Emergency Department Research Articles

Closing gaps in emergency care

Abstract: Current socio, political, and economic events may disproportionately affect those who are identified as vulnerable, as well as their presentation to Canadian emergency departments. The housing crisis, food instability, and concurrent issues with mental health and addictions are a harsh reality for many of these individuals. The emergency department may not be suited to complex health and social issues, but it provides an essential safety net for the vulnerable who cannot access care through traditional primary care routes. Alternative, patient-centered solutions to the problem are necessary, and advanced practice nurses can be the key to appropriately organizing and delivering integrated care innovative models. Raising awareness and influencing public policy to drive meaningful social change and address alarming health inequities is an important consideration for nurses working in emergency departments.

Accuracy of the Quebec Pre-Hospital Triage Scale (EQTPT) in Predicting the Need for Trauma Team Activation: A Retrospective Administrative Data Study

Background: Trauma team activation at a Level 1 trauma centre In Quebec, Canada, is primarily at the emergency department’s staff discretion. Trauma teams may be activated prehospital, based on information provided by field paramedics or in the emergency department based on the patient’s condition on arrival. In this study, we examined over and undertriage rates based on present trauma team activation criteria. We also examined if trauma team activation, for those patients solely meeting pre-hospital major trauma criteria, would result in significant overactivation of the trauma team. Methods: This is a single-centre retrospective medical record review. Primary ambulance transport reports from May 15, 2018 to December 31, 2020, were screened to identify patients aged ≥16 years who met pre-hospital trauma triage criteria to bypass community hospitals to arrive directly at the Level 1 trauma centre. We examined pre-hospital triage criteria, trauma team involvement, Injury Severity Scores (ISS) and final disposition. Patients were evaluated for over and undertriage and rates were compared to the rates assuming all patients were to have a trauma team activation. We considered patients overtriaged if they had a full trauma team activation but had an ISS <12 and were discharged from the emergency department. Undertriage was defined as any patient with an ISS ³12 and did not have a trauma team activation. Results: Of the 371 patients who met study inclusion criteria, 123 (33.3%) did not meet trauma team activation criteria, while 214 (57.7%) had a trauma team activation. Of these, 49 patients (13.2%) were undertriaged and 31 patients (8.4%) were overtriaged and 25.8% of the major trauma patients (ISS ³ 12) were undertriaged. A trauma team activation for all meeting field triage criteria increased overtriage to 25.3% and brought undertriage rates to 0%, with statistically significant differences based on the Wilcoxon signed ranks test (p<0.05). Conclusions: In this study, undertriage rates were well above 5%. Trauma team activation, based on local field trauma triage criteria adapted from the CDC-ACSCOT field triage criteria, eliminates undertriage and keeps overtriage rates below 35%. This research suggests that field triage criteria accurately predict major trauma and the need for the involvement of the trauma team and that the condition of the trauma patient in the pre-hospital setting is accurately predicting the need for advanced trauma care

Characteristics and Antibiotic Treatment of Patients with Cellulitis in the Emergency Department

Background: Cellulitis is a common infection in Emergency Departments (EDs), and unclear diagnostics may lead to unnecessary treatment with broad-spectrum antibiotics. The aim of this study was to characterize patients with cellulitis admitted to the ED, describe the type and route of antibiotic treatment and compare the prognosis for cellulitis to that for other infections. Methods: This multicenter, cross-sectional study prospectively included adult patients admitted to the ED suspected of having an infection. Data were collected from medical records, and an expert panel assigned a final diagnosis to each patient. Only patients diagnosed with an infection were included in this study. Results: A total of 777 patients were included, of which 77 were diagnosed with cellulitis. Diabetes, obesity and prior cellulitis were associated with cellulitis with an OR of 2.01 [95% CI: 1.17–3.46], OR 2.66 [95% CI: 1.54–4.59] and OR 14.88 [95% CI: 7.88–28.08], respectively. The majority of the patients were treated, according to the regional guidelines, with narrow-spectrum antibiotics. Broad-spectrum antibiotics were rarely used. The patients with cellulitis were hospitalized for a shorter time compared to those with other infections, but 26% were readmitted within 30 days. The 30-day mortality of the patients with cellulitis was 3.9% and did not differ significantly from other infections.

