Emergency Room Physicians Research Articles

Abstract 4120657: A Personal Risk Assessment Device in Patients with Chest Pain

Introduction: Early prehospital chest pain assessment improves acute coronary syndrome (ACS) outcomes and can reduce unnecessary Emergency Room (ER) visits but requires medical personnel and electrocardiographic (ECG) equipment. Objective: To evaluate the feasibility of a personal credit-card sized chest pain self-assessment device (HeartBeam, Santa Clara, CA, USA) in diagnosing ACS. Methods: ACS risk was estimated by serial likelihood ratio analysis of 3 components: pre-existing coronary heart disease (CHD) risk (pre-calculated based on pooled ASCVD equation), chest pain characteristics (interactive proprietary questionnaire), and integrated near-orthogonal 3-lead self-recorded vectorcardiogram (VCG) with optional comparison to baseline using portable handheld HeartBeam recorder. Final ACS risk was graded High/Intermediate/Low by the cloud-based proprietary algorithm. High risk was considered positive for ACS. Results: 184 ER patients with chest pain (Age 57 +/- 7years, 90 Male, 43 (23%) ACS) comprised learning (n=96) and test (n=88) sets. ACS sensitivity was 28/28 (100%) in learning and 15/16 (94%) in test set with specificity of 43% and 42% respectively. In the subset of patients with pain-free portable VCG recorded 9 months later used as a “reverse baseline” (n=110) sensitivity was 17/17 (100%) and 11/12 (92%), specificity 54% and 58% in learning and test set, respectively (p>0.1 with no baseline). Single patient missed by the analysis had known coronary disease with usual anginal episode resulting in minor troponin leak. In “reverse baseline” analysis 41/110 (37%) patients were classified as Low risk compared to 18/184 (10%) without baseline (p<0.001), all negative for ACS. Based on the analysis of CHD risk factors, chest pain characteristics, and 12-lead ECG, a consensus of 3-member ER chest pain unit physicians panel had sensitivity/specificity of 94/54% for the whole and 93/48% for the “reverse baseline” groups (p>0.1 with HeartBeam device). Conclusion: HeartBeam chest pain self-assessment device provides accurate ACS detection comparable to expert ER physicians using 12 lead ECG. The presence of baseline recording reduces the number of false positive results. If confirmed in larger studies, it can be used to facilitate outpatient chest pain assessment and triage by remote physicians and patients themselves.

Efficacy of a portable non-mydriatic fundus camera for "rule-out papilledema" consultations: A prospective study.

Ophthalmology is frequently consulted to "rule-out papilledema." We assessed the efficacy of a portable, non-mydriatic fundus camera in detecting optic disc edema in the inpatient and emergency room settings during "rule-out papilledema" consultations, comparing to the gold standard dilated fundus examination (DFE). This prospective, blinded, cohort study included 124 non-mydriatic fundus photographs (62 patients) that were obtained over the 11-month enrollment period. The images, along with a brief clinical history, were evaluated independently by an attending neuro-ophthalmologist (NO), general ophthalmologist (GO), emergency room (ER) physician, and ophthalmology resident (OR), for the presence of disc edema and indication for consultation. Results were compared to DFE. Sensitivity, specificity, and area under receiver operating characteristic (ROC) curves were determined to evaluate the efficacy of the camera. On DFE, disc edema was present in 51 eyes (41.1%). Compared to DFE, NO assessment had the greatest combined sensitivity (84.3%) and specificity (97.3%) for the detection of disc edema, followed by that of GO (sensitivity 77.4%, specificity 100%), OR (sensitivity 96.1%, specificity 80.8%), and ER clinician (sensitivity 68.6%, specificity 89.0%). Areas under ROC curves for NO, GO, OR, and ER physician were all statistically significant for the detection of disc edema (0.908, P < 0.001; 0.892, P < 0.001; 0.885, P < 0.001; 0.788, P < 0.001, respectively). Clinicians were able to correctly identify optic disc edema using non-mydriatic fundus photography. Non-mydriatic fundus photography may be an effective inpatient or telemedicine tool to assess for optic disc edema.

"Code Headache": Development of a protocol for optimizing headache management in the emergency room.

