Emergency Department Research Articles

Improving prehospital risk stratification using deep learning ECG interpretation in suspected acute coronary syndrome

Abstract Introduction Most patients presenting with chest pain in the Emergency Medical Services (EMS) setting are suspected of non-ST-elevation acute coronary syndrome (NSTE-ACS). Distinguishing true NSTE-ACS from non-cardiac chest pain based solely on the electrocardiogram (ECG) is challenging. Recent advances in artificial intelligence (AI) models for ECG interpretation show promising results. Purpose The aim of this study is to develop and validate a Convolutional Neural Network (CNN)-based model to diagnose NSTE-ACS within the prehospital ECG and to compare it to current prehospital available diagnostic tools. Methods For this study, a training/internal validation cohort (n= 4891) and external validation cohort (n= 754) were used, both consisting of suspected NSTE-ACS patients, and the first prehospital standard 12-lead ECG at presentation was extracted. A CNN (ECG-AI) was trained and validated to detect NSTE-ACS. The training/internal validation cohort was extracted from suspected NSTE-ACS patients presenting to the emergency department. The external validation cohort was extracted from a prehospital, prospective cohort study in which subjects were assessed by EMS paramedics. A validated prehospital clinical risk score (preHEART) was calculated, which includes manual on-site ECG analyses by EMS paramedic (ECG-EMS) and a point-of-care (POC) troponin assessment, and compared to ECG-AI in diagnosing NSTE-ACS. Results In the external validation cohort, 202 (27%) subjects were diagnosed with NSTE-ACS. ECG-AI had a better diagnostic performance than ECG-EMS (AUC 0.70 (0.66–0.74) vs. AUC 0.65 (0.61–0.70), p=0.045) for diagnosing NSTE-ACS. The overall diagnostic accuracy of preHEART was AUC 0.78 (0.74–0.82) and superior compared to ECG-AI (p= 0.001). Incorporating ECG-AI instead of ECG-EMS into preHEART led to a significant improvement in diagnostic performance (AUC 0.83 (0.79–0.86,p < 0.001)). Conclusion Integrating AI in prehospital ECG interpretation improves NSTE-ACS diagnosis. However, clinical risk scores still yield the best diagnostic performance in the prehospital setting and their accuracy could be further enhanced through AI.ROC prehospital diagnostic toolsROC preheart and preheart-AI

Comparing statistical forecasting methods for modelling respiratory virus healthcare demand

Abstract Background Emergency departments in the United Kingdom are under sustained pressure with rising demand for healthcare, gradually decreasing the functionality of the NHS. Forecasts can aid management in the allocation of appropriate healthcare supplies and staffing needs in advance of an expected surge, as well as allow stakeholders to assess most likely outcomes and potential worst-case scenarios. This is especially valuable during the seasonal waves of respiratory infections. Respiratory viruses are usually concentrated in a 6-8 week seasonal surge during the winter period, creating large pressure on the health system. Current forecast models’ performance depreciates significantly after 1 week. This analysis will forecast 6 weeks of respiratory health admissions, comparing traditional and newly emerging forecasting methods. Methods Using 20 years of English hospital admissions data, we evaluated both within season training models (2-20 weeks) and longer term seasonal models (1-10 years), to forecast 6 weeks of hospital admissions. Respiratory admissions were defined according to ARI/ILI ICD10 codes assigned in hospital, stratified by age and region. Models were iteratively constructed, trained and probabilistic forecasts were evaluated across the respiratory season of September to April using Weighted Interval Score. Averages of each model across iterations were generated for comparison. Results For non-seasonal models, shorter model training lengths created better forecast models for 6 weeks. For seasonal models, optimal training length varied across model complexity. Simple models performed best at forecasting 1 week, however performance deteriorated the most as the forecast window increased. Overall, the Prophet model performed best on average at forecasting 6 weeks across all scenarios. Conclusions Applying our framework for optimal model selection in forecasting analysis will help to inform better practice for future health demand modelling. Key messages • This analysis will inform better practice for future health demand forecasting 6 weeks in advance, allowing for preparation of resources for seasonal surges in healthcare demand. • This analysis suggests using models with modest levels of increased complexity over simpler models could significantly improve forecast performance in the short-medium term.