Intravesical Tranexamic Acid for Patients Requiring Continuous Bladder Irrigation in the ED: A Non-Randomized Feasibility Study

Objectives Tranexamic Acid (TXA) is a well studied clot stabilizer that may have benefit when used intravesically prior to continuous bladder irrigation (CBI). This study determined the feasibility of conducting a randomized controlled trial using TXA intravesically in patients who present to the emergency department (ED). The study goals were to recruit 20 participants within a six-month time frame and have an 80% recruitment rate. Methods Potential participants were identified at triage if they presented with a complaint of hematuria or urinary retention and were over the age of eighteen. Informed consent was obtained if the patient needed CBI and met inclusion/exclusion criteria. If consented, TXA was instilled intravesically at the start of CBI treatment and the patient was followed until their CBI treatment was complete. Results A total of 14 (out of 18) participants were recruited over eight months. The mean age of participants was 74.5 +/- 7.4 years with only one of the 14 participants identifying as female. For resource management, the study was designed to include support from an on-call nurse. The on-call nurse was called seven out of fourteen times and came into hospital one time. Eight participants did not require hospital admission after the TXA intervention. The mean length of hospital stay for participants was 4.6+/-2.7 days. The mean ED length of stay was 8.1+/-4.9 hours. There were no reported adverse events. Conclusion The recruitment rate of 78% indicated that the study was acceptable to participants, but we were unable to meet our goal of recruiting 20 participants over six months. Study protocol was followed, and no adverse events were found.

The Incidence and Severity of Pediatric Injuries Sustained by Electric Bikes and Powered Scooters: The Experience of an Urban, Tertiary Pediatric Emergency Department.

This study aimed to describe the incidence and severity of electrical bicycle (E-bike)- and power scooter (P-scooter)-related injuries and their secular trends among pediatric patients presenting to a pediatric emergency department (ED). This retrospective cohort study of patients aged <18 years who sustained E-bike and P-scooter injuries was performed between 2018 and 2023. We explored trends of severe trauma cases, ED visits, hospitalizations, and surgical interventions. Severity of trauma was rated by either an injury severity score (ISS) of >15 or the patient's need for acute care as defined by intensive care unit (ICU) admission, direct disposition to the operating room, acute interventions performed in the trauma room, and in-hospital death. Of the 1466 pediatric patients who presented to our pediatric ED following P-scooter and E-bike injuries, 216 (14.7%) were hospitalized, with a median age of 14.0 years (interquartile range, 10.5-16.0 years) and male predominance (69.0%). The number of ED visits increased 3.5-fold by study closure, with a parallel increase in hospitalizations, surgical interventions, and severe trauma cases. The relative percentages of severe trauma cases were not significantly different over time. Among hospitalized patients, 3 patients (1.4%) died and 9 (4.1%) required rehabilitation care. The incidence and severity of E-bike and P-scooter injuries and fatalities continue to increase within the pediatric population. Current personal and road safety regulations are providing inadequate in preventing these injuries, highlighting an urgent need for revision and stricter enforcement.

Factors associated with vision loss in idiopathic intracranial hypertension patients with severe papilledema.

