Patients Attending Emergency Departments Research Articles

Spectrum of diseases and injuries presentation among patients visiting Emergency Department at Janaki Medical College Teaching Hospital

Background & Objectives: The Global Burden of Disease study is a systemic effort to quantify the comparative magnitude of the health loss due to diseases, injuries and risk factors by age, sex and geographies in specific point of time. Five out of ten causes of disease burden in 2017 in Nepal are Non-Communicable Disease (NCDs), ischemic heart disease (IHD), Chronic Obstructive Pulmonary Disease (COPD), Lower Respiratory Tract Infection (LRTI) and Tuberculosis (TB). We aimed to find out the demographic, clinical presentation and outcome of Emergency patients at Janaki Medical College Teaching Hospital (JMCTH) Emergency department. Materials and Methods: A descriptive observational study of patients visiting ED at Janaki Medical College, Ramdaiya, Bhawadi, Dhanusha. Distinctiveness of adult patients who entered the emergency department (ED) in a hospital in Nepal were prospectively recorded in the local emergency registry from 2023-04-15 to 2023-07-18. Post-ED mortality, patient households were followed-up by telephone interviews at 90 days. Patients were diagnosed, treated and admitted in different wards for further evaluation and treatment. Data were collected, analyzed, interpreted, using SPSS version 20. Results: The majority of patients were male (55.58%) predominantly from Dhanusha (79.4%). Common symptoms included musculoskeletal pain (16.5%), abdominal pain (13.3%), and fever (9.9%). The most common diseases were acute pain abdomen (21.26%) and hypertension (11.06%), Abrasions (35%) and cut injuries (13.59%) were the most frequent injuries. Most of the patients were admitted to the observation ward (52.9%). Conclusion: Most patients attending emergency department were young males from Dhanusha, primarily of Terai Madheshi and other castes. The results emphasize the necessity of better emergency care services and public health initiatives in Janakpurdham, as well as the critical role of emergency departments which provides services in wide range of acute and chronic diseases.

To flex or not to flex: oesophageal soft food bolus obstruction in the modern age.

Oesophageal soft food bolus obstruction is a common presentation to emergency departments. Often these patients are given medication with little evidence of efficacy. Although many cases self-resolve, some require removal of the obstruction. Delay in removal can lead to complications such as oesophageal perforation and mediastinitis. Traditionally, removal was performed by ENT surgeons using rigid oesophagoscopy, but oesophago-gastro duodenoscopy offers a safer alternative that does not require a general anaesthetic. The current performance, pathways and outcomes of patients attending emergency departments across three health boards in Scotland were reviewed. In total, 313 patients admitted for oesophageal soft food bolus obstruction were identified. Mixed practice for a single common presentation was observed. In addition, it was found that the majority of patients are already managed by surgery and gastroenterology services with good outcomes and low morbidity. Patients presenting with soft food bolus obstruction should be referred to local surgery and gastroenterology services in the first instance.

Core requirements of frailty screening in the emergency department: an international Delphi consensus study.

Frailty is associated with adverse outcomes among patients attending emergency departments (EDs). While multiple frailty screens are available, little is known about which variables are important to incorporate and how best to facilitate accurate, yet prompt ED screening. To understand the core requirements of frailty screening in ED, we conducted an international, modified, electronic two-round Delphi consensus study. A two-round electronic Delphi involving 37 participants from 10 countries was undertaken. Statements were generated from a prior systematic review examining frailty screening instruments in ED (logistic, psychometric and clinimetric properties). Reflexive thematic analysis generated a list of 56 statements for Round 1 (August-September 2021). Four main themes identified were: (i) principles of frailty screening, (ii) practicalities and logistics, (iii) frailty domains and (iv) frailty risk factors. In Round 1, 13/56 statements (23%) were accepted. Following feedback, 22 new statements were created and 35 were re-circulated in Round 2 (October 2021). Of these, 19 (54%) were finally accepted. It was agreed that ideal frailty screens should be short (<5 min), multidimensional and well-calibrated across the spectrum of frailty, reflecting baseline status 2-4weeks before presentation. Screening should ideally be routine, prompt (<4h after arrival) and completed at first contact in ED. Functional ability, mobility, cognition, medication use and social factors were identified as the most important variables to include. Although a clear consensus was reached on important requirements of frailty screening in ED, and variables to include in an ideal screen, more research is required to operationalise screening in clinical practice.