Hospital and one-year outcomes following a hypertensive urgency or emergency: a major challenge

Abstract Introduction Hypertension is an important issue, and recommendations are constantly evolving based on the latest research findings and directions. Hypertensive emergencies are defined as a severe elevation of blood pressure associated with organ damage. End organ damage was defined as the presence of one of the following findings: encephalopathy, ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, acute heart failure, acute coronary syndrome, or aortic dissection. Furthermore, malignant hypertension is a HE characterized by small artery fibrinoid necrosis in the kidney, retina and brain. All these definitions are confusing, but what about their evolution? Objective:The present study aims to analyze the mortality in the short and long term (12months), the survival of the hypertensive patients, the frequency of malignant hypertension and hypertensive retinopathy. Methods For this purpose, we conducted a prospective study including all patients who followed or were diagnosed with hypertension and admitted to the emergency department for hypertensive urgency/emergency, from January to March 2023; after that, we studied the evolution of these patients for one year until January 2024. Demographic data, disease history, blood pressure, clinical presentation on admission, target organ involvement, ophthalmological examination and evolution during hospitalization were studied. Statistical analysis was performed using SPSS software. Preeclampsia and chronic renal failure were excluded.Result: Our work brought together 300 patients, mainly female, with an average age of 63.4. One hundred fifteen were admitted for HE and 185 for HU. The most common presenting symptoms at admission were headache, focal neurologic deficit and dyspnea. Malignant hypertension was identified in 9 patients based on optical coherence tomography angiography by identifying subclinical microvascular damage, and investigation is still in progress searching for hypertensive retinopathy grade III-IV Keith-Wagner in the second group. Patients were mainly hospitalized for hypertensive emergencies. Regarding their therapeutic management, except for the acute lowering of blood pressure in stroke, there was no consensus initially; ideally was to determine which organs are affected to assess the need for specific intervention other than lowering blood pressure. Overall, 49 had died from HE n=44/115(vs n=5/185 for HU). Of these, 33 have died at the Hospital (mortality was higher for HE and attributable to neurovascular emergencies rather than cardiovascular emergencies) and ten at 12 months. Conclusion Properly managing patients who come to the Emergency Department for BP elevation faces many difficulties. Can we still talk about hypertensive emergencies/urgency, discuss retinal lesions, and the importance of hypertension monitoring? However, all those definitions can be potentially life-threatening; these results justify better follow-up and treatment for these patients.

A Case of A Middle-Aged Woman with Cor Triatriatum Dexter and Sick Sinus Syndrome: Comprehensive Cardiovascular Evaluation

This case study discusses a 51-year-old woman with a complex cardiovascular condition, cor triatriatum dexter, complicated by sick sinus syndrome. The patient presented with a history of bradycardia, dizziness, and amaurosis, and was admitted to the emergency department due to numbness in her right limb. Diagnostic examinations, including computed tomography (CT) and cardiac color-ultrasound screening, revealed cor triatriatum dexter along with an enlarged left atrium and ventricle. Additional findings included the absence of the inferior vena cava and polysplenic syndrome. Based on these results, double-chamber pacemaker surgery was recommended, supported by cardiac and thoracic-abdominal CT angiography and three-dimensional vascular reconstruction. This case underscores the importance of comprehensive examinations in identifying associated cardiovascular abnormalities.

Evolving atrial fibrillation (AF) care in New Zealand (NZ): a nurse specialist-led clinic aiming to improve standardisation, equity, cost-effectiveness, and lifestyle modification in AF management

Abstract Background Management of atrial fibrillation (AF) in NZ is challenging and variable between regions. NZ has a diverse population with Māori and Pacific ethnic groups, in particular, facing significant difficulties with access to care and inequity in treatment. The integration of nurse specialists into the care of patients with AF is increasingly recognised and discussed in AF management, including the European Society of Cardiology (ESC) guidelines. This approach also allows emphasis on managing lifestyle factors, pivotal contributing factors in disease burden Objective This study assesses the efficacy of a nurse specialist-led AF clinic in a large regional centre in New Zealand. We look specifically at the standardisation of care, lifestyle management, the impact on health equity in managing AF, and the cost-effectiveness of these strategies. Methods A retrospective analysis of the first year of the clinic’s establishment was conducted reviewing the outcomes, attendance, and adherence to management guidelines. The clinic is running three days per week to follow up those presenting to the Emergency Department with a primary diagnosis of AF. After discharge, appointments are available within 48-72 hours of presentation. The clinics efficacy and ability to serve wider NZ populations will also be presented alongside a recently-published, similar initiative in Christchurch, NZ. Results Over the first year, 247 appointments were made (Median age 66, interquartile range 58-76, 48% male, 75% NZ European). 168 patients were established on a rhythm control strategy, with 20 directly referred for ablation, 26 receiving cardioversions, and the remainder established on anti-arrhythmic medication strategies. Lifestyle modifications were addressed with majority of these patients. Demographic data also highlighted once more, a need to focus on equity with only 17.4% of appointments attended by Māori and Pacific patients, lower than would be expected given population data and relative disease burden. Conclusions The Nurse Specialist-led AF clinic shows promising outcomes and is a positive step forward in AF management in this region of NZ. Incorporating ESC guidelines with emphasis on lifestyle factors and including rhythm control strategies to good effect. This clinic brings international standards to a local stage and throws a focus on our unique healthcare needs and an emphasis on equitable delivery of care. This clinic is scalable, effective, and an inclusive approach to AF care.