Our aim was to compare factors associated with poor versus good visual outcomes in idiopathic intracranial hypertension (IIH) patients with severe papilledema at initial presentation. Retrospective review of consecutive IIH patients (1/1/2013-6/10/2023) with severe papilledema (Frisén grade 4-5 and/or atrophy in at least one eye); Patients were divided into "poor visual outcome" (poor visual acuity and constricted visual field in at least one eye) and "good visual outcome" (good visual acuity and only mild visual field changes in both eyes) at >6 months for medically-treated patients and >3 months follow-up for surgically-treated patients. We included 134 IIH patients with severe papilledema (70 had poor and 64 had good visual outcomes). No significant differences existed for age, gender, race, hypertension, haemoglobin, or cerebrospinal fluid opening pressure. The poor-outcome group had significantly greater BMI (mean 39.2 vs 35.1 kg/m2, p = 0.004), and worse initial HVF-MD (-20.04 vs -5.81 dB, p < 0.0001). Poor-outcome patients saw more prior health-care providers (4.7 vs 2.4, p < 0.0001), with delayed neuro-ophthalmology encounters (58.5 vs 15.2 weeks, p = 0.001). 41.4% of poor-outcome patients were initially seen in outside emergency departments (ED) (vs 14.1% of good-outcome patients, p = 0.0005), while only 27.1% were seen by eye-care providers (vs 53.1% of good-outcome patients, p = 0.0027). No poor-outcome patients initially consulted our institution's ED vs 7.8% of good-outcome patients. Although patients with poor visual outcome did not seek medical care later than good outcome patients, they had delayed diagnosis/treatment because of prior outside ED visits andlack of prior eye-care provider evaluations, suggesting that early diagnosis and specialized management of papilledema is essential for patients with symptoms of intracranial hypertension.

Subconjunctival Hemorrhages Are Rare Among Infants With Cough and Gastrointestinal Conditions.

Subconjunctival hemorrhages (SCHs) are uncommon injuries in young children beyond the neonatal period and have been associated with abuse. In otherwise well infants, they are sometimes attributed to commonly observed symptoms that invoke Valsalva maneuvers, such as cough, vomiting, and constipation. Our study aims to ascertain the prevalence of SCH among children presenting to emergency care with cough, vomiting, and constipation. We conducted a cross-sectional secondary analysis of a prospectively collected dataset of children aged 1 month to 3 years presenting to a tertiary pediatric emergency department (ED). Children with and without SCH were identified at the time of their examination by ED providers. Children were assigned to Valsalva symptom groups of cough, vomiting, and/or constipation based on review of the ICD-10 codes associated with the ED encounter. Descriptive statistics and prevalence were calculated for each group. Chi-square testing of proportions was used to compare the prevalence of SCH based on the presence or absence of the 3 symptoms of interest. Four thousand seven hundred seventeen qualifying ED encounters were captured, with 2 total cases of SCH identified (0.4 per 1000). SCHs were uncommonly observed in patients with cough (0.5 per 1000), vomiting (0 per 1000), and constipation (0 per 1000). We found no significant differences in the prevalence of SCH based on the presence or absence of cough (P = 0.87), vomiting (P = 0.52), or constipation (P = 0.82). SCH is an uncommon finding in children under 3 years and is similarly uncommon among children with cough, vomiting, or constipation. It should not be attributed to uncomplicated presentations of cough, vomiting, or constipation, and alternative diagnoses, including abuse, should be carefully considered in the differential diagnosis of SCH.

Pediatric acetaminophen intoxication in Korea: characteristics and prognosis

Purpose: Acetaminophen overdose accounts for the largest proportion of pediatric poisoning reported in South Korea. We investigated the characteristics and prognosis of pediatric acetaminophen overdose.Methods: We retrospectively reviewed medical records of patients younger than 19 years with acetaminophen overdose who visited the emergency department (ED) of Pusan National University Children’s Hospital from January 2009 through December 2022. We investigated age, sex, dose, clinical findings, and treatment, and compared the differences in the variables according to the intentionality of ingestion and the presence of hepatotoxicity.Results: Among the 132,691 pediatric patients who visited the ED during the period, 555 did for drug intoxication, of whom 51 with acetaminophen overdose were included in this study. The overdose was intentional in 43 patients (the intentional group; median age, 15.4 years [interquartile range, 13.9-16.8]) and accidental in 8 patients (the accidental group; 7.7 years [2.3-15.4]). The mean ingested dose was higher in the intentional group than in the accidental group (170.3 ± 129.0 vs. 105.3 ± 37.5 mg/kg; P = 0.016). Hospitalization tended to be implemented more frequently in the intentional group (53.5% vs. 12.5%; P = 0.081). All patients with hepatotoxicity (n = 10) belonged to the same group, and showed a higher or longer median age (15.9 [14.6-17.1] vs. 13.8 years [13.7-16.4]; P = 0.030), mean ingested dose (13,230.0 ± 10,544.8 vs. 7,654.0 ± 6,752.3 mg; P = 0.043), mean time from ingestion to arrival at the ED (22.6 ± 23.4 vs. 5.5 ± 6.4 hours; P = 0.048), and frequency of hospitalization (80.0% vs. 39.0%; P = 0.048).Conclusion: It is necessary to track the occurrence of hepatotoxicity in patients who intentionally ingest acetaminophen.