Patients presenting at the emergency room (ER) with headache often encounter a hostile atmosphere and experience delays in diagnosis and treatment. The aim of this study was to design a protocol for the ER with the goal of optimizing the care of patients with urgent headache to facilitate diagnosis and expedite treatment. A narrative literature review was conducted via a MEDLINE search in October 2021. The "Code Headache" protocol was then developed considering the available characteristics and resources of the ER at a tertiary care center within the Spanish National Public Health system. The Code Headache protocol comprises three assessments: two scales and one checklist. The assessments identify known red flags and stratify patients based on suspected primary/secondary headaches and the need for pain treatment. Initial assessments, performed by the triage nurse, aim to first exclude potentially high morbidity and mortality etiologies (HEAD1 scale) and then expedite appropriate pain management (HEAD2 scale) based on scoring criteria. HEAD1 evaluates vital signs and symptoms of secondary serious headache disorders that can most benefit from earlier identification and treatment, while HEAD2 assesses symptoms indicative of status migrainosus, pain intensity, and vital signs. Subsequently, ER physicians employ a third assessment that reviews red flags for secondary headaches (grouped under the acronym 'PEACE') to guide the selection of complementary tests and aid diagnosis. The Code Headache protocol is a much needed tool to facilitate quick clinical assessment and improve patient care in the ER. Further validation through comparison with standard clinical practice is warranted.

Utilizing Local Anesthesia Only for Penile and Scrotal Urologic Surgery: A Prospective Study on Patient Tolerability and Surgical Outcomes for a Sedation-free Option

ObjectiveTo prospectively assess surgical outcomes, complications, and patient-reported tolerability of invasive scrotal surgeries under local anesthesia (LA) alone, without sedation, compared to tolerability of penile procedures commonly performed in this manner. MethodsAdult patients undergoing penile and scrotal surgeries under LA only were enrolled from August 2022 to June 2023 (NCT05617261). Demographics, surgeon-perceived and patient-reported pain, and surgical variables were collected. Tolerability to the procedures and future anesthetic choice for a repeat procedure was assessed on follow-up. Complication data was collected, including recurrence, infection, excessive pain, and emergency room and family physician visits. Results107 patients were enrolled with a mean age ± SD of 42.2 ± 16.4 years. There was a 100% procedural success rate and no cases of perioperative complications or escalation of anesthetic. 92.4% (n=97) of patients indicated they would opt for LA only for a hypothetical repeat procedure. Of the minority opting for general anesthetic, most indicated discomfort or preferring an element of amnesia. No differences between intraoperative pain or tolerability scores of invasive scrotal procedures compared to penile procedures were observed. On univariate analysis, longer procedure duration (p=0.003), cannabis use (p=0.01), and higher intra-operative pain (p=0.005) was associated with lower tolerability. ConclusionLA alone in an office-based setting is promising for scrotal surgeries. It offers similarly high patient tolerability compared to procedures that are routinely performed under LA, with the preservation of outcomes. Adopting this method has the potential for substantial cost savings, reduced wait times, enhanced accessibility, and improved surgical efficiency.

A Case of Fatal Poisoning: Use of 2-4 Dinitrophenol for Weight Loss

Aim: 2,4-dinitrophenol (DNP®) causes rapid weight loss. Therefore, this drug is used for weight loss, is mostly sold on internet sites, and is banned for sale owing to its deadly side effects. In this case report, we aimed to report a patient who was admitted to our hospital with DNP poisoning. Case: In the present study, we present a 29-year-old patient who took 200-mg DNP® once a day for 5 days and who applied to our emergency department approximately 6 hours after taking two tablets on the last day. He developed cardiopulmonary arrest 8 hours after admission despite all supportive treatments and died despite effective and adequate cardiopulmonary resuscitation. Conclusion: DNP poisoning can be fatal even in small doses. It is difficult to control because the drug is freely available on the internet, and urgent diagnosis and treatment is critical. In recent times, where sedentary life and obesity are on the rise, people should be better informed about healthy living and the risks associated with weight loss drugs that can be obtained illegally. Preventing the unauthorized sale of these products, which have a limited response to treatment and a high mortality rate, over the internet and early recognition of poisoning by emergency room physicians is the most important preventive measure in DNP poisonings and the most important step in treatment.