A patient with unexplained hypoxemia after a fall diagnosed with platypnea orthodeoxia syndrome: approaches to resolving discrepancies between level of hypoxemia and clinical presentation.

Platypnea orthodeoxia syndrome (POS) is a rare cause of hypoxemia. Diagnosis of POS is challenging, requiring a high index of clinical suspicion, special investigations, and collaboration with multiple specialists. We describe an 86-yr-old male who presented to the emergency department with hip pain after a witnessed fall. He was noted to be hypoxemic at presentation with a peripheral oxygen saturation (SpO2) of 84% on room air, with an inadequate increase in oxygenation after administration of a fractional concentration of inspired oxygen (FIO2) of 1.00. A chest radiograph, computed tomography pulmonary angiogram, and Doppler ultrasound of the liver were unremarkable. In the supine position with an FIO2 of 0.65, his SpO2 and arterial partial pressure of oxygen (PaO2) (96% and 74mm Hg, respectively) increased significantly relative to the seated position (84% and 50mm Hg, respectively). Contrast transthoracic echocardiography (TTE) showed a large patent foramen ovale (PFO) with right-to-left shunt. Transthoracic echocardiography showed rotation of the patient's heart, enabling direct alignment of the inferior vena cava with the PFO, creating a large anatomical right-to-left shunt in the seated position. Right heart catheterization confirmed a large PFO with normal right-sided heart pressures. He was treated with a septal occlusion and his SpO2 in the seated position improved immediately. The patient was discharged home without requiring supplemental oxygen. Platypnea orthodeoxia syndrome is a rare presentation of hypoxemia. Positional changes in oxygenation are the cardinal feature of POS. Discordance between lung imaging and the severity of hypoxemia should prompt investigation for an intracardiac shunt, which can occur in POS even in the absence of increased right-sided heart pressures. Either contrast TTE or transesophageal echocardiography is necessary to make this diagnosis.

Unexpected manifestations of a perforated gallbladder: a case study and imaging assessment

Gallbladder perforation can be caused by delayed diagnosis of cholecystitis and, more rarely, trauma. Despite advancements in imaging modalities, diagnosis is often challenging, leading to further delays in diagnosis and increased morbidity and mortality. In this report, we discuss a 49-year-old Caucasian male who presented to the emergency department with severe, out-of-proportion pain and fevers following a mechanical fall. Blood tests were unremarkable, but portal venous contrast-enhanced CT of the abdomen-pelvis showed a thickened gallbladder with perihepatic fluids, and CT of the chest revealed bilateral lobar atelectasis. After a period of conservative management, the patient eventually underwent diagnostic laparoscopy, revealing a perforated gallbladder with biliary peritonitis.

Remote monitoring and prioritisation for patients awaiting transcatheter aortic valve implantation safely mitigates longer waiting times