Exploring Inpatient Unit Nurses’ Experience with Emergency Department Crowding, Access and Flow, and Associated Patient Outcomes

Background: Emergency department crowding and hospital access and flow are complex and long standing issues that negatively impact healthcare delivery. This study aims to address these issues through the perspectives of inpatient unit nurses. Strategies to alleviate ED crowding are supported by research exploring ED staff perspectives; however, a paucity of research exists addressing the perceptions of inpatient unit nurses and other key stakeholders. Methods: The research aims were addressed using qualitative method. Semi-structured virtual interviews were completed with eleven inpatient unit registered nurses from two hospital sites. A 17-question interview tool facilitated the collection of data. Results: Three main themes emerged from the data analysis. Inpatient unit nurses identified ED crowding, hospital access and flow, and site congestion as key areas of concern. In addition, the influence of understaffing was viewed as a contributor to ED crowding, resulting in negative outcomes for patient care. Conclusion: This study is the initial step to understanding different experiences, perceptions and knowledge on emergency department crowding and access and flow processes. Further research exploring diverse viewpoints on this topic is necessary given the interconnected organizational structure of healthcare today and how key stakeholders, outside of the emergency department, strongly influence access block and ED outflow.

Development and validation of an early acute kidney injury risk prediction model for patients with sepsis in emergency departments

In this study, we aimed to develop and validate a nomogram to predicting the risk of sepsis-associated acute kidney injury (SA-AKI) in patients admitted to emergency departments (EDs). We randomly divided a retrospective dataset of 391 patients with sepsis into a 294-person training cohort and a 97-person validation cohort, and developed three predictive models using multivariate logistic regression analysis and clinical insight. No difference was observed between the three models using the DeLong test and Model 3 was selected as the risk prediction model based on the principle of least inclusion indicators. The use of vasopressor drugs, patient age, platelet count, procalcitonin, and D-dimer levels were included. The training and validation cohorts had a consistency index of 0.832 and 0.866, respectively, indicating high accuracy and stability in predicting SA-AKI risk. The area under the receiver operating characteristic curve was 0.832, showing excellent discrimination. The calibration curves for the training and validation cohorts showed excellent calibration. The decision curve and clinical impact curve analyses showed that the net clinical benefit of using the nomogram was greatest over a probability threshold of 0.05–0.90. In addition, the model showed moderate validity in predicting the 30-day survival and the incidence of major adverse renal events within 30 days. The nomogram developed for SA-AKI risk assessment in patients in EDs showed good discriminability and clinical utility. It can provide a theoretical basis for emergency physicians to prevent SA-AKI.

SEPSIGN: early identification of sepsis signs in emergency department.