The Efficacy of a Multidisciplinary Approach and Diagnostic-Therapeutic Algorithm for Vertebral Metastases with Spinal Cord Compression.

Background and Objectives: Metastatic spinal cord compression represents a substantial risk to patients, given its potential for spinal cord and/or nerve root compression, which can result in severe morbidity. This study aims to evaluate the effectiveness of a diagnostic-therapeutic algorithm developed at our hospital to mitigate the devastating consequences of spinal cord compression in patients with vertebral metastases. Materials and Methods: The algorithm, implemented in our practice in January 2022, is based on collective clinical experience and involves collaboration between emergency room physicians, oncologists, spine surgeons, neuroradiologists, radiation oncologists, and oncologists. To minimize potential confounding effects from the COVID-19 pandemic, data from the years 2019 and 2021 (pre-protocol) were collected and compared with data from the years 2022 and 2023 (post-protocol), excluding the year 2020. Results: From January 2022 to December 2023, 488 oncological patients were assessed, with 45 presenting with urgency due to suspected spinal cord compression. Out of these, 44 patients underwent surgical procedures, with 25 performed in emergency settings and 19 cases in elective settings. Comparatively, in 2019 and 2021, 419 oncological patients were evaluated, with 28 presenting with urgency for suspected spinal cord compression. Of these, 17 underwent surgical procedures, with 10 performed in emergency scenarios and 7 in elective scenarios. Comparing the pre-protocol period (years 2019 and 2021) to the post-protocol period (years 2022 and 2023), intrahospital consultations (commonly patients neurologically compromised) for spine metastasis decreased (105 vs. 82), while outpatient consultations increased remarkably (59 vs. 124). Discussion: Accurate interpretation of symptoms within the context of metastatic involvement is crucial for patients with a history of malignancy, whether presenting in the emergency room or oncology department. Even in the absence of a cancer history, careful interpretation of pain characteristics and clinical signs is crucial for diagnosing vertebral metastasis with incipient or current spinal cord compression. Early surgical or radiation intervention is emphasized as it provides the best chance to prevent deficits or improve neurological status. Preliminary findings suggest a notable increase in both the number of patients diagnosed with suspected spinal cord compression and the proportion undergoing surgical intervention following the implementation of the multidisciplinary protocol. The reduced number of intrahospital consultations (commonly patients neurologically compromised) and the increased number of visits of outpatients with vertebral metastases indicate a heightened awareness of the issue, leading to earlier identification and intervention before neurological worsening necessitating hospitalization. Conclusions: A comprehensive treatment planning approach is essential, and our multidisciplinary algorithm is a valuable tool for optimizing patient outcomes. The protocol shows potential in improving timely management of spinal cord compression in oncological patients. Further analysis of the factors driving these changes is warranted. Limitations: This study has limitations, including potential biases from the retrospective nature of data collection and the exclusion of 2020 data due to COVID-19 impact. To enhance the robustness of our results, long-term studies are required. Moreover, the single-center study design may limit the validity of the findings. Further multicenter studies would be beneficial for validating our results and exploring underlying factors in detail.

Irradiate the knowledge gap: Empowering residents for blood product selection at Albany Medical Center.

