Hospital Emergency Research Articles

Clinical characteristics of patients requiring emergency hospitalization due to immune-related adverse events: a retrospective study

BackgroundImmune checkpoint inhibitors (ICIs) have revolutionized cancer treatment, offering hope for various malignancies by enhancing the immune response against tumors. However, ICIs are associated with unique immune-related adverse events (irAEs), which differ significantly from conventional chemotherapy-induced toxicities. These irAEs, which affect more than 70% of patients and often escalate to severe grades, present substantial clinical management challenges and frequently necessitate emergency hospitalization. Therefore, this study aimed to investigate the clinical characteristics of patients requiring emergency hospitalization due to irAEs during ICI therapy to enhance understanding and improve management strategies.MethodsThis retrospective study evaluated patients who received ICIs at Iwate Medical University Hospital between August 1, 2016, and December 31, 2022, and required emergency hospitalization due to irAEs. Clinical data were extracted from the medical records, including patient demographics, presenting complaints, time from ICI initiation to hospitalization, irAE diagnoses, and treatment outcomes. The Spearman rank correlation coefficient was used to analyze the associations between the chief complaints and irAE diagnoses.ResultsOf 1009 ICI-treated patients, 96 required emergency hospitalization for irAEs. The cohort's mean age was 73 years, with 75.0% of patients being male. Among patients who required emergency hospitalization, a high proportion were undergoing treatment for lung cancer (41.7%). The median hospitalization duration was 87 days. The chief complaints included dyspnea (34.4%) and fatigue (34.4%), with gastrointestinal and respiratory disorders being the most frequent irAEs (35.4%). Significant correlations were observed between dyspnea and respiratory diseases (Rs = 0.66), skin diseases and disorders (Rs = 0.81), pain and musculoskeletal disorders (Rs = 0.59), and diarrhea and gastrointestinal disorders (Rs = 0.49). Corticosteroids were administered to 64.6% of the patients. Despite emergency interventions, 8.3% of patients succumbed to irAEs, while 33.3% resumed ICI therapy after hospitalization.ConclusionsEmergency hospitalization due to irAEs is a considerable concern in ICI therapy, occurring in 9.5% of treated patients. The high incidence of severe irAEs within the first 3 months of treatment underscores the need for early and vigilant monitoring. This study highlights the importance of recognizing and promptly managing irAEs to improve patient outcomes. Future strategies should focus on developing comprehensive management frameworks and enhancing patient and caregiver education to recognize symptoms that warrant immediate medical attention.

Differences in emergency hospitalization trauma patients during and after the COVID-19 pandemic.

The spread of COVID-19 has a huge impact on the medical system, affecting the normal order of routine patients, especially obvious effect on the Shenzhen Third People's Hospital as the designated hospital for COVID-19 patients. After the epidemic was loosened in early December 2022, the normal medical order gradually restored in China. How much was the impact on the admission and treatment of emergency trauma patients during and after the epidemic? This study aims to compare the differences between trauma patients admitted to the emergency department during and after the COVID-19 pandemic. The study included all trauma patients admitted through the emergency department from January 2020 to March 2024. Clinical data were collected, and a retrospective comparative analysis was performed on the characteristics of the two groups of trauma patients during and after the pandemic, including gender, age, average length of hospital stay, proportions of admissions to various departments, proportions of severe cases, proportions of surgical patients, and mortality rates, using statistical methods for analysis. The proportion of male patients during the pandemic (69.98%) was higher than after the pandemic (67.01%). The proportion of patients under 60 years of age during the pandemic was higher than that after the pandemic. There was no significant difference in the average hospital stay between patients during and after the pandemic (P>0.05). Comparisons between the two groups in terms of admissions to departments such as otolaryngology, hepatobiliary surgery, hepatic surgery, orthopedics, urology, neurosurgery, gastroenterology surgery, thoracic surgery, ophthalmology and intensive care unit showed no significant differences (P>0.05). The proportion of surgical patients during the pandemic (75.09%) was higher than after the pandemic (69.53%). The mortality rate during the pandemic (0.13%) was lower than after the pandemic (2.45%). The COVID-19 pandemic has impacted trauma patients admitted through the emergency department, with increases in the proportion of male and younger patients, surgical cases, and a decrease in mortality rates during the pandemic.