Because 20-30% of patients with sepsis deteriorate to critical illness, biomarkers that provide accurate early prognosis may identify which patients need more intensive treatment versus safe early discharge. The objective was to test the performance of sVEGFR2, suPAR and PCT, alone or combined with clinical signs and symptoms, for the prediction of clinical deterioration. This prospective observational study enrolled patients with suspected infection who met SIRS criteria without organ dysfunction (delta SOFA <2 from baseline) from 16 emergency departments. The primary endpoint was clinical deterioration (increased SOFA score ≥2 points, new or increased organ support, or death) within 72 hours of enrollment. Diagnosis and classification of infection status were adjudicated. 724 patients were enrolled, (54% men, median age 55 [38-70] y-o). Infection origin was abdominopelvic (21%), skin and soft tissues (17%), urinary (16%) and pulmonary (15%). 176 (24%) patients deteriorated, with a 28-day mortality of 1.4%. They had lower sVEGFR2 level (6.17 [5.00-7.40] vs 6.52 [5.40-7.84], p=0.024), higher circulating suPAR (5.25 [3.86-7.50] vs 4.18 [3.16-5.68], p<0.001) and higher PCT level (0.32 [0.08-1.80] vs 0.18 [0.05-0.98], p=0.004). suPAR demonstrated superior performance (AUC=0.65 [0.60-0.70]), compared to other biomarkers (PCT, AUC=0.57 [0.52-0.62] and sVEGFR2, AUC=0.58 [0.53-0.64]). Maximum accuracy was achieved from the combination of clinical information, sVEGFR2 and suPAR, yielding an AUC of 0.74 [0.69-0.78] and NPV 0.90 [0.88-0.94]. sVEGFR2 and suPAR were insufficiently accurate to rule out clinical deterioration. Panels of biomarkers will likely be needed to capture the heterogeneous mechanistic pathways involved in sepsis-related organ failure.

Patterns of Viral Pathogens Causing Upper Respiratory Tract Infections in Children Under 13 Years Old: A Retrospective Analysis

Background: Respiratory viral infections strain healthcare globally, accounting for 15% of encounters in the UAE. However, seasonal prevalence in the region remains unclear. This hospitalbased study aims to understand viral causes of upper respiratory tract infections (URTIs) in children under 13, focusing on influenza and RSV. Methods: We conducted a retrospective chart review at Hatta Hospital in Dubai, collecting data from pediatric patients under 13 years old with URTI diagnoses from 2022 to 2023. Nasopharyngeal aspirate samples were analyzed using a multiplex chain reaction (mPCR) assay to identify viral pathogens. Data were collected from the hospital’s emergency department, walk-in clinic, and admitted patients. Results: During the study period, 2714 samples were analyzed, with 1870 (69%) testing positive for any respiratory pathogen. Most infected individuals were males (56.7%), aged between 1 and 3 years (37.9%). Single viral infections were predominant (85.3%), with 27.3% attributed to Human Enterovirus/Rhinovirus, 26.6% to Influenza A, and 10.2% to respiratory syncytial virus (RSV). The RSV season was observed to span from August to December, peaking in October, while Influenza A had semi-seasonal peaks in June and October. Hospital admissions varied significantly between single (21%) and multiple viral infections (27%). Of 340 children hospitalized with single viral infections, 28.2% were infected with Human Enterovirus/Rhinovirus, 16.7% with RSV, and 13.5% with Influenza A. Conclusion: The study provides insights into viral epidemiology among children in the UAE, highlighting the high prevalence and seasonal peaks of viral pathogens. Awareness of these trends can reduce unnecessary streptococcal testing and antibiotic overuse. Understanding the seasonal patterns aids in optimizing prophylactic measures and vaccination strategies for RSV and influenza, benefiting high-risk infants and children.

Epilepsy in Loeys-Dietz Syndrome: The Rare Concurrence of a Connective Tissue and Neuronal Migration Disorder

We present a 7-year-old girl who presented to our emergency department in active status epilepticus. Seizures responded to standard antiepileptic medications; however, baseline work-up for seizure etiology remained unremarkable. Her new-onset seizures were further investigated via EEG and MRI brain, which revealed focal epileptiform discharges and periventricular nodular heterotopia, respectively. Concurrently, the clinical evaluation revealed extensive marfanoid features, and a personal history of eczema and asthma. Her family history was pertinent for aortic valve disease, asthma, and tall stature. Given the peculiar skeletal features, allergic propensities and coexistent weighty family history, a molecular genetic panel analysis for Marfan Syndrome and Loeys-Dietz Syndrome (LDS) were sought. Genetic testing revealed an underlying heterozygous variant in the TGFBR-1 gene; thereby confirming the presence of LDS. The child had responded well to single antiepileptic agent therapy and was discharged in good condition with regular outpatient cardiac and neurology follow-up. This is a unique case reported of a child with genetically diagnosed LDS concurring with an underlying neuronal migration disorder, manifesting in an acute, severe, and lifethreatening fashion.