Proposal and Definition of an Intelligent Decision- Support System Based on Deep Learning Techniques for the Management of Possible COVID-19 Cases in Patients Attending Emergency Departments

Proposal and Definition of an Intelligent Decision- Support System Based on Deep Learning Techniques for the Management of Possible COVID-19 Cases in Patients Attending Emergency Departments

Analysis of Blood Cultures of Patients Presenting to the Emergency Department in a Tertiary Healthcare Hospital in Mumbai

Aim and objectives: Analysis of blood cultures taken from patients attending emergency departments is an important exercise in determining the common pathogens prevalent in the region. The distribution of these infective pathogens keeps changing over time, and the rise in antimicrobial-resistant pathogens makes it difficult to routinely conduct effective empirical broad-spectrum antimicrobial therapy. This study aimed to analyse the results of blood cultures obtained from patients presenting to the Emergency Department of a Tertiary Healthcare Hospital in Mumbai and provide updated and detailed information on the distribution of causative pathogens in adult sepsis and study their antibiotic-susceptibility pattern. Materials and methods: A hospital-based prospective cross-sectional study of 121 positive blood culture reports was conducted at the Department of Emergency Medicine, Fortis Hospital Mulund, Mumbai, which included all adult (age &gt; 18 yrs) suspected sepsis patients arriving to the Emergency Department whose blood cultures were sent from the Emergency Department from January 2021 to December 2021. Results: The study showed that mean age of the study cases was 59.3 years with 59.5% cases that belonged to the elderly age group with a male predominance (56.2% males–43.8% females). Overall, Gram-negative isolates were seen in 95% cases, while Gram-positive isolates were seen in only 1.7% cases. The most common organism isolated from cases with sepsis was Escherichia coli (45.5%) followed by Klebsiella (13.2%), Salmonella (10.7%), Stenotrophomonas (7.4%) and Pseudomonas (5%). Among Gram-positive organisms, Staphylococcus aureus was the most common organism isolated (1.7%). Escherichia coli isolates showed poor sensitivity towards fluoroquinolones and cephalosporins while good sensitivity towards aminoglycosides, carbapenems and combination drugs like Cefoperazone and Sulbactam and Piperacillin and Tazobactam. These findings suggest that Gram-negative organisms are the most common isolates observed in this study, with E. coli being the predominant pathogen followed by Klebsiella. High-level antimicrobial resistance was observed in sepsis cases for commonly used antimicrobials like fluoroquinolones and cephalosporins.

Predictive Factors and Bio-Clinical Scoring Systems of Massive Blood Transfusion in Trauma Patients Attending Emergency Department

Predictive Factors and Bio-Clinical Scoring Systems of Massive Blood Transfusion in Trauma Patients Attending Emergency Department

Treatment Outcome, Pattern of Injuries and Associated Factors Among Traumatic Patients Attending Emergency Department of Dessie City Government Hospitals, Northeast Ethiopia: A Cross-Sectional Study.