Gender-Specific Insights into Depression in Patients with Ischemic Heart Disease: Findings from a Pilot Study Using a Self-Developed Questionnaire

Background/Objectives: Ischemic heart disease (IHD) significantly affects mental health, with gender-specific differences being observed in psychological responses. This pilot study aimed to explore these differences in the demographic, clinical, psychological, psychiatric, and social profile of patients diagnosed with IHD. Methods: A descriptive, cross-sectional design was used, recruiting 183 adult patients diagnosed with coronary artery disease and depression at the Psychiatry Department of Arad County Emergency Hospital, Romania, between May 2021 and May 2024. Data were collected using a self-developed tool, named the Depression Assessment in Ischemic Heart Disease Questionnaire (DA-IHDQ), alongside standardized assessments. Statistical analysis was performed using JASP statistical software (Version 0.19.1, University of Amsterdam, Amsterdam, Netherlands), employing binomial and multinomial tests for categorical data, and Cronbach’s alpha was used to assess internal consistency. Results: This study found significant demographic differences, with female patients exhibiting higher levels of emotional distress and severe depression compared with the male subjects. Women reported greater social isolation and a stronger desire to seek for psychological or psychiatric support. Furthermore, a positive correlation between depression severity and physical symptoms was observed in both genders. Conclusions: These findings highlight the importance of recognizing gender-specific responses to IHD, emphasizing the need for tailored interventions in mental healthcare and cardiac rehabilitation. Future research should further explore these differences to enhance the understanding of the psychosocial/psychiatric aspects of IHD and improve patient outcomes.

Advanced Practice Nurses in Primary Care and Their Impact on Health Service Utilisation, Costs and Access Globally: A Scoping Review.

Synthesise evidence on advanced practice nurses' impact on health services utilisation, healthcare costs, access and quality of care globally. Scoping review. A scoping review guided by the Joanna Briggs Institute Manual for Evidence Synthesis and the PRISMA-ScR checklist. PubMed, CINHAL and Embase for articles between 2016 and 2023. Eighteen studies were included (14 from the United States, two from the Netherlands and one from Australia and New Zealand each). Outcomes included health services utilisation, healthcare costs, access, and quality of care. Most studies reported advanced practice nursing patients had fewer emergency department (9 of 11 studies), fewer hospital (re-)admissions (9 of 10 studies) and primary care visits (3 of 3 studies). Seven (of eight) studies found advanced practice nursing care was associated with significantly lower healthcare costs. For access and quality of care, advanced practice nursing care was associated with lower consultation rates, similar mean number of patients seen, higher protocol adherence, more rural patient care and lower-to-similar quality delivery of chronic disease management. Majority of the studies reported that advanced practice nursing care was associated with lower emergency department visits, hospital readmissions and costs. Access to care outcomes varied under advanced practice nursing care. Advanced practice nursing care can improve patient outcomes, reduce costs and impact access and quality of care. Practices need supportive work environments for advanced practice nurses to deliver high-quality, effective care. Addressing the need for a synthesis of up-to-date evidence, this review highlights the importance of advanced practice nurses in primary care. Findings can inform global workforce development strategies to address health inequalities through effective advanced practice nursing integration. No patient or public contribution is required for this study.

Apallic syndrome of toxic origin: the diagnostic criteria

Background. The global epidemic of strong synthetic opioids and “new” psychoactive substances has increased the number of overdoses that cause prolonged coma with subsequent persistent vegetative state or apallic syndrome. The purpose was to investigate the clinical manifestations, functional and pathohistological changes of the brain in apallic syndrome due to severe drug poisoning (overdose). Materials and methods. A retrospective analysis of the medical data of six people aged 21–38 years with drug poisoning involving illegal methadone, psychostimulants, barbiturates and alcohol was carried out. Results. Among the patients of the toxicology department of the Kyiv City Clinical Emergency Hospital in 2008–2020, an increase in the number of cases of apallic syndrome was noted from 0.025 to 0.14 ‰, which correlates with mass poisonings with illegal methadone. A key role in the diagnosis of apallic syndrome of toxic origin belongs to the neurological and behavioural examination of the patient, which should be carried out by experienced neurologists specialising in counselling people with poisoning. Functional magnetic resonance imaging and positron emission tomography are the modern standard for diagnosing vegetative states; however, these methods are still difficult to access in Ukraine. The visualization zones of the pathological process in the brain in case of toxic damage are mainly basal ganglia and/or thalamus and dentate nucleus, cortical zone of grey matter, periventricular zone of white matter, corticospinal tract and corpus callosum; asymmetric white matter damage as a sign of demyelination; parietal-occipital subcortical vasogenic edema and lesions of the central pons are characteristic. Forensic and histological studies of the cerebral cortex revealed diffuse loss of neurons, neuronophagia, satellitosis, deformed pyramidal neurons with apical dendrites and manifestations of homogenising necrosis, angiomatosis microfoci and neuropil vacuolation, mineralization of the tissue and a moderate glial reaction around the petrifications. Conclusions. For the health care system of Ukraine, it remains relevant to improve the existing definitions and diagnostic criteria of the apallic syndrome, which attracts the attention of doctors in connection with an increase in cases of life extension of patients after waking up from a long coma.