Abstract Background • The UK National Health Service (NHS) faces an unprecedented backlog of over 400,000 patients awaiting critical cardiac procedures, incurring thousands of excess deaths (1). • Longer waiting times to transcatheter aortic valve implantation (TAVI) can increase rates of unplanned hospitalisation and death (2). • Remote patient monitoring (RPM) can improve cardiovascular clinical outcomes (3), but its effectiveness in detecting and managing TAVI waiting list deterioration is untested. Purpose 1. Measure the systemic increase in waiting time to TAVI 2. Determine if RPM and prioritisation: · Is acceptable to patients · Detects clinical deterioration · Mitigates the expected increase in adverse events associated with longer waiting times · Does not unfairly disadvantage patients who are not prioritised Methods • We performed an observational cohort study including all patients awaiting TAVI at one UK regional centre between 24th April and 15th November 2023. • Patients were supported to complete an online or telephone-based weekly symptom questionnaire. • Responses were monitored by non-specialist nurses staffing a 'hub', with rule-based escalation to the TAVI team, who could prioritise treatment (Figure 1). • A historical control cohort who did not receive RPM was identified, as sequential unselected patients on the TAVI waiting list in reverse order, from 24th April 2023 to 1st January 2023. This cohort was propensity score-matched to adjust for age, sex, ethnicity and comorbidities. • Waiting time was defined as the date difference between a patient being placed on the waiting list and TAVI completion. • We defined patient acceptability as >80% engagement with at least one symptom questionnaire. • Sensitivity was calculated as the percentage of escalations to the TAVI Consultant resulting in prioritisation. • Kaplan-Meier survival analysis was performed for the primary endpoint of adverse events, defined as emergency department presentation, unplanned hospitalisation or death. Results • The median waiting time to TAVI increased by one month (104 days versus 75 days, p<0.001). • There was 99% (200/202) engagement with RPM • Despite the increased waiting time, there was no significant difference in rate of adverse events between the propensity score-matched RPM and historical control groups (12.5% versus 13.7%, p=0.86) (Figure 2) • 87% (27/31) of escalations to the TAVI Consultant resulted in treatment prioritisation • There was a non-significant difference in median waiting time between prioritised and non-prioritised patients during the study period, but with no clinical consequence to the delay (97 versus 120 days, p=0.16). Conclusions • An RPM pathway can detect patient deterioration on TAVI waiting lists with high sensitivity • RPM-based prioritisation for patients awaiting TAVI can mitigate the increased risk of adverse events associated with longer waiting times, without unfairly disadvantaging non-prioritised patients.Figure 1.RPM pathwayFigure 2

Empowering health literacy: Turkiye’s Health Literacy Action Plan 2022-2026

Abstract Issue/Problem The ‘Health Literacy Action Plan 2022-2026’ of the Turkish Ministry of Health addresses the critical public health issue of limited health literacy, leading to increased hospital admissions, inappropriate emergency department use, and poor health outcomes. This underscores a significant challenge in individual health self-management and higher healthcare expenditure within the country. Description of the Problem The Health Literacy Action Plan aims to tackle disparities in health literacy levels among people. It employs customized teaching schemes, digital communication, and inclusive healthcare practices to reach every demographic group. The plan seeks to enhance health knowledge and empowerment among Turkish people by increasing access to medical information, simplifying clinician instructions, and promoting closer communication between patients and healthcare professionals. Results Comparative evaluation of nationwide surveys conducted in 2017 and 2023 with 15,000 participants shows remarkable improvements. Despite delays due to the pandemic, the action plan led to a notable increase in adequate health literacy levels from 31.9% in 2017 to 46.1% in 2023. Additionally, significant improvements were observed in ailment prevention and health promotion, with health literacy levels in disease prevention increasing from 28.4% to 45.7%. Lessons The Health Literacy Action Plan plays a crucial role in developing and implementing multifaceted public health strategies based on data and stakeholder participation. These interventions, requiring continuous monitoring and adjustment, are essential steps toward achieving high-level health literacy. Key messages • Strategic health literacy interventions are essential for improving health outcomes and optimizing the use of public resources. • Evidence-based interventions and ongoing evaluation are key to promoting health literacy.

Knowledge on Foot Ulcer among Diabetic Patients: A Cross-Sectional Study in a Public Hospital

Background: The main purpose of the study was the knowledge of foot ulcer among diabetic patients, a cross-sectional study in a public hospital. The number of patients who suffering from Diabetes mellitus is rapidly increasing in our country. Methods: The study was an analytical cross-sectional study. The study population consisted of males and females who were suffering from diabetes mellitus in the emergency department of Fatima General Hospital. This study was conducted in the Emergency department of Fatima General Hospital. The sample size was 119,8 weeks from October 2017 to November 2017. Data was collected through a semi-structured questionnaire. the interview was focused on obtaining information about the higher-risk foot ulcers in Diabetic patients in Dhaka. Results: The depth of knowledge of foot ulcers among the diabetic patient was poor. Employed patients were more knowledgeable than the unemployed. Also, smokers & female patients were more knowledgeable than the rest. EWMCJ Vol. 12, No. 1&2, January-July 2024: 34-42