Traumatic injuries are a major cause of emergency room visits and hospital workload, and they are a global health concern. Therefore, this study aimed to assess the pattern of injuries, treatment outcomes, and associated factors among traumatic patients attending the emergency department of Dessie City Government Hospitals, Northeast Ethiopia. An institutional-based retrospective cross-sectional study was conducted among 415 traumatic patients selected by using a systematic random sampling technique, from July 1, 2019, to June 30, 2022. Data were collected through document review. The data were presented with frequency tables and graphs. Data were entered using EPI data version 4.6 and exported to SPSS version 26 for analysis. Both bi-variable and multivariable logistic regression analyses were performed to analyze the relationship between the independent variable and the outcome variable. As a measure of association, the adjusted odds ratio was utilized, which has a 95% confidence level. Statistically significant variables were those with a p-value of less than 0.05. From 420 patient charts, 415 traumatic patients' charts were reviewed in this study, with a response rate of 98.8%. The prevalence of good treatment outcomes among traumatic patients was found to be 67% [95% CI: 62.2, 72.0]. In the final multivariable analysis, having comorbidity [AOR=, 0.31 95% CI: 0.16, 0.60], arriving within one hour [AOR=4.79, 95% CI: 2.10, 10.94], arriving two up to twenty-four hours [AOR=2.25, 95% CI: 1.34, 3.78] and being conscious at admission [AOR=1.82, 95% CI: 1.02, 3.26] had a significant association with a good treatment outcome among traumatic patients. Trauma constitutes a major public health problem in our setting and contributes significantly to unacceptably high morbidity and mortality. Interventions should be targeted at urgent injury prevention and management strategies, along with the establishment of a pre-hospital emergency medical service system.

Frailty assessment of older patients in the emergency department.

An ageing population is leading to an increase in patients attending emergency departments (EDs) with comorbidities and age-related syndromes such as frailty. Frailty is a clinical syndrome defined as an increased vulnerability to age-related or disease-related insults in older adults due to diminishing physiological reserves. It also places increased demands on staff and hospital services. Screening for frailty early in the care pathway ensures goal-directed and timely care. This article provides an overview of frailty and its assessment in older people presenting to the ED. It discusses the most commonly used frailty assessment tool in the ED, the Clinical Frailty Scale, and identifies that the results of frailty assessment should be used to initiate appropriate individualised care in older patients.

Etiological Spectrum of Surgical Acute Abdomen among patients attending Emergency Department

Background: Acute abdomen is a common health issue that ranges from trivial to life threatening condition thus requiring hospital admissions, correct diagnosis and treatment. Aim: To determine the etiological spectrum of surgical acute pain abdomen among patients attending emergency department at government hospital-Lahore. Study design: Cross sectional study. Methodology: Present study enrolled both genders (n=154) through simple random sampling technique following ethical approval. All baseline investigations were done at time of enrollment. All information was collected through structured questionnaire. Radiological investigations like ultrasonography (USG) and computer tomography (CT) scan were done on appropriate indication. Data was evaluated by using SPSS v.24. Chi-square test was used to compare the symptoms, diagnosis, treatments and clinical signs between the both genders. A p-value ≤0.05 was considered significant. Results: Mean age of the patients was 41.4±16.5 years. There were 82(53.2%) males and 72(46.8%) females. Symptoms like abdominal pain, burning micturation, diarrhea and guarding were significantly higher in males. The proportion of localized pain was higher in female as compared to male but statistically insignificant. Practical Implication: As there is a high incidence of acute abdomen among our population and there is lack of local data regarding exact epidemiology of this health issue. The findings of this study emphasized the etiological spectrum of acute surgical abdomen. This helped in pointing out the loop holes regarding correct diagnosis while identifying different presentations of serious illnesses. Conclusion: It was concluded that patients present differently with acute abdomen so common diagnosis should be made and prompt examination need to be done. Timely intervention and management can therefore prevent major complications. Keywords: Acute abdomen, Appendicitis, Perforation peritonitis and Surgical Intervention.

Evaluating the impact of a pulse oximetry remote monitoring programme on mortality and healthcare utilisation in patients with COVID-19 assessed in emergency departments in England: a retrospective matched cohort study

BackgroundTo identify the impact of enrolment onto a national pulse oximetry remote monitoring programme for COVID-19 (COVID-19 Oximetry @home; CO@h) on health service use and mortality in patients attending Emergency...

Translation and cultural adaption of the emergency department-consumer assessment of healthcare providers and systems (ED CAPHS)-A questionnaire to measure patient experience in Denmark.