A pilot study of a digital education program (INFORM-AF) for patients living with atrial fibrillation

BackgroundThere are many unmet educational needs for people living with atrial fibrillation (AF). Digital health offers promise; however, evidence is largely lacking. Hence, the objective of this study was to determine the system usability, feasibility, and efficacy of a digital education program (INFORM-AF) for patients living with atrial fibrillation on AF-related knowledge and quality of life.MethodsA pilot study was conducted. Patients diagnosed with AF were recruited from two metropolitan hospitals in Blacktown and Sutherland, New South Wales, Australia, following index hospitalisation. The INFORM-AF education program was delivered using the QStream™ digital platform directly to participants’ smartphones over 6 weeks. Outcome measures included AF knowledge (JAKQ), AF quality of life (AFEQT) and system usability (SUS). Surveys were completed in-hospital at baseline and via phone at 6 weeks, 3, 6 and 12 months.ResultsThirty-two participants were enrolled, 2 were lost to follow up and 2 withdrew. 28 were included in the analyses. Mean age was 60 years (32–79 years), 56% female. There were significant improvements in AF knowledge (62% pre vs 73% post, p < 0.001) and AF quality of life at 6 weeks (53.7 ± 22.4 pre and 67.9 ± 25.5 post, p = 0.016) Knowledge improvements were the greatest in the risk factor, symptom recognition, and when to seek assistance domains. System usability was excellent (mean 84 SUS score).ConclusionsThe INFORM-AF education program demonstrated system usability and feasibility with improvements in AF knowledge and quality of life at 6 weeks, 3, 6 and 12 months. INFORM-AF will be evaluated in a larger clinical trial on outcomes including emergency department visits, hospitalisation, and healthcare utilisation.Trial registrationhttps://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=381531.Date registered 15/04/2021.

Medical emergencies in hospital: The role of treatment escalation plans in out-of-hours decision-making.

Out-of-hours medical emergencies are common in acute hospitals, and are often attended by staff who are unfamiliar with the patient's clinical background. Information in the hospital notes may or may not include guidance about how best to deal with clinical deterioration. The use of Treatment Escalation Plans (TEPs) attempts to address these deficiencies. This was an observational, questionnaire-based evaluation of the experience of trainee hospital doctors who attended out-of-hours medical emergencies. Sixty-five medical emergencies were evaluated by a total of 38 doctors. Thirty patients had a TEP, attended by 20 doctors, and 35 without a TEP were attended by 27 doctors. Information from medical notes to facilitate decision-making was deemed sufficient by the attending doctor in 77% of patients with a TEP, compared to 54% of patients with no TEP. Only 10% of patients with a TEP had their treatment escalated at the time of the call, whereas this occurred in 20% of patients without a TEP (NS). A TEP was deemed 'somewhat' or 'very' helpful by trainees in 21/30 of the cases who had one. In 27/35 cases who did not have a TEP, trainees deemed that it would have been helpful to have had one. Twelve of 38 participants (32%) considered that there was a discrepancy between what was 'expected' and what they considered to be 'right' when managing out-of-hours emergencies. TEPs have an important role in delivering key information that shapes out-of-hours decision-making in deteriorating patients. Both objective outcomes and the subjective quality of medical decision-making are enhanced when a TEP is available.