e23236 Background: Transfusion-associated graft versus host disease (ta-GvHD) poses risks for immunocompromised patients. Indications for irradiated blood products include hematological malignancies and bone marrow transplant cases. In instances of severe acute pancytopenia, the initial contact at the emergency room (ER) is typically a nurse, followed by the ER physician. Patients referred from the local private practice, New York Oncology and Hematology (NYOH) office to our local hospital, Albany Medical Center (AMC), often bring comprehensive paper charts, but those coming directly from home frequently lack necessary documents, relying on the medical teams' expertise to ensure appropriate blood product selection. We aim to improve understanding of transfusion products and their indications. Methods: An initial pre-survey questionnaire was sent to internal medicine residents. Of the 33 responses received, 87.9% were aware of the need for irradiated blood products in hematological malignancies, 66.6% knew it was not required for solid tumors, and only 57.6% knew about the need for CAR-T patients. Additionally, only 15.2% knew where to find information on selecting irradiated blood products at AMC. The analysis highlighted a significant knowledge gap in transfusing irradiated blood products for hematological and oncological malignancies. In response, a user-friendly educational resource was created and displayed in residents' conference rooms during inpatient rotations, with plans for intermittent educational sessions over the next months. A comprehensive educational initiative addressed this aspect of patient care within the inpatient service, distributing detailed materials and discussions with the internal medicine residents at AMC. The focus was on emphasizing the critical requirement for irradiated blood products in specific clinical scenarios, particularly when managing patients with hematological malignancies and other conditions where irradiated blood is medically indicated. Results: A follow-up survey, conducted four months after distributing educational material on medicine floors, included responses from 27 internal medicine residents. Notably, 100% and 88.9% were knowledgeable about the necessity of irradiated blood products in hematological malignancies and bone marrow transplant recipients, respectively. Additionally, 24 out of 27 residents were aware that irradiated products are unnecessary for solid tumor malignancies in adult patients. All residents knew where to find information on blood product selection at AMC, and 92.6% found the education material helpful. Conclusions: Improved knowledge among residents underscores our commitment to patient care. We aim to extend education on irradiated blood product necessity beyond our residency program. Our long-term vision is to broaden this critical knowledge across the healthcare community at AMC.

A mother's call to arms.

Due to the rapid proliferation of vape stores and their ubiquity across the country, many consumers assume that their products are safe, well-studied, and accurately labeled. However, there is rapidly emerging evidence that Delta 8, sold as an alternative to high concentrate tetrahydrocannabinol (THC) marijuana (still illegal in most states) is associated with severe depression, psychosis, and even suicide, particularly in vulnerable adolescent and young adult populations. This trend is well-known to emergency room physicians and psychiatry, and the number of online family advocacy groups is increasing. Delta 8 effects have recently been featured in popular media by the New York Times, Discover, USA Today, and more. The United States Food and Drug Administration (FDA) has reported an increase in complaints and Substance Abuse and Mental Health Services Administration (SAMHSA) released an advisory warning in 2023 about cannabidiol which included Delta 8. For those already affected and their families, however, any regulation will come too late as they face an uncertain future and much anxiety about whether the psychosis will abate or prove permanent. This 55-word story illustrates one mother's rage at the devastation Delta 8 has caused her family. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Clinical Characteristics and Delayed Diagnosis of Pediatric Patients Presenting to the Emergency Department With a Newly Diagnosed Central Nervous System Tumor: A Single Institutional Experience.

Due to the varied symptomatology and inconsistent features on neurologic exam, central nervous system (CNS) tumors are difficult to diagnosis in a timely manner. To determine the clinical, neurological, and neuroimaging features of newly diagnosed CNS tumors presenting to the emergency department (ED). We evaluated a retrospective cohort of 121 consecutive patients presenting to a tertiary care pediatric ED over 7 consecutive years with newly diagnosed CNS tumors. Clinical symptomatology, neurologic findings reported by emergency room and neurology physicians, neuroimaging features, and time to diagnosis were analyzed. A total of 116 (48 female, median age 8.0 years (interquartile range, 4.4-12.6), 52% Hispanic) presented to the ED (64% self-referred) diagnosed with a brain tumor (54% posterior fossa, 24% embryonal, 24% low-grade glioma, 16% high-grade glioma) resulting in hospital admission in 92% of cases. Five were diagnosed with extradural spinal, clivus, or orbital apex tumors. Symptomatology or duration did not differ when stratified by demographics, location, or histologic subtype. Moderate degree of concordance was observed among neurologic examinations performed by ED physicians and neurologists. Delayed diagnosis (median delay = 3.5 [1-7] months) was seen in 14% of patients, 13 with primary brain tumors (11 hemispheric, 2 brain stem). Six children with delayed diagnosis of low-grade glial tumors had a nonfocal neurologic examination in comparison to 5 patients with abnormal examinations observed with primary spinal or extradural CNS tumors. Four patients with posterior fossa tumors (3 medulloblastoma, 1 ependymoma) had normal/near normal neurologic examination at presentation despite posterior fossa symptomatology related to increased intracranial pressure. Our series highlights the complexity of symptomology and neurologic findings in children presenting to the ED with newly diagnosed CNS tumors who may have a normal neurologic examination. Standardization of symptom assessment and focused neurologic examinations may lead to earlier neuroimaging and prevent delayed diagnosis.