Artificial intelligence to detect pulmonary congestion on chest computed tomography in consecutive dyspnoeic patients

Abstract Background Pulmonary congestion is a hallmark of acute heart failure (AHF), and essential for the diagnosis, treatment, and risk stratification. We have previously shown that a low-dose chest CT has four times greater odds than chest radiographs to detect pulmonary congestion. However, implementation is limited by shortage of radiologists. We hypothesized that artificial intelligence (AI) can detect pulmonary congestion on chest CT and aimed to develop and validate an AI-algorithm to detect pulmonary congestion on chest CT. Methods We extracted all chest CT-scans ordered acutely (N= 4840 unique patients) by medical departments at X Hospital from 2016-2021. A random subset of these CT-scans (N= 2187) was used to develop an AI-algorithm to detect pulmonary congestion, using the radiology reports as reference. The remaining subset (N= 1094) was used for internal validation. We externally validated the AI-algorithm in a different cohort (X), comprising of 236 consecutive dyspnoeic patients admitted to the emergency department, all examined with a low-dose, non-contrast chest CT (LDCT). The primary outcome was pulmonary congestion adjudicated by clinical on-call radiologists with access to the medical record, and two independent, blinded research thoracic radiologists. The default AHF thresholds for the optimal cut-off, rule-in threshold and rule-out threshold was established from the internal validation. Results Of 236 patients (median age 74 years, 57% male), 62 (26%), 64 (27%) and 60 (26%) had pulmonary congestion on LDCT evaluated by the on-call radiologists and the two thoracic research radiologists, respectively. The AI-algorithm included ten discriminating features of pulmonary congestion, and the results demonstrate an AUC of 0.95 [95%CI: 0.93-0.98] to predict pulmonary congestion by the on-call radiologists. The results were confirmed by the two expert research radiologists, with an AUC of 0.91 [95%CI: 0.88-0.95] and 0.94 [95%CI: 0.90-0.97], respectively. The sensitivity and specificity of the AI-default threshold was 89% [95%CI: 78-95%] and 89% [95%CI: 83-93%], respectively. The rule-in threshold demonstrated a sensitivity of 97% [95%CI: 86-100%] and the rule-out threshold had a specificity of 96% [95%CI: 92-98%], Figure 1. Conclusion We developed and validated a novel AI-algorithm with promising potential for the rapid automatic detection of pulmonary congestion as the underlying cause of dyspnoea in consecutive acute patients.

Characteristics, clinical care, and outcomes of sepsis among patients boarding in the emergency department.

Patients who first meet clinical criteria for sepsis while boarding in the emergency department (ED) may not receive optimal sepsis care. Assess the association between ED boarding status and sepsis quality of care and outcomes. We conducted a retrospective cohort study of adult patients admitted to a large academic hospital from July 2021 to October 2023 who had clinical features consistent with sepsis present while physically in the ED. We compared outcomes for patients who experienced time zero (T-0; the time clinical features of sepsis were first present) while boarding in the ED (physically in the ED but admitted to a different service) to those experiencing T-0 while still under the care of the ED provider team. We used logistic regression to estimate the association between ED boarding status at T-0 and compliance with the US Centers for Medicare & Medicaid Services (CMS) Severe Sepsis and Septic Shock: Management Bundle (SEP-1) core measure, individual bundle element compliance, and hospital mortality adjusting for prespecified covariates. In a subgroup analysis among patients who had not already received antibiotics before T-0, we conducted a Cox proportional hazards model to estimate the association between boarding status on time-to-antibiotics. Among 4795 patients meeting a clinical definition of sepsis in the ED, 422 (8.8%) experienced T-0 as ED boarders. These patients were similar in age, sex, and comorbidities compared with patients experiencing T-0 while still under ED care. Fewer patients with T-0 as an ED boarder received SEP-1 compliant care (25% vs. 38%, p < .001), including a lower proportion of fluid resuscitation (15% vs. 26%, p = .004) and lactate assessment (62% vs. 94%, p < .001). Overall, more patients in the ED boarder group received antibiotics within 3 hours, but one-third of patients had already received antibiotics prior to T-0. Among patients who had not already received antibiotics prior to T-0, experiencing T-0 as an ED boarder was associated with a decreased likelihood of receiving antibiotics (hazard ratio [HR]: 0.67 [95% confidence interval [CI], 0.54-0.84]) and longer time to antibiotics from T-0 (142 min vs. 100 min, p = .007). Sepsis patients experiencing T-0 as a boarder in the ED have a lower likelihood of receiving SEP-1 compliant care compared to patients who experience T-0 while still under ED care.