Artificial Intelligence–Generated Emergency Department Summaries and Hospital Handoffs

Artificial Intelligence–Generated Emergency Department Summaries and Hospital Handoffs

Aggressivity in Schizophrenia: The Risk and Confounders in a Romanian Setting

&lt;p dir="ltr"&gt;&lt;span&gt;There is an increased stigma in Romania regarding schizophrenia patients, who are thought to be violent and dangerous. However, there is little research on this topic that analyzes the exact risk of aggressive behavior, especially considering the high prevalence of alcohol and substance abuse, conditions also associated with a potential risk of violent behavior. The objectives of this study were to compare aggressivity levels between patients with schizophrenia admitted to an emergency hospital and healthy individuals and to find possible risk factors. This case-control study, matched for age and gender included 50 patients hospitalized for schizophrenia and 50 healthy participants from an emergency psychiatric facility in Romania. We collected demographic data and screened for major mental disorders using the Mini International Neuropsychiatric Interview (MINI). Aggressivity levels were measured with the Buss-Perry Aggression Questionnaire (BPAQ). The CAGE questionnaire and the Drug Abuse Screening Test (DAST-10) were used to screen for alcohol and substance use disorder. The results highlighted a 3.93 times increase in aggressivity in the schizophrenia group, with the involvement of specific violent domains. Younger men with alcohol abuse had a higher risk of violent acts. Schizophrenia patients appear to present an increased risk of violence, but this must be carefully assessed and confounders considered. Public health programs are needed to increase treatment compliance and decrease alcohol and other psychoactive substances consumption. &lt;/span&gt;&lt;/p&gt;

Establishing a telemedical supported trans-sectoral collaboration network from community support to emergency care for outpatient care recipients: study protocol of a prospective non-randomized complex intervention study with a pragmatic approach, Stay@Home – Treat@Home

BackgroundDemographic changes in Germany are increasing the number of outpatient care recipients, who often resort to emergency care due to difficulties accessing timely outpatient medical care. Previous studies suggest that early detection and telemedical interventions could reduce unnecessary hospitalizations. The new form of healthcare aims to provide continuous, flexible healthcare for outpatient care recipients using digital technologies to detect health deteriorations and facilitate interventions at home. The goal of our study is to evaluate, whether the number of emergency situations and hospital stays will be reduced, and health outcomes will be improved compared to standard care.MethodsIn this prospective non-randomized complex intervention study with a pragmatic approach, we aim to evaluate a new form of healthcare focused on establishing an interdisciplinary network for outpatient care in the homes of care-dependent individuals. Utilizing a digital interactive health diary, health data will be gathered from participants, caregivers, and healthcare providers, covering both stable primary care and acute situations. A telemedical network will coordinate measures, including non-medical aid, nursing care, and medical assistance. A total of 1,500 participants will be recruited for the intervention group, matched with a control group from health insurance data. A second control group with n=300 will provide self-reported measures. The study is planned to span eight quarters, with data collected from the digital interactive health diary and health insurance records. Evaluation perspectives include health insurance, patients, and healthcare providers, assessing utilization and costs compared to standard care, health status, health-related quality of life, care dependency, interdisciplinary cooperation, and usability of the new technology.DiscussionDemographic change results in a larger older people population, exacerbating mobility issues and care dependency, worsened by the shortage of medical personnel. Stay@Home – Treat@Home aims to enable home health monitoring and care, reducing hospitalizations. The digital interactive health diary supports direct communication, allows remote monitoring, and empowers patients and caregivers to manage health changes. Nursing aid personnel and physicians can access entries for informed interventions. The development of the digital interactive health diary aims to improve the situation of care-dependent individuals. Evaluating its effectiveness and efficiency is crucial for the development and implementation of new technologies.Trial registrationGerman Clinical Trials Register, ID: DRKS00034260, registered on May 14, 2024 (retrospectively registered): https://drks.de/search/de/trial/DRKS00034260 and https://who.int/clinical-trials-registry-platform/network/who-data-set.

Personalized Patient Data and Behavioral Nudges to Improve Adherence to Chronic Cardiovascular Medications