Automatic detection of midfacial fractures in facial bone CT images using deep learning-based object detection models

BackgroundMidfacial fractures are among the most frequent facial fractures. Surgery is recommended within 2 weeks of injury, but this time frame is often extended because the fracture is missed on diagnostic imaging in the busy emergency medicine setting. Using deep learning technology, which has progressed markedly in various fields, we attempted to develop a system for the automatic detection of midfacial fractures. The purpose of this study was to use this system to diagnose fractures accurately and rapidly, with the intention of benefiting both patients and emergency room physicians. MethodsOne hundred computed tomography images that included midfacial fractures (e.g., maxillary, zygomatic, nasal, and orbital fractures) were prepared. In each axial image, the fracture area was surrounded by a rectangular region to create the annotation data. Eighty images were randomly classified as the training dataset (3736 slices) and 20 as the validation dataset (883 slices). Training and validation were performed using Single Shot MultiBox Detector (SSD) and version 8 of You Only Look Once (YOLOv8), which are object detection algorithms. ResultsThe performance indicators for SSD and YOLOv8 were respectively: precision, 0.872 and 0.871; recall, 0.823 and 0.775; F1 score, 0.846 and 0.82; average precision, 0.899 and 0.769. ConclusionsThe use of deep learning techniques allowed the automatic detection of midfacial fractures with good accuracy and high speed. The system developed in this study is promising for automated detection of midfacial fractures and may provide a quick and accurate solution for emergency medical care and other settings.

Management of Dental Trauma of Senior-Year Medical Students Attending Medical School in Tokat

Aim: Since trauma often requires immediate intervention, the initial care of patients is typically provided by emergency room physicians. Emergency departments prioritize the treatment of conditions that threaten the patient's overall health, which can lead to overlooking the treatment of traumatic dental injuries. Early intervention in dental and surrounding tissue injuries is crucial for prognosis. Therefore, it is important to assess the knowledge and awareness of dental trauma among medical doctors, who are often the first responders in trauma cases. The aim of this study is to evaluate the knowledge and approaches of senior-year medical students regarding dental traumas in Tokat city, Türkiye. Materials and Methods: For this cross-sectional study, a validated questionnaire consisting of 10 questions previously used in similar studies was used. Students completed the questionnaire online using the Google® Forms program. The data obtained in this study were analyzed using the SPSS v23 (Chicago, IL, USA) software package program. Frequency and percentage values were obtained. Results: While 7.1% of the students stated that they would reimplant the avulsed tooth, 71.4% stated that they would refer the patient to the dentist. While 42.8% of the students preferred sterile saline solution for handling the avulsed tooth, 20.2% preferred wet gauze. While 85.7% of the students found the level of knowledge about oral and dental injuries insufficient, 71.4% stated that they would like to participate in an educational program on this subject. Conclusions: It has been observed that senior medical school students have insufficient knowledge about intervening in injuries to teeth and surrounding tissues. Curriculum regulation and training programs are required to improve students' knowledge and awareness about injuries to teeth and surrounding tissues. Students should also be informed that they can access the free IADT ToothSOS Mobile App on the International Association for Dental Trauma (IADT) website (http://www.iadt-dental-trauma.org), which can guide them on emergency response to dental trauma when they encounter dental trauma.

Abstract TP53: Above Par on the Back Nine: Improving Triage of Posterior Circulation Stroke