The aim of this study was to translate and culturally adapt The Emergency Department-Consumer Assessment of Healthcare Providers and Systems (ED CAPHS) to the Danish ED context. In Denmark, a large number of patients attend emergency departments (ED) every year. During their ED visits, examinations, tests and encounters with different healthcare professionals occur frequently. Moreover, patients receive much information. Patients' direct experiences of care can provide valuable insights into what works and what does not in health care. The emergency department-consumer assessment of healthcare providers and systems (ED CAPHS) is a valid questionnaire designed to measure patients' experiences with ED care and is intended for patients discharged home following their ED visit. The translation process was systematically planned and executed using the principles of good practice for the translation and cultural adaptation process for patient-reported outcomes (PRO) guidelines by the ISPOR. The translation and cultural adaption process were successfully conducted. Three items concerning language and race were omitted as they are not distinct in Danish ED context. Furthermore, a few conceptual factors and linguistic challenges were discussed and harmonised during the reconciliation and harmonisation process respectively. The Danish survey ED CAPHS DK containing 32 items was proofread and finalised. Overall, patients reported that the survey was relevant and comprehensive, as it focused on essential factors when discharged directly home after an ED admission. ED CAPHS DK is found to be content valid and ready for use. However, a future study testing the Danish version using confirmative factor analysis and internal consistency reliability is needed to ensure construct validity and reliability.

Factors associated with longer wait times, admission and reattendances in older patients attending emergency departments: an analysis of linked healthcare data

Background and objectiveCare for older patients in the ED is an increasingly important issue with the ageing society. To better assess the quality of care in this patient group, we...

HEAR SCORE: A Proposal to Use Only Anamnestic and EKG Data to Evaluate Patients with Very Low Risk Chest Pain

Chest pain in a common symptom in patients attending Emergency Department worldwide and can be related to an extensive variety of disorders, so it represents a diagnostic and logistic challenge for Emergency physicians. The aim of this study is to identify a subgroup of patients with a low pre-test probability of major adverse cardiac events, for which there is no need of troponin testing, to avoid potential harm from false-positive testing and long length stay in ED. We retrospectively analyzed data of patients that attended ED of Siena complaining chest pain from January 2019 to August 2021. We used a modified HEART score, only evaluating history, EKG, age and risk factors. A 0-1 HEAR score was considered at very low risk for adverse cardiac events. Sensitivity, specificity, PPV, NPV and incidence of adverse cardiac events were calculated. The accuracy of HEAR score was evaluated with ROC curve. The correlation of adverse cardiac events with HEAR score 0-1 was evaluated with Fisher test. In this study, we included 2046 patients, of which 279 were classified at very low risk. The incidence of adverse cardiac events in this population was 0.36%. Sensibility was 97.5%, sensitivity 61%, PPV 36.8%, NPV 99.1%. The AUC for global accuracy of HEAR score was 0.945. Chi-square's P value for the association between adverse cardiac events and HEAR score 0-1 was <0.001. The draft presented in this study answers to the necessity to make a personalized path for patients attending ED with chest pain. The choice to avoid troponin testing may appear risky, but data from this study and from other similar show that a careful evaluation of clinical data and EKG allows to correctly discriminate which patients will not have adverse cardiac events, reducing the length of stay in ED.

Oncology-related emergencies discharged from the emergency department.

Cancer patients attending emergency departments (EDs) often present with acute symptoms and are frequently admitted. This study aimed to characterise the profile of oncology patients who were discharged from the ED. This was a retrospective audit of patients with cancer-related diagnoses who presented to the ED at the Singapore General Hospital (SGH) over a 6-month period from 1 October 2018 to 31 March 2019 and were directly discharged from the ED. Data was extracted from the hospital's electronic medical record system. Of the 492 participants included in the study, the majority were triaged as Priority 2 (61.4%), while 30.7% were triaged as Priority 3, 6.9% as Priority 1 and 1.0% as Priority 4. There was no statistical difference between the National Early Warning scores across the different triage categories in these patients. The most common complaint was (44.3%), followed by genitourinary symptoms (19.5%) and those related to devices, catheters or stomas (17.3%). More investigations of all types were done for patients being managed in Priority 1 (57.6%) than in the other triage categories (40.1% for Priority 2, 23.2% for Priority 3 and 12.0% for Priority 4). Treatment procedures carried out were mainly symptomatic (analgesics, antiemetics, proton pump inhibitors) for 79.8% of the patients. There were no significant differences in the proportion of patients requiring various treatment modalities among the triage categories. Selected oncological patients may potentially be managed in an ambulatory setting.