Poor medication adherence is common. Text messaging is increasingly used to change patient behavior but often not rigorously tested. To compare different types of text messaging strategies with usual care to improve medication refill adherence among patients nonadherent to cardiovascular medications. Patient-level randomized pragmatic trial between October 2019 to April 2022 at 3 US health care systems, with last follow-up date of April 11, 2023. Adult (18 to <90 years) patients were eligible based on diagnosis of 1 or more cardiovascular condition(s) and prescribed medication to treat the condition. Patients who did not opt out and had a 7-day refill gap were randomized to 1 of 4 study groups. Generic text message refill reminders (generic reminder); behavioral nudge text refill reminders (behavioral nudge); behavioral nudge text refill reminders plus a fixed-message chatbot (behavioral nudge + chatbot); usual care. Primary outcome was refill adherence based on pharmacy data using proportion of days covered at 12 months. Secondary outcomes were clinical events of emergency department visits, hospitalizations, and mortality. Among 9501 enrolled patients, baseline characteristics across the 4 groups were comparable (mean age, 60 years; 47% female [n = 4351]; 16% Black [n = 1517]; 49% Hispanic [n = 4564]). At 12 months, the mean proportion of days covered was 62.0% for generic reminder, 62.3% for behavioral nudge, 63.0% for behavioral nudge + chatbot, and 60.6% for usual care (P = .06). In adjusted analysis, when compared with usual care, mean proportion of days covered was 2.2 percentage points (95% CI, 0.3-4.2; P = .02) higher for generic reminder, 2.0 percentage points (95% CI, 0.1-3.9; P = .04) higher for behavioral nudge, and 2.3 percentage points (95%, 0.4-4.2; P = .02) higher for behavioral nudge + chatbot, none of which were statistically significant after multiple comparisons correction. There were no differences in clinical events between study groups. Text message reminders targeting patients who delay refilling their cardiovascular medications did not improve medication adherence based on pharmacy refill data or reduce clinical events at 12 months. Poor medication adherence may be due to multiple factors. Future interventions may need to be designed to address the multiple factors influencing adherence. ClinicalTrials.gov Identifier: NCT03973931.

Clinical effectiveness of oral antivirals for non-hospitalized adult COVID-19 patients aged 18–60 years

ABSTRACT Objective To investigate the effectiveness of oral antiviral agents – nirmatrelvir – ritonavir or molnupiravir in non-hospitalized COVID-19 patients aged <60 years. Methods This retrospective cohort study analyzed data of patients aged 18–60 years diagnosed with COVID-19 between 1 January 2022, and 30 June 2023. Propensity score matching was used to balance the demographic and clinical characteristics of patients receiving oral antivirals (nirmatrelvir – ritonavir or molnupiravir) and untreated controls. The primary outcome was a composite of all-cause emergency department visits, hospitalizations, or mortality within 30 days. The secondary outcomes included each individual component of the primary composite outcome. Results Two matched cohorts (antiviral group and control group) comprising 52,585 patients with balanced baseline characteristics were created using propensity score-matching. During follow-up period, the antiviral group demonstrated a lower risk of the primary outcome than the control group (hazard ratio [HR] 0.772, 95% confidence interval [CI] 0.736–0.808, p < 0.001). The antiviral group also exhibited a reduced risk of individual secondary outcomes, including emergency department visits (HR 0.780, 95% CI, 0.738–0.825), hospitalization (HR 0.755, 95% CI, 0.715–0.840), and mortality (HR 0.297, 95% CI, 0.147–0.600). Conclusion Oral antiviral agents were associated with lower risks of all-cause emergency department visits, hospitalizations, and mortality in non-hospitalized COVID-19 patients aged <60 years.