Background and Purpose: Notoriously difficult to recognize, posterior circulation strokes (PCS) can be some of the most devastating. It is incumbent on the triage nurse to recognize these signs and symptoms. This project was developed to educate frontline ED staff on early identification of posterior strokes, decrease time to recognition, and improve outcomes. Methods: The community Primary Stroke Center (PSC) identified the need to improve recognition of PCS after a series of treatment-eligible patients were missed. A team was created including the directors of the PSC and associated Comprehensive Stroke Center (CSC), emergency room physicians, and nurses. A triage algorithm was created to capture as many strokes as possible without a glut of false positives. This included focal and non-focal signs of stroke. ANY sign of stroke should initiate the code stroke (CS) process provided that the presentation was within 24 hours of last known well, the presentation was sudden, and the symptoms were disabling to the patient. Once approved, the algorithm and education were provided to all patient-facing ED staff. Updates were added to huddle notes and a copy of the algorithm was made available at all triage areas. Data was collected retroactively for a total of 16 months, 8 months prior to the intervention and 8 months after. Results: - For all PCS the median time from arrival to initiation of CS improved from 9 minutes to 1 minute - For all PCS the median time from arrival to confirmation of stroke improved from 597 minutes to 249 minutes - Prior to intervention, only 60% of CS-eligible patients had a CS initiated, compared to 92% after - Ninety-day Rankin was from 0-2 in 86% of PCS patients prior to intervention compared to 100% after Conclusions: A clear triage process can maximize identification of PCS, increase capture of treatment-eligible patients, and decrease disability. A PSC with tele-stroke coverage and ongoing education improved identification of posterior circulation strokes and outcomes. Key takeaways for success include clear and concise code stroke algorithm, support from providers, and ongoing educational interventions. While this data is preliminary, we will continue to track and trend. Next steps should include education directed to EMS personnel in the field.

Information and approaches of emergency department physicians in the Cappadocia region regarding the preparation of forensic reports

Aims: Forensic reports; these are physician’s opinion and opinion reports, which are mostly prepared by emergency room physicians regarding the medical conditions of people and reported to the judicial authorities. In this study; it was aimed to examine the attitudes and behaviors of emergency physicians working in the Cappadocia region regarding the preparation of forensic reports. Methods: This cross-sectional study; it was conducted with a survey applied to 73 emergency physicians working in Nevşehir city center and districts. The data was created based on the answers given to this survey form. Results: The majority of physicians participating in the study are general practitioners (87.7%). The average length of service of the participants is 2.3 1.1 years. Most physicians reported that the forensic medicine training they received was insufficient (75.3%). Survey answers of the participants; They were compared in terms of their titles, length of service and forensic medicine training. Conclusion: Regular in-service training should be provided at intervals so that more appropriate forensic reports can be kept and physicians can have more information about the legal part of forensic reports.

Current evidence on the use of pocus in the diagnosis of pneumothorax in emergency rooms: a systematic review

Introduction: Point of Care Ultrasound (POCUS) is currently recognized as useful and, in some cases, mandatory, such as during invasive procedures. Its bedside application includes differential diagnosis and therapeutic management of complex clinical conditions during hemodynamic instability. The emergence of portable devices with superior image quality and their applicability in emergency rooms and intensive care units has demonstrated high diagnostic effectiveness. Objective: It was to highlight the use of POCUS in the diagnosis of pneumothorax in emergency rooms, through a systematic review of meta-analytic articles, systematic reviews, and observational studies from the last 11 years (2012 to 2023). Methods: The PRISMA Platform systematic review rules were followed. The search was carried out from October to December 2023 in the Scopus, PubMed, Science Direct, Scielo, and Google Scholar databases. The quality of the studies was based on the GRADE instrument and the risk of bias was analyzed according to the Cochrane instrument. Results and Conclusion: A total of 127 articles were found, 43 articles were evaluated in full and 31 were included and developed in the present systematic review study. Considering the Cochrane tool for risk of bias, the overall assessment resulted in 22 studies with a high risk of bias and 26 studies that did not meet GRADE and AMSTAR-2. Most studies did not show homogeneity in their results, with X2=61.5%&lt;50%. It was concluded that the POCUS method is operator-dependent and has greater sensitivity (78 to 90%) and specificity greater than 98% in chest radiography. However, when performed correctly by trained professionals, following protocols, it proved to be useful for identifying and treating pneumothorax. POCUS is a portable, fast, and low-cost bedside examination that does not involve ionizing radiation, in addition to identifying a precise location for performing thoracentesis in cases of pneumothorax, which assists clinical physicians in urgent and emergency rooms, as well as in external environments such as rescue helicopters. There is a consensus among the authors researched that, to obtain clinical evidence on the use of POCUS in the diagnosis of pneumothorax, more randomized controlled studies are necessary, which reinforce the use of this versatile equipment in different urgent and emergency scenarios