Magnitude and associated factors of delirium among patients attending emergency department at Jimma medical center, Jimma, southwest Ethiopia, 2022

BackgroundDelirium is a severe neuropsychiatric condition that occurs frequently in all medical settings. It has been associated to serious consequences like higher mortality, institutionalization, and longer hospital stays. Delirium is missed in emergency rooms in 57% to 83% of patients, despite its frequent incidence and detrimental repercussions.ObjectivesThe purpose of this study was to determine the prevalence and contributing causes of delirium in patients who visited the emergency room at Jimma Medical Center in Jimma, southwest Ethiopia, in 2022.MethodsFrom August 1 through September 30, 2022, a cross-sectional study was undertaken at a hospital. The study enrolled 422 participants, who were chosen through a systematic random sampling. The Richmond Agitation Sedation Scale (RASS) was used to evaluate different subtypes of delirium and level of arousal. The Confusion Assessment Method (CAM) was used to determine the presence or absence of delirium. Epi Data V3.1 was used to enter the data, and Version 20 of the Statistical Package for Social Scientists was used to export it (SPSS V20). Bivariate and multivariable logistic regressions were performed to identify the related factors. Variables with a p-value of less than 0.05 were considered to be significant.Result26.6% of participants (n = 107) were found to have delirium. Alcohol use (AOR = 3.6, 95% CI (2.5–8.1), visual impairment (AOR = 2.34, 95% CI (1.89–3.68), frequent admission (AOR = 3.47, 95% CI (1.24–7.34), bladder catheterization (AOR = 1.4, 95% CI (1.21–2.89), and benzodiazepine exposure (AOR = 1.5, 95% CI (1.01–2.3) had a significant association with delirium.ConclusionAccording to this study, delirium was very common among patients in the emergency room. Benzodiazepine exposure, numerous admissions, visual impairment, current alcohol consumption, bladder catheterization, and frequent admissions all significantly increased the risk of delirium. To address identifiable causes and enhance patients’ health outcomes, early recognition is crucial.

Prediction rule of supratherapeutic peak serum salicylate level in poisoning patients attending emergency departments

Background:Analgesic poisoning is common in Hong Kong. Analgesics containing salicylate are easily available. Salicylate poisoning may be encountered in the daily practice of the accident and emergency department. The issue of routine salicylate screening was discussed in a number of articles, and the viewpoints of most authors were that routine salicylate screening was unnecessary.Objectives:The primary outcome is to explore the predictive factors of supratherapeutic peak serum salicylate level (&gt;2.17 mmol/L) and delineate the role of routine screening serum salicylate level in poisoned patients attending the accident and emergency department.Methods:This is a retrospective cohort study. Poisoning cases presented to Hong Kong Poison Information Centre between 1 July 2008 and 31 October 2020 with serum salicylate level checked were included. The demographics, laboratory parameters and clinical outcomes were reviewed.Results:There were 8673 cases included with serum salicylate level checked, accounting for 17% of all poisoning cases. Sixty-six (0.76%) cases had supratherapeutic peak serum salicylate level and 11 (0.13%) of them were undeclared salicylate ingestion. Worse clinical outcomes were observed in cases with supratherapeutic peak serum salicylate level. Univariate analysis showed that tinnitus, hyperthermia, alkalaemia, metabolic acidosis, respiratory alkalosis and therapeutic use of aspirin were significantly associated with supratherapeutic peak serum salicylate level. Variables with p &lt; 0.3 were entered into the backward stepwise logistic regression by likelihood ratio. A clinical prediction rule with three attributes (tinnitus, therapeutic use of aspirin and partial pressure of CO2&lt;5 kPa) was derived. It showed 100% sensitivity in internal validation.Conclusion:Serum salicylate level should be checked in poisoned patients with (1) tinnitus, (2) the therapeutic use of aspirin or (3) partial pressure of CO2&lt;5 kPa in arterial or venous blood gas. Routine salicylate screening remained a tool for clinicians not experienced in toxicology.