РЕЗУЛЬТАТЫ ДЛИТЕЛЬНОГО МЕДИЦИНСКОГО НАБЛЮДЕНИЯ НЕПОСРЕДСТВЕННЫХ УЧАСТНИКОВ АВАРИИ НА ЧАЭС В РОССИЙСКОЙ ФЕДЕРАЦИИ

Purpose: to present the materials of long-term (38 years) monitoring of the health status of a group of patients who had underwent acute radiation syndrome (ARS) in 1986 as a result of the Chernobyl accident and had been living in the territory of the Russian Federation. Materials and methods: the results of cytogenetic dynamic observation of 74 direct participants in the Chernobyl accident who had been examining at the clinic in the period from 1986 to 2012, as well as the results of dynamic inpatient observation of 10 of them permanently residing in Moscow, are summarized. Medical supervision consisted of annual planned hospitalizations in connection with patient requests, or emergency hospitalizations in connection with the detection of acute or exacerbation of a chronic disease. Laboratory and instrumental examination of organs and organ systems critical to the effects of radiation, as well as an extended cancer search, was carried out. Results: according to cytogenetic studies for all degrees of severity of ARS, starting from the 1st degree, the frequency of translocations in blood lymphocytes significantly exceeds the spontaneous level. The initial level of translocations depends on the initial dose estimate. The time of decrease in the frequency of translocations due to the presence of part of the translocations in unstable cells, from the initial value to an established constant level, apparently occurs in the first 5-8 years. Analysis of individual blood curves revealed transient moderate cytopenia, most often thrombocytopenia. Myelodysplastic syndrome (MDS) and leukemias were detected in 5 patients (2- Moscow group, 3- Ukranian group) from the entire group who underwent ARS as a result of the Chernobyl accident, which significantly exceeds the expected level. The diagnosis of radiation cataract was established in 11 patients. Two patients underwent surgical treatment. In the acute period ARS local radiation injuries (LRI) was detected in 59 patients. By 2005, 38 patients with the effects of LRI were observed (33 in Ukraine and 5 in Moscow). The most severe long-term consequences in the form of pronounced cicatricial atrophic changes, radiation fibrosis, and late radiation ulcers were detected in patients with grade III – IV LRI. 1 out of 10 observed patients developed primary multiple metachronous cancer of the genitourinary system, 2 patients – prostate cancer, 1 – metastatic lesion with an undetected primary tumor, 3 – multiple foci of basal cell skin cancer. The causes of death in 8 out of 10 patients were: cardiovascular pathology, MDS and leukemia, cirrhosis of the liver, oncological disease with undetected primary localization of the tumor, suicide in an oncological patient. Conclusions: The experience of providing medical care to victims of the Chernobyl accident with acute radiation injuries and further in the period of long-term consequences indicates the need to maintain constant readiness to provide medical care in case of a radiation accident, as well as adequate information during and after the accident, which will reduce the long-term consequences. Patients who have undergone ARS need lifelong medical supervision and the provision of necessary medical care. The main causes of permanent disability of patients who have undergone ARS are the consequences of LRI (recurrent late radiation ulcers, radiation fibrosis, contractures, scars, etc.). Radiation cataract is the cause of temporary disability (before surgical treatment). Patients who have undergone ARS need adequate social adaptation. The revealed effect of exposure to relatively uniform radiation is an increase in the frequency of MDS and leukemia.

Nomogram for Predicting in-Hospital Severe Complications in Patients with Acute Myocardial Infarction Admitted in Emergency Department.

There is lack of predictive models for the risk of severe complications during hospitalization in patients with acute myocardial infarction (AMI). In this study, we aimed to create a nomogram to forecast the likelihood of in-hospital severe complications in AMI. From August 2020 to January 2023, 1024 patients with AMI including the modeling group (n=717) and the validation group (n=307) admitted in Changsha Central Hospital's emergency department. Conduct logistic regression analysis, both univariate and multivariate, on the pertinent patient data from the modeling cohort at admission, identify independent risk factors, create a nomogram to forecast the likelihood of severe complications in patients with AMI, and assess the accuracy of the graph's predictions in the validation cohort. Age, heart rate, mean arterial pressure, diabetes, hypertension, triglycerides and white blood cells were seven independent risk factors for serious complications in AMI patients. Based on these seven variables, the nomogram model was constructed. The nomogram has high predictive accuracy (AUC=0.793 for the modeling group and AUC=0.732 for the validation group). The calibration curve demonstrates strong consistency between the anticipated and observed values of the nomogram in the modeling and validation cohorts. Moreover, the DCA curve results show that the model has a wide threshold range (0.01-0.73) and has good practicality in clinical practice. This study developed and validated an intuitive nomogram to assist clinicians in evaluating the probability of severe complications in AMI patients using readily available clinical data and laboratory parameters.

Safety and Diagnostic Utility Pulmonary Embolism Rule-Out Criteria (PERC) and D-Dimer in Emergency Department.

This study aimed to assess the diagnostic value and safety of using Pulmonary Embolism Rule-Out Criteria (PERC) in an emergency care setting. We conducted a retrospective application of the PERC to the patients suspected of having pulmonary embolism (PE) and who underwent computed tomography pulmonary angiogram (CTPA) Karolinska University Hospital's emergency department (ED) from 2016 to 2017. The patient data, including D-dimer (DD) and ED waiting times were extracted from the Karolinska Venous Thromboembolism cohort (VTE cohort). Among the 295 patients included in the cohort, 34 (11.5%) were diagnosed with PE. Of these 202 (68.5%) patients were PERC-positive, while 93 (31.5%) were PERC-negative. Among the 93 PERC-negative patients, three had PE; resulting in a sensitivity of 91% (95% CI: 0.77-0.97), a specificity of 34% (95% CI: 0.29-0.40), and a false negative rate (FNR) of 8.8%. Combining positive DD and PERC resulted in a sensitivity of 100% (95% CI: 0.86-1.00), a specificity of 23% (95% CI: 0.15-0.34), and no FNR. When patients classified as high risk for PE (determined by clinical gestalt) were excluded, no PEs were missed. The median total ED stay was 450 minutes in patients who underwent CTPA compared to 203 minutes in the reference group ( p < 0.0001). Using the PERC rule along with DD testing in low-risk patients effectively rules out PE in ED without the need for further testing. Properly using PERC may significantly reduce patients' waiting time in the ED.