Sphericity index for bedside diagnosis of acute myocarditis

BackgroundDifferentiating acute myocarditis (AMY) from dilated cardiomyopathy (DCM) in a patient presenting with acute heart failure and poor systolic function is of utmost importance to initiate timely anti-inflammatory treatment in AMY. Using cardiac magnetic resonance (CMR) or endomyocardial biopsies (EMB) as gold standards might be limited due to the likelihood of hemodynamic compromise. Eccentric myocardial remodeling as measured by sphericity index (SPI) might be useful in differentiating AMY from DCM, due to the progressive increase in transverse LV diameter in DCM. The primary outcome parameter of our study was to test the diagnostic accuracy of SPI in the differentiation of AMY from DCM, while the secondary outcome parameter was to compare the diagnostic accuracy of SPI to troponin I in the same context. For this purpose, we conducted a retrospective study involving a chart review of the files of sixty patients admitted with acute heart failure due to hypokinetic left ventricle in our hospital. Patients were divided after CMR imaging into two groups: group 1 with AMY (n = 30) and group 2 with DCM (n = 30). Demographic and clinical characteristics of the patients, including heart rate, need for mechanical ventilation, use of milrinone, epinephrine and norepinephrine, troponin I, and 2D-derived sphericity index, were collected from patients’ files.ResultsPatients with AMY had a higher need for mechanical ventilation inopressors and vasopressors; 73% of AMY patients required mechanical ventilation and epinephrine use, compared to less than 50% of DCM patients. Troponin I elevation was more marked in AMY compared to DCM patients (0.25 ± 0.04 vs. 0.21 ± 0.03, respectively). SPI was significantly higher in DCM compared to AMY cases, denoting a spherical configuration of the myocardium acquired due to progressive remodeling, because of the chronicity of the pathology. ROC analysis revealed that an SPI ≤ 0.38 was 100% sensitive in differentiating DCM from AMY, compared to a 53% sensitivity with the commonly used troponin I.ConclusionAMY diagnosis can be achieved by the assessment of sphericity index rather than troponin I. The bedside nature and noninvasiveness of SPI should reshape the practice in this context. SPI assessment can be part of point-of-care echocardiography, taught to emergency room (ER) physicians and intensivists.

Country and health expenditure are major predictors of withholding anticoagulation in atrial fibrillation patients at high risk of stroke

BackgroundGuidelines for patients with atrial fibrillation (AF) at high thromboembolic risk recommend oral anticoagulants (OACs) for preventing stroke and systemic embolism (SE). The reasons for guideline non-adherence are still unclear.AimThe...

The role of Neuroimaging in Patient Selection and Safety Monitoring during Lecanemab Treatment

AbstractBackgroundLecanemab (Leqembi) is a monoclonal antibody therapy approved in the United States for the treatment of Alzheimer’s disease (AD). Administration of lecanemab in community settings will be guided by the appropriate use recommendations (AURs) that are soon to be published.MethodThe lecanemab AUR’s use clinical trial data as well as evidence from research and clinical practice regarding AD to inform clinicians how to administer lecanemab with optimal safety and opportunity for efficacy. Neuroimaging will play a significant role in selecting the appropriate patients for administration of lecanemab as well as in safety monitoring for adverse events such as amyloid related imaging abnormalities (ARIA). In this presentation we will review the selection and monitoring guidelines for lecanemab as detailed in the AURs.ResultMost ARIA are asymptomatic, but a few cases are serious or fatal. While micro‐ and macrohemorrhages are rare, they can occur in patients receiving lecanemab. Patients who are apolipoprotein E4 (APOE4) gene carriers, and especially those that are APOE4 homozygotes, are at higher risk for ARIA than APOE4 non‐carriers. The AURs recommends genotyping to better inform risk discussions with patients who are candidates for lecanemab therapy. The AURs recommends a screening MRI and periodic along with symptom‐triggered MRI surveillance to detect asymptomatic and symptomatic ARIA and address it appropriately.ConclusionClinician and institutional preparedness are mandatory for the use of lecanemab. This includes training of neurologists, geriatric psychiatrists, radiologists, primary care, emergency room and intensive care physicians, and stroke neurologists in safety monitoring and treatment of symptomatic ARIA.