Estimates of intra-cluster correlation coefficients from 2018 USA Medicare data to inform the design of cluster randomized trials in Alzheimer’s and related dementias

BackgroundCluster randomized trials (CRTs) are increasingly important for evaluating interventions embedded in health care systems. An essential parameter in sample size calculation to detect both overall and heterogeneous treatment effects for CRTs is the intra-cluster correlation coefficient (ICC) of both outcome and covariates of interest. However, obtaining advance estimates for the ICC can be challenging. When trial outcomes will be obtained from routinely collected data sources, there is an opportunity to obtain reliable ICC estimates in advance of the trial. Using USA national Medicare data, we estimated ICCs for a range of outcomes to inform the design of CRTs for people living with Alzheimer’s and related dementias (ADRD).MethodData from 2018 Medicare Fee-for-Service beneficiaries, specifically, 1,898,812 individuals (≥ 65 years) with diagnosis of ADRD within 3436 hospital service areas (treated as clusters) and 306 hospital referral regions (treated as fixed strata), were used to calculate unadjusted and adjusted ICC estimates for three outcomes: death, any hospitalizations, and any emergency department (ED) visits and three covariates: age, race and sex. We present both overall and stratum-specific ICC estimates. We illustrate their use in sample size calculations for overall treatment effects as well as detecting treatment effect heterogeneity.ResultsThe unadjusted overall ICCs for death, hospitalizations, and ED visits were 0.001, 0.010, and 0.017 respectively. Stratum-specific ICCs varied widely across the 306 HRRs: median 0.001, 0.010 and 0.025 for death, hospitalizations, and ED visits respectively and 0.007, 0.001, and 0.080 for age, sex and race. An interactive R Shiny app is provided that allows users to retrieve estimates overlayed on a map of the USA.ConclusionsWe presented both adjusted and unadjusted ICCs for outcomes as well as unadjusted ICCs for covariates of potential interest from population-level data in the USA and demonstrated how the estimates may be used in sample size calculations for CRTs in ADRD.

Association between temperature and air pollutants with atrial fibrillation presentations to emergency departments.

Understanding the impact of environmental exposures on disease incidence is important for environmental guidelines, health services management, and advising patients. We aimed to assess the relationship between daily mean temperature and common pollutants with atrial fibrillation (AF) presentations to emergency departments (EDs). The study included consecutive adult patients presenting with AF to EDs from 1/1/2014 to 31/12/2020 with linkage to hospital and emergency discharge diagnosis data. A time series quasi-Poisson regression with a distributed lag nonlinear model was fitted to assess the association between AF with mean air temperature and five common pollutants, overall and according to sex and region, with adjustment for season, day of the week, long-term trend, and co-pollutants. In 82 575 AF presentations to EDs during the study period, mean (standard deviations [SD]) (SD) age was 69.6 (SD 14.7) years and 50.7% were female. AF presentations were associated with elevated levels of Particulate Matter (PM) 2.5 (≥57.7 µg/m3) and nitrous dioxide (NO2) (≥16.5 parts per billion), but not mean air temperature or other pollutants (carbon monoxide, sulphur dioxide, or ozone). The attributable fraction of AF presentations relating to above optimal NO2 and PM 2.5 levels was 7.24% and 3.81% resulting in 854 and 450 annual excess AF presentations, respectively. High levels of NO2 and PM 2.5 are associated with increased risk of AF presentations to EDs. These findings have important implications for environmental policies and advice to patients susceptible to AF presentations to EDs, especially in regions with higher baseline levels of PM 2.5 or NO2.