Randomized Study Comparing Continuous Glucose Monitoring and Capillary Glucose Testing in Patients with Type 2 Diabetes After Hospital Discharge.

The benefits of continuous glucose monitoring (CGM) in managing hyperglycemia in hospitalized patients with type 2 diabetes (T2D) have been documented in observation and intervention clinical studies. However, the benefits of CGMs after hospital discharge in improving the care of patients with T2D remain unknown. This pilot randomized clinical trial aimed to compare the effectiveness and safety of using the FreeStyle Libre 2 CGM versus capillary point-of-care (POC) glucose testing (standard of care) in insulin-treated patients with T2D for up to 12 weeks after hospital discharge. We assessed safety (hypoglycemia), efficacy (mean daily glucose), and healthcare utilization (emergency room visits and hospital admissions) associated with the use of FreeStyle Libre 2 CGM compared to capillary POC testing following hospital discharge. Among 100 participants (mean age 54.3±10.7 years, HbA1c 10.46 ± 2.24%, median diabetes duration of 9.0 years, IQR 1.0, 42), there were no significant differences in baseline clinical characteristics between the groups at discharge. We observed a trend toward improved glycemic control in the CGM group, including increased time in range (TIR) 70-180 mg/dl, reduced time above range (TAR) > 180 and 250 mg/dl, and decreased hypoglycemia and insulin requirements after discharge compared to the POC group. There were no differences in emergency room visits or hospitalization between the study groups. The results of this pilot study indicate that the use of CGM leads to improved glycemic control, reduced hypoglycemia, and decreased glucose variability compared to POC glucose testing after hospital discharge. gov ID #: 05822232.

Safety of SGLT2 Inhibitors and Urinary Tract Infections in Clinical Practice—A Cross-Sectional Study

Background and Objectives: Type 2 diabetes (T2DM) affects millions across the globe, generating a veritable public health issue through quality-of-life-reducing chronic complications, among which urinary tract infections are the most common. A shift in the disease managing paradigm from a glucose-centered view to a concept of cardio-reno-metabolic health has uniquely placed SGLT2 inhibitors as viable medication for the complex management of T2DM and its comorbidities. Some concerns have been raised over the increased likelihood of urinary tract infections (UTIs) associated with SGLT2 inhibitor use. The current study aims to evaluate the risk of developing urinary tract infections if patients with type 2 diabetes take SGLT2 inhibitors and determine those factors which make these patients more prone to develop this undesired complication. Materials and Methods: A cross-sectional, noninterventional evaluation of 328 patients with type 2 diabetes consecutively admitted to the Diabetes Clinic of “Pius Brinzeu” County Emergency Hospital in Timisoara, between January and February of 2024, was performed by examining medical charts and running statistical analyses using MedCalc version 22.26.0.0. Results: There was no statistical difference between patients taking SGLT2 inhibitors and those taking other glucose lowering medications when examining the presence of UTIs. Those patients with a higher HbA1c or BMI showed an increased predisposition to contracting UTI. The female gender was also associated with an increased likelihood of UTI. A further evaluation of the sublot of patients taking SGLT2 inhibitors revealed that not only higher BMI or HbA1c could be a predictor for the likelihood of developing UTI, but also a longer duration of T2DM was a predisposing factor. Conclusions: The use of SGLT2 inhibitors did not increase the likelihood of developing a urinary tract infection in this patient population.

Genome Analysis of SARS-CoV-2 Delta variant in the Kurdistan region of Iraq.

Since its isolation in the UK, the SARS-CoV-2 Delta variant has become an epidemic. This study aimed to decipher the viral appearance and genomic characterization of the Delta variant isolated from patients in the Kurdistan region of Iraq. Samples were collected from the West Erbil Emergency Hospital, and infection by SARS-CoV2 was confirmed using Real-Time PCR. The sequenced samples were analyzed and compared to the previously published data on Delta variants. The analysis showed that the variant belongs to SARS-CoV2 Delta variant B.1.617.2, including most of the previously detected mutations in India. The variant includes 13 mutations (11 substitutions and 2 deletions) on the spike region. Some substitutions are the same as the previous Delta isolate (T19R, G142D, T478K, D614G, L452R, P681R, and D950N). However, other substitutions (E156G, T250I, T19A, and L861W) were unique in the spike protein of the Delta variant (EPI_ISL_7405941) found in the Iraq variants. The impact of the novel mutations needs more study, but the common ones are shown to enhance transmission and escape from immunity. Future studies need to focus on the impact of the different vaccines in the Kurdish population on the Delta variant and the effect of the novel mutations on transmissibility and escape from immunity.