Clinical impact of the implementation of monocyte distribution width (MDW) measurement on time to anti-infective administration in sepsis patients in the emergency department: a before/after cohort study

BackgroundTimely recognition of sepsis in emergency department (ED) is challenging. We evaluated the impact of implementing the biomarker monocyte distribution width (MDW) at bedside, on the time to anti-infective administration.MethodsWe conducted a before-and-after cohort study in the ED of an academic hospital in Paris, to compare sepsis patients care and outcomes, before and after the implementation of point of care (POC) MDW measurement in the ED. During post-implementation period (period-2), MDW was measured with complete blood count by ED nurses with results given in 2 min: if above 21.5 units, ED physicians were asked to consider sepsis and to start an anti-infectious as soon as possible. Primary endpoint was time to anti-infectious administration (TTA) from ED arrival, and secondary endpoints were TTA from sepsis onset (TTAS), length of stay, mortality, and hospitalization rates.ResultsIn total, 255 patients (period-1) and 180 patients (period-2) with sepsis were included. The TTA was 5.4 h (3.5–7.7) period-1 and 4.9 h (IQR 2.5–7.1) in period-2 (p = 0.06). MDW implementation significantly reduced the median TTAS from to 3.7 h (IQR 1.5–5.8) in period-1, to 2.2 h (IQR 0.5–4.5) in period-2 (p < 0.001). Mortality rates remained similar between the two periods (18% vs. 16% respectively, p = 0.4), as did hospitalization rates (93% vs. 91%, p = 0.4) and ED length of stay (7.2 h (5.3–9.8) vs 7.0 (5.4–9.4), p = 0.7).ConclusionImplementing POC MDW measurement in the ED protocols enhances the timeliness of anti-infective administration from sepsis onset, meeting current sepsis management guidelines.

Prospective and External Validation of Machine Learning Models for Short- and Long-Term Mortality in Acutely Admitted Patients Using Blood Tests

Background: Predicting mortality in emergency departments (EDs) using machine learning models presents challenges, particularly in balancing simplicity with performance. This study aims to develop models that are both simple and effective for predicting short- and long-term mortality in ED patients. Our approach uses a minimal set of variables derived from one single blood sample obtained at admission. Methods: Data from three cohorts at two large Danish university hospitals were analyzed, including one retrospective and two prospective cohorts where prognostic models were applied to predict individual mortality risk, spanning the years 2013–2022. Routine biochemistry analyzed in blood samples collected at admission was the primary data source for the prediction models. The outcomes were mortality at 10, 30, 90, and 365 days after admission to the ED. The models were developed using Light Gradient Boosting Machines. The evaluation of mortality predictions involved metrics such as Area Under the Receiver Operating Characteristic Curve (AUC), sensitivity, specificity, negative predictive values, positive predictive values, and Matthews correlation coefficient (MCC). Results: A total of 43,648 unique patients with 65,484 admissions were analyzed. The models showed high accuracy, with very good to excellent AUC values between 0.87 and 0.93 across different time intervals. Conclusions: This study demonstrates that a single assessment of routine clinical biochemistry upon admission can serve as a powerful predictor for both short-term and long-term mortality in ED admissions.

Long term care-acute system integration and transformation: Innovations in models of care.

The article discusses innovations in integrating Long-Term Care (LTC) and acute systems, focusing on Humber River Health's (HRH) model. Older adults in LTC homes are vulnerable to avoidable Emergency Department (ED) visits due to frailty and medical complexity. HRH developed an integrated care model centred on LTC Remote Monitoring (RM) with LTC partners, leveraging nurse-led care models, digital tools, and virtual care hub to reduce avoidable ED transfers. Key components include the PREVIEW-ED© tool for early detection of clinical deterioration, LTC+ Hub and LTC++ Diagnostic Imaging and Transportation, supporting improved access to healthcare services. The program aligns with the Quintuple Aim, emphasizing patient and provider experiences, population health, cost reduction, and health equity. Results show significant reductions in ED visits, hospital lengths of stay, and associated costs, while enhancing resident and provider experiences. The LTC RM model is positioned as a scalable solution for system transformation in integrated care.

Knowledge of Palliative Care in Men and Women Diagnosed With Metastatic Breast Cancer.

The purpose of this study was to evaluate knowledge of Palliative Care (PC) and the impact of systemic and patient-related factors on the use of PC in a diverse population of men and women diagnosed with metastatic breast cancer. A telephone administered survey was used with patients receiving treatment at a Cancer Center in an urban area of the Northeast US. Descriptive statistics and chi square analysis were used. Of the 101 participants, 44% had no knowledge of PC and only 21.78% indicated that they were receiving palliative care. Participants who reported being followed by palliative care were less likely to have been treated in the emergency department in the past year (P = 0.003) or to have been hospitalized (P = 0.042). However, when asked about symptom burden, using the Edmonton Symptom Assessment Scale, patients who reported being followed by PC were more likely to report severe pain as compared to patients not receiving PC (P < 0.001). There were no associations found between race/ethnicity or social determinants of health and knowledge of PC or receipt of services. This sample of men and women diagnosed with metastatic breast cancer and being treated in a Cancer Center had limited knowledge and exposure to Palliative Care services across race and ethnicity. While no specific disparity was noted, the utilization of PC was low. Whether a function of a lack of referrals or patient preference, an effort should be made to increase PC referrals for all patients diagnosed with cancer.

Fostering Nurses’ Support in the Workplace: Addressing Job Burnout Among Malaysian Medical Doctors Working in Public Hospitals

Job burnout in employees is caused by individual factors, including demographic characteristics and nurses’ support. This study analyzed the relationship between nurses’ support and job burnout among medical doctors in Malaysian public hospitals. This research was a correlational study with a cross-sectional design. The research sample was 471 employees, using the non-probability sampling method with the purposive and quota sampling techniques. Data collection used the Abbreviated Maslach Burnout Inventory (aMBI) and nurses’ support items. The data in this study were analyzed using the Statistical Package Social Science (SPSS) and Partial Least Squares Structural Equation Modelling (PLS-SEM) software. Findings suggest that 77 medical doctors who participated in the study were from Hospital Pulau Pinang, from the Emergency Department, mostly female, ranging from 24-56 years old, single, and have an MBBS education level. The study assessed the measurement model’s loading, average variance extracted (AVE), and composite reliability (CR) where the loadings were above 0.60. AVEs were greater than 0.50 and CRs were greater than 0.708. Additionally, the bootstrap BCI LL (-0.079) and UL (-0.002) for nurses’ support and job burnout were not straddled a 0 in between. Job burnout had a negative association with nurses’ support. In particular, nurses’ support towards medical doctors lowers their risk of job burnout, which has a substantial impact on medical doctors’ overall well-being. The findings indicated that medical doctors who had complete support from their nurses performed their jobs more efficiently, displayed good task performance, and experienced less job burnout.

The Role of GABA Receptors in Anesthesia and Sedation: An Updated Review.