Accuracy of substance exposure history in patients attending emergency departments after substance misuse; a comparison with biological sample analysis

Context Acute toxicity caused by illicit substance use is a common reason for emergency department (ED) presentation. Knowledge of the substances involved is helpful for predicting and managing potential toxicity, but limited information is available about the accuracy of patient-reported substance exposure. This study assessed the accuracy of the history of exposure in those reporting use of a single substance by comparison with those identified by detailed toxicological analysis, focusing on synthetic cannabinoid receptor agonists (SCRA). Methods Adults (≥16 years) presenting between March 2015 and July 2021 to participating UK hospitals with toxicity after reporting use of a single illicit substance were included. Exposure details were documented from medical records and blood and/or urine samples analysed using high-resolution accurate mass liquid chromatography-mass spectrometry (HRAM LCMS). Sensitivity, specificity, and positive and negative predictive values of the exposure history were calculated by comparison with biological sample analysis (“gold standard”). Results Single substance exposure was reported for 474 (median age 33 years, IQR: 18 range 16–75, 80% males) patients. Analysis commonly identified multiple substances (Median 3, IQR 2–5). A history of exposure was documented for 121 of 151 patients where a SCRA or metabolite was detected on analysis (sensitivity 80.1%, 95% CI 72.9, 86.2%). Corresponding proportions were lower for 3,4-methylenedioxymethamphetamine (MDMA, 44/70, 62.9%., 95% CI 50.5%, 74.1%), heroin 41/108 (38.0% 95% CI 28.8–47.8%) and cocaine (22/56, 31.3%, 95% CI 20.9, 43.6%). Conclusions Multiple undeclared substances were detected analytically in most patients reporting single substance use. Clinicians should be alert to the potential presence and toxicity of unreported substances when managing patients presenting after substance misuse.