Comparative effectiveness of sodium-glucose cotransporter-2 inhibitors for recurrent nephrolithiasis among patients with pre-existing nephrolithiasis or gout: target trial emulation studies.

To emulate target trials comparing recurrence of nephrolithiasis among patients with pre-existing nephrolithiasis (overall and stratified by concomitant gout) initiating sodium-glucose cotransporter-2 (SGLT-2) inhibitors versus an active comparator. Target trial emulation studies. Canadian population database, January 2014 to June 2022. 20 146 patients with nephrolithiasis and type 2 diabetes, including those with concomitant gout at baseline, a high risk group. Initiation of an SGLT-2 inhibitor or glucagon-like peptide-1 (GLP-1) receptor agonist, with a dipeptidyl peptidase-4 (DPP-4) inhibitor as alternative comparator. The primary outcome was recurrent nephrolithiasis events ascertained from diagnoses during emergency department visits, hospital admissions, or outpatient visits. Secondary outcomes included nephrolithiasis resulting in hospital admission or emergency department visits and flare-up of gout, as well as a positive control outcome (genital infection) and negative control outcomes (osteoarthritis encounter and appendicitis). Poisson and Cox proportional hazards regression models were used (primary analyses), as well as overlap weighting. After inverse probability of treatment weighting, 1924 recurrent nephrolithiasis events occurred among the 14 456 weighted patients who used an SGLT-2 inhibitor (105.3 per 1000 person years), compared with 853 events among the 5877 weighted patients who used a GLP-1 receptor agonist (156.4 per 1000 person years). The adjusted rate ratio was 0.67 (95% confidence interval (CI) 0.57 to 0.79) and rate difference was -51 (95% CI -63 to -40) per 1000 person years, with a number needed to treat (NNT) of 20. Among those with recently active nephrolithiasis, the absolute rate difference was 219 per 1000 person years (NNT of 5). Protective associations persisted for nephrolithiasis events that required emergency department visits, hospital admissions, or procedures, and when an SGLT-2 inhibitor was compared with a DPP-4 inhibitor (rate ratio 0.73 (0.68 to 0.78), rate difference -38 (-46 to -29) per 1000 person years (NNT of 26)). Protective associations also persisted among patients with nephrolithiasis and concomitant gout, with a rate ratio of 0.67 (0.57 to 0.79) and rate difference of -53 (95% CI -78 to -27) per 1000 person years versus a GLP-1 receptor agonist (NNT of 19), and 0.63 (0.55 to 0.72) and-62 (-81 to -42) per 1000 person years, respectively, versus a DPP-4 inhibitor (NNT of 16). Furthermore, SGLT-2 inhibitor use was associated with a lower rate of gout flare-ups (rate ratio 0.72, 0.54 to 0.95, rate difference -16, -31 to -1 per 1000 person years) compared with GLP-1 receptor agonists (0.65, 0.52 to 0.82, and -21, -33 to -9 per 1000 person years) compared with DPP-4 inhibitors. SGLT-2 inhibitor initiators showed higher risk of genital infection (eg, hazard ratio 2.21, 95% CI 1.68 to 2.90, and rate difference 13 per 1000 person years), but no altered risk of osteoarthritis encounter (0.87, 0.68 to 1.1, and -2 per 1000 person years) or appendicitis (1.07, 0.69 to 1.67, and 1 per 1000 person years). Results were similar when propensity score overlap weighting was applied. The benefits associated with SGLT-2 inhibitor for patients with nephrolithiasis in these target trial emulations suggest they may be a useful addition to current treatments to simultaneously manage nephrolithiasis recurrence and comorbidities, including gout.

The patient's medical home: A meta-analysis of case studies exploring its impact on patient outcomes

This meta-analysis investigates the impact of the Patient's Medical Home (PMH) model on healthcare delivery, focusing on quality of care, patient satisfaction, accessibility, and cost-effectiveness. Utilizing a comprehensive search across multiple databases, studies relevant to the PMH model were identified and analyzed, adhering to strict inclusion and exclusion criteria. The findings reveal significant improvements in the adherence to practice guidelines for chronic disease management, patient satisfaction scores, access to primary care services, and reductions in overall healthcare costs, with a notable reduction in emergency department visits and hospital admissions. Despite moderate heterogeneity among studies, indicating variability in PMH implementation, the analysis underscores the PMH model's potential to enhance healthcare delivery. This study contributes to the growing body of evidence supporting the PMH model's effectiveness in improving healthcare outcomes and efficiency, advocating for its broader adoption and adaptation across diverse healthcare settings. The research highlights the importance of addressing implementation challenges to fully realize the PMH model's benefits, marking a significant step towards patient-centered, sustainable healthcare reform.

Comment on "Delirium prevalence in emergency department patients: A systematic review and meta-analysis".

Comment on "Delirium prevalence in emergency department patients: A systematic review and meta-analysis".

Acute coronary syndrome and Khat consumption in Yemeni women admitted to Coronary Care and Intensive Care in major hospital in Yemen

Background: There is a significant percent of normal coronaries in patients with a history of documented myocardial infarction among Yemeni patients who have undergone diagnostic coronary angiogram, and they theoretically attributed that to the effect of Khat as a vasoconstrictor to the coronary artery. Also, unadjusted comparisons of mortality and major morbidity after acute myocardial infarction have generally indicated that women have a poorer outcome than men. Methods: Data was collected prospectively from 15 hospitals in 8 governorates with acute coronary syndrome registry in the Gulf countries. All female patients who were admitted in any monitored bed in Coronary Care Units (CCU) or Intensive Care Units (ICU) with a provisional diagnosis of acute coronary syndrome (ACS) were included in the study. The presentations with khat chewing were compared with all other known and documented risk factor outcomes among women using multiple logistic regressions. Results There were 50.5% regular khat chewers of female patients at presentations to the general emergency department with an attack of acute coronary syndrome; 14.4% of all female patients have no other risk factors except khat. These patients were relatively younger and had a lower body mass index (BMI) when compared with the incidence of acute events in other populations. They had no significantly worse outcome during hospitalization in comparison to the males of the same age group. Conclusions It seems likely that there is at most only an intermediate association between Khat and the development of acute coronary syndrome in females, with less mortality and morbidity after suspected acute myocardial infarction. However, a larger study is needed, with more complete adjustment for coexisting risk factors, to determine whether the female has a worse outcome, which increases with khat.

Frequency and mechanism of injury for unintentional paediatric femoral fractures associated with consumer products over a 10-year period in the USA.

Femoral shaft fractures tend to be rare among children; however, these injuries are the most common major paediatric injuries treated by orthopaedic surgeons. The purpose of this study is to characterise the demographics and mechanisms of femoral injury associated with consumer products in the age group treated with spica casting, children 6 months to 6 years, to identify areas for injury prevention. Data from 2012 to 2021 were obtained from the National Electronic Injury Surveillance System maintained by the Consumer Products Safety Commission, documenting emergency department visits for unintentional injuries associated with consumer products. Narrative descriptions were analysed to identify common factors in the injury events such as location, products and mechanisms of action. From 2012 to 2021, the estimated incidence of femur fractures was 23.5 cases per 100 000 children with no significant difference in yearly frequency. The most common mechanism of injury was a fall with the most frequent fracture sources being bed/bunk beds (16.1%), floor (slips/falls, 9.7%) and trampolines (9.7%). Most fractures occurred at the patient's home (58.4%). The incidence of injury outside of the home and frequency of fractures involving play structures/trampolines increased with age. The incidence and demographic characteristics of paediatric femur fractures associated with consumer products have remained consistent over the past 10 years. As home was the most common location of fracture, prevention of femur fractures should focus on caregiver education around high-risk sources of fracture (bed, stairs and trampolines) and manufacturers should consider design alternatives that discourage potential misuse.