(011) Catatonia Presentation and Evaluation of Creatine Kinase Blood Level as a Screening Tool by Emergency Room Physicians

(011) Catatonia Presentation and Evaluation of Creatine Kinase Blood Level as a Screening Tool by Emergency Room Physicians

Diagnostic Delays in Cutaneous Coccidioidomycosis: a Report from Central California.

Cutaneous Coccidioidomycosis (CC) infection can present with a wide variety of clinical presentations and is well known as a 'great imitator'. We performed a retrospective analysis of patients with CC in a large referral center in Central Valley, California, from 2010 to 2022 using the ICD9 and ICD10 codes for coccidioidomycosis and CC. We identified forty patients with CC during the study period. The mean age of the study population was 43 years (with standard deviation of 14.08). Among these, 60% were men and 40% women. The appearance of the lesions varied from ulcers, plaques, nodules, blisters, cellulitis, and abscesses. The most common site of CC lesions was in the lower extremities (42.5%), followed by upper extremities (30%), chest and abdomen, head and neck (25% each). Only 22.5% of the 40 cases were diagnosed as CC and 15% were diagnosed as erythema nodosum. Rest were diagnosed initially as bacterial cellulitis in 37.5%, tinea in 7.5% and others in 12.5%. There was resolution of the cutaneous lesions in all patients with antifungal treatment. The mean time of diagnosis from onset of symptoms on an average was 12 weeks (8-16weeks) in our study with 75% cases initially misdiagnosed. Comprehensive knowledge about the manifestations and evaluation of CC among primary care providers and emergency room physicians is essential to prevent delays in diagnosis and treatment.

A-320 Validation of a Multi-Analyte Immunoassay for Distinguishing Bacterial Versus Viral Infections in a Pediatric Cohort

Abstract Background Clinical presentation of viral and bacterial infections or co-infections overlaps significantly. Pathogen identification is the gold standard for appropriate treatment. Recently, FDA approved a multivariate index test called MeMed-BV on the MedKey analyzer that distinguishes viral and bacterial infections based on a score derived from the differential expression of 3 host proteins. Here, we sought to validate the MeMed-BV immunoassay on the MedKey analyzer in our pediatric hospital, following guidelines from the Clinical and Laboratory Standards Institute. Methods The analytical performance of MeMed-BV was evaluated by precision (intra- and inter-assay), accuracy (sensitivity and specificity) and interference studies. A retrospective cohort study (n = 60) was conducted to assess the diagnostic accuracy using plasma samples from pediatric patients with acute febrile illness who visited the emergency department of the Texas Children's Hospital, Houston, TX, for whom a C-reactive protein test was requested. The following inclusion criteria were employed: 1) age ≤18 years during the clinical encounter; 2) peak fever &amp;gt;37.5°C with the onset of symptoms such as cough, sore throat, abdominal pain or nausea and vomiting; 3) duration of symptoms ≤7 days; and 4) a positive nucleic acid amplification test (for virus) or abnormal blood culture (for bacteria). Patients with 1) active malignancy, 2) congenital immunodeficiency, 3) active immunosuppressive or immunomodulatory therapy and 4) human immunodeficiency virus or hepatitis B/C virus infection were excluded. Clinical performance was evaluated by blinded adjudication from our emergency room physicians. Results MeMed-BV showed acceptable intra- and inter-assay precision with a range of &amp;lt;3 score units in both the high-score bacterial and the low-score viral samples. Accuracy studies revealed a sensitivity of 94% and specificity of 88% for identifying bacterial infections or co-infections. Our MeMed-BV results showed an excellent agreement (R = 0.998) with the manufacturer's laboratory data and compared well with ELISA studies. Gross hemolysis and icterus did not affect the assay, but gross lipemia showed a considerable bias in samples with a moderate likelihood of viral infection. Importantly, the MeMed-BV score performed better than routinely measured infection-related biomarkers like white blood cell counts, procalcitonin and C-reactive protein in classifying bacterial infections. Furthermore, it is important to note that the score but not individual levels of the biomarkers, should be used to discriminate between bacterial and viral infections. Conclusion MeMed-BV score on the MedKey analyzer demonstrated acceptable analytical performance and is reliable for distinguishing viral and bacterial infections or co-infections in pediatric patients. Future studies are warranted to examine the clinical utility, especially with respect to reducing the need for blood cultures and reducing the time to treatment for the patient.