P15 Acupuncture treatment of Costochondritis, a case series

Introduction/BackgroundI had been practising acupuncture for 30 years and noticed while working in the rheumatology clinic that costochondritis had a particular response to acupuncture. As this condition is extremely debilitating and often misdiagnosed, a case series of 8 cases is presented, the majority of whom were seen in primary care.Description/MethodCostochondritis is characterised by anterior chest pain associated with painful tender costochondral (CC) joints felt on palpation. These mainly affect the 2nd to 5th costochondral junctions, either unilateral or bilateral. Other areas of the anterior and lateral chest wall can also be affected. The pain is often severe and nocturnal, of sudden onset and can be associated with shock, nausea and dyspnoea, causing patients to call for an ambulance. Tietze's syndrome is a rare variant of this, usually affecting younger patients.Patients with persistent chest wall pain were offered acupuncture. Details of age, duration of symptoms, number of treatments and VAS pain scores were recorded day and night, (Table 1) pre and post treatment Patients with thoracic pain were excluded.0.25*25mm and 0.25*30mm needles were used with silicon tips and a guide tube, to help prevent painful insertion. An infra-red lamp (Bio-lamp) was used + electro-acupuncture (EA) if insufficient improvement after two close treatments, sessions were continued weekly.Acupuncture points used were local tender/trigger points + distal Chinese points P6 and LI4. Other points used were CV 17, GB 34, SI6, GB39 or Sp 6 and St36. An average of 4.7 sessions were needed.Audit of Acupuncture Treatment Table 1P15 Table 1PATIENTAGEDURATION OFNUMBER OFVAS INITIAL (0-10)VAS FINALYEARSPROBLEMTREATMENTSDAYNIGHTDAYNIGHT1375 MTHS410100022618 MTHS8 (1 EA)5.57.5023653 WEEKS5 (+EA)79114584 DAYS4972256210 WEEKS7 (+EA)68026346 WEEKS447227289 MTHS314008255 YEARS38700Recurrence of pain3651 WEEK4 (+EA)88126345 WEEKS228227282 WEEKS11311Six patients took daily analgesia which was rapidly reduced to nil. All completed their treatment until their pain stabilised. There were no adverse events.Average improvement in the day was 89% and night 85%. Recurrences of pain improved by 11% in the day and 72% at night. The attacks of severe chest pain and dyspnoea stopped, abating anxiety.Discussion/ResultsCostochondritis is a highly debilitating condition and I had noticed that acupuncture could be a dramatic treatment for this[i]. It can affect up to a third of patients attending emergency departments with atypical chest pain[ii] and 1-3% of patients in primary care[iii].It seems to be a missed diagnosis by Accident and Emergency (A&E) doctors and GPs, perhaps because the chest wall was not carefully palpated. One patient had ankylosing spondylitis (AS) and another had systemic lupus erythematosus but attributed her pain to prolonged laughter. Five patients attended cardiology clinics including one who had a coronary angiogram. Another had tests for upper abdominal pain which also were normal.All the patients were female although quoted F:M ratio is 7:3Differential diagnoses include: acute coronary syndromes, lung problems, trauma, upper gastroenterology pathology or neoplasiaPathogenesis is unclear but the onset can be acute and follow:Respiratory tract infection Extreme sneezing, coughing or laughterChest wall trauma Micro trauma from costovertebral dysfunctionFibromyalgia Inflammation from inflammatory joint disease.[i] Alexander R; White A. Acupuncture in a Rheumatology Clinic. Acupuncture in Medicine; Dec 2000 vol.18 (no.2): 100-103[ii] Disla E; Rhim HR; Reddy A; Karten I; Taranta A. A prospective analysis in an emergency department setting. Arch Intern Med. 1994; 154(21):2466-2469[iii] Ayloo A; Cvengros T; Marella S. Evaluation and treatment of musculoskeletal chest pain. Prim Care (Review) Dec 2013 40(4): 863-87Key learning points/ConclusionNormal management of costochondritis includes analgesia, physiotherapy, steroid injections and occasionally surgery[i]. 30% can have protracted pain. There are isolated reports of acupuncture for this condition, integrated with conventional medicine[ii] [iii]. Acupuncture also has been used for myofascial trigger points including costochondritis[iv].Acupuncture is now an accepted modality of pain management and in 2021 was recommended in NICE guidelines for the treatment of Chronic Primary Pain alongside exercise programmes and CBT ahead of analgesic medication[v]. It has also been recommended in the management of low back pain in patients aged 60 years and over as a non-drug treatment[vi].This paper highlights the fact that acupuncture appears to be a safe effective treatment for costochondritis, with further research and more access needed for this therapeutic modality.Increased awareness of this condition would make complex invasive investigations less necessary.[i] Gologorsky R; Hornik B; Velotta J. Surgical Management of Medically Refractory Tietze's Syndrome. Annals of Thoracic Surgery; Dec 2017; vol. 104 (no. 6)[ii] Jonkman FAM.; Jonkman-Buidin M.L; Stolwijk P.W.J. Surprise after successful treatment of a patient with noncardiac chest pain using acupuncture. Medical Acupuncture; Feb 2015; vol.27(no 1):83-90[iii] Lin, Katerina; Tung, Cynthia. Integrating Acupuncture for the Management of Costochondritis in Adolescents. Medical Acupuncture; Oct 2017; vol.29(no 5): 327-330[iv] Baldry P. Cardiac and non-cardiac chest wall pain. Acupuncture in Medicine;1997; vol.15(no.2): 42-45[v] NICE guideline; Chronic Pain (primary and secondary) in over 16s (NG 193 April 2021)[vi] Traeger A; Underwood M;Ivers R; Buchbinder R. Low back pain in people aged 60 years and over. BMJ 2022 vol. 376: e066928

Clinical features associated with ADB-BUTINACA exposure in patients attending emergency departments in England

Objective Synthetic cannabinoid receptor agonists (SCRA) are commonly encountered new psychoactive substances. Here we report the recent detection of ADB-BUTINACA in samples from patients attending United Kingdom emergency departments with toxicity after suspected drug misuse and describe the associated clinical features. Methods Consenting adults (≥16 y) presenting to participating hospitals with toxicity after suspected drug misuse have been included in the Identification Of Novel psychoