronotype is a moderator variable between shift type and mean reaction time, such that matching the chronotype of nurses in acute and critical care units with the appropriate shift type improved their mean reaction time. It is hoped that the results of this study could serve as a reference for acute and critical care nurses when scheduling their shifts.