GABA (γ-aminobutyric acid) receptors are constituents of many inhibitory synapses within the central nervous system. They are formed by 5 subunits out of 19 various subunits: α1-6, β1-3, γ1-3, δ, ε, θ, π, and ρ1-3. Two main subtypes of GABA receptors have been identified, namely GABAA and GABAB. The GABAA receptor (GABAAR) is formed by a variety of combinations of five subunits, although both α and β subunits must be included to produce a GABA-gated ion channel. Other subunits are γ, δ, ε, π, and ϴ. GABAAR has many isoforms, that dictate, among other properties, their differing affinities and conductance. Drugs acting on GABAAR form the cornerstone of anesthesia and sedation practice. Some such GABAAR agonists used in anesthesia practice are propofol, etomidate, methohexital, thiopental, isoflurane, sevoflurane, and desflurane. Ketamine, nitrous oxide, and xenon are not GABAR agonists and instead inhibit glutamate receptors-mainly NMDA receptors. Inspite of its many drawbacks such as pain in injection, quick and uncontrolled conversion from sedation to general anesthesia and dose-related cardiovascular depression, propofol remains the most popular GABAR agonist employed by anesthesia providers. In addition, being formulated in a lipid emulsion, contamination and bacterial growth is possible. Literature is rife with newer propofol formulations, aiming to address many of these drawbacks, and with some degree of success. A nonemulsion propofol formulation has been developed with cyclodextrins, which form inclusion complexes with drugs having lipophilic properties while maintaining aqueous solubility. Inhalational anesthetics are also GABA agonists. The binding sites are primarily located within α+/β- and β+/α- subunit interfaces, with residues in the α+/γ- interface. Isoflurane and sevoflurane might have slightly different binding sites providing unexpected degree of selectivity. Methoxyflurane has made a comeback in Europe for rapid provision of analgesia in the emergency departments. Penthrox (Galen, UK) is the special device designed for its administration. With better understanding of pharmacology of GABAAR agonists, newer sedative agents have been developed, which utilize "soft pharmacology," a term pertaining to agents that are rapidly metabolized into inactive metabolites after producing desired therapeutic effect(s). These newer "soft" GABAAR agonists have many properties of ideal sedative agents, as they can offer well-controlled, titratable activity and ultrashort action. Remimazolam, a modified midazolam and methoxycarbonyl-etomidate (MOC-etomidate), an ultrashort-acting etomidate analog are two such examples. Cyclopropyl methoxycarbonyl metomidate is another second-generation soft etomidate analog that has a greater potency and longer half-life than MOC-etomidate. Additionally, it might not cause adrenal axis suppression. Carboetomidate is another soft analog of etomidate with low affinity for 11β-hydroxylase and is, therefore, unlikely to have clinically significant adrenocortical suppressant effects. Alphaxalone, a GABAAR agonist, is recently formulated in combination with 7-sulfobutylether-β-cyclodextrin (SBECD), which has a low hypersensitivity profile.

Unexpected multiple sclerosis-like symptoms in a rheumatoid arthritis patient treated with Etanercept: A case report.

Although tumor necrosis factor (TNF) inhibitors are used to prevent autoimmune disease, but they can cause adverse effects. Multiple sclerosis syndrome is one of the rare complications following treatment with TNF inhibitor. We reported a case of rheumatoid arthritis with unfavorable outcome post Etanerecept therapy. Tumor necrosis factor (TNF) inhibitors are prescribed to treat various autoimmune diseases such as rheumatoid arthritis (RA). Etanercept, a human anti-TNF monoclonal antibody, is a therapeutic option in autoimmune and inflammatory diseases. One of the rare adverse effects of Etanercept is developing central nervous system and peripheral nervous system demyelination however, there is controversy in the cause of it. In this case, we presented a 35-year-old woman with multiple sclerosis (MS)-like symptoms due to taking Etanercept. She had a history of RA since the age of 18 years and was referred to the emergency department with signs and symptoms of para paresthesia, progressive paraparesis of both lower limbs, and urinary retention a year after Etanercept treatment. We discontinued the Etanercept and started Methylprednisolone and Rituximab. Rapid clinical improvement was noted and in the approximately 6-month follow-up, she did not exhibit any neurological worsening. So it is probable that the initiation of Etanercept triggered MS-like syndrome in these patients and healthcare practitioners should take heed of this adverse effect.

Brief psychodynamic psychotherapy for adolescents and their families in crisis: a pilot study

ABSTRACT The global rise in adolescent self-harm and suicidal behaviours has intensified the demand for mental health services in the UK. This has further strained already underfunded and understaffed resources, resulting in longer waiting times and increased emergency department visits among teenagers. To address the overwhelming need for effective community-based emergency support, a brief psychodynamic crisis therapeutic intervention was developed within a CAMHS adolescent crisis team, inspired by child psychotherapist Ruth Schmidt Neven’s work on time-limited psychotherapy with adolescents and their families. This 12-session intervention offers both individual therapy for the adolescent and sessions for their parents, along with regular family reviews. Two psychotherapists work closely together on each case – one with the young person, the other with the parents. The brief model views crises as opportunities for deeper understanding, moving beyond diagnostic and symptom-centred approaches, as well as standard risk management and safety-planning strategies, and underlines the centrality of parent involvement in adolescent crisis work. This paper outlines the intervention’s theoretical foundation, guiding principles, and practical design, and presents preliminary findings from a pilot study of 22 cases, run over two and a half years. Early results suggest broad potential for this psychodynamic crisis approach in various adolescent crises, and merit further investigation.