Evaluating the Impact of Maternal Lipid Profiles on Fetal Cardiac Function at Mid-Gestation: An Observational Study

Background: Maternal dyslipidemia during pregnancy may influence fetal cardiac development and function, potentially predisposing offspring to cardiovascular diseases later in life. This study aims to evaluate the relationship between maternal lipid profiles and fetal cardiac function at mid-gestation, utilizing detailed echocardiographic assessments. Methods: In this prospective cohort study conducted at the Obstetrics and Gynecology Clinic of the Timișoara Municipal Emergency Hospital, 19 pregnant women aged 27–40 years were recruited and divided into two groups based on their triglyceride levels: Group A (triglycerides ≤ 150 mg/dL, n = 48) and Group B (triglycerides &gt; 150 mg/dL, n = 28). Maternal demographic data and lipid profiles were recorded. Fetal echocardiographic measurements, including global longitudinal strain and ventricular function parameters, were obtained between 20 and 24 weeks of gestation. Statistical analyses, including subgroup comparisons, correlations, and regression analyses, were performed. Results: Maternal BMI was significantly higher in Group B compared to Group A (31.94 ± 2.80 vs. 27.01 ± 2.40 kg/m2, p &lt; 0.001). Group B showed higher mean triglyceride levels (163.43 ± 11.34 mg/dL) compared to Group A (131.42 ± 10.57 mg/dL, p &lt; 0.001). Fetal echocardiographic measurements indicated reduced global longitudinal strain in fetuses of Group B mothers (LV strain: −19.86% ± 6.83% vs. −26.14% ± 5.92%, p = 0.017). Significant correlations were found between maternal triglyceride levels and fetal LV strain (r = 0.536, p = 0.019). Regression analysis identified maternal triglyceride levels and BMI as significant predictors of reduced fetal LV strain (β = 0.45, p = 0.021 and β = 0.39, p = 0.038, respectively). Conclusions: Elevated maternal triglyceride levels, LDL cholesterol, and BMI are associated with altered fetal cardiac function parameters at mid-gestation, suggesting that maternal lipid profiles may impact fetal cardiac development. These findings underscore the importance of monitoring lipid levels during pregnancy and suggest potential benefits of managing dyslipidemia to improve fetal cardiac outcomes. However, the study included only a small sample; therefore, the study needs to be continued with a larger group.

Challenges and perceived impacts of ambulance diversions during emergency department overcrowding: a multi-stakeholder study

ABSTRACT OBJECTIVES Ambulance diversion has emerged as a strategy to address Emergency Department (ED) overcrowding, but the question of when or whether diversion should be triggered is widely debated. Although the positive and adverse impacts of diversion have been primarily studied using quantitative data, little is known about the experience and perceptions of key stakeholders involved in diversions. Our study aims to explore the challenges and impacts of ambulance diversion as experienced by key stakeholders and their suggestions for improving the diversion process. METHODS We conducted semi-structured interviews with key stakeholders including physicians, nurses and paramedics across two EDs and four fire stations. All interviews were audio-recorded following consent and transcribed verbatim. The transcripts were subjected to thematic analysis to identify key themes and sub-themes. Coding discrepancies were resolved through iterative discussions until no new themes were identified. RESULTS A total of 33 stakeholders were interviewed. The primary reasons for ambulance diversions were perceived to be resource constraints in EDs, overcrowding and bed block situations. Challenges during diversions included communication breakdowns, operational delays, lack of clarity in diversion criteria and emotional stress for both Emergency Medical Services (EMS) and hospital staff. Participants felt diversions impacted patient safety, staff morale, system efficiency and could generate inter-institutional conflict. Suggestions on improvements focused on use of alternative care pathways, improving hospital’s flow issues, better information sharing, and optimizing the diversion process through strategizing the timing and duration of diversions. Reworking the hierarchical approach of dissemination of information to ground staff was also suggested. CONCLUSIONS This study highlights that while diversions may offer temporary relief for overwhelmed hospitals, they also pose challenges and negative impacts on receiving hospitals and EMS operations. Our findings underscore the need for systemic improvements to address the root causes of ED overcrowding and enhance understanding among stakeholders involved in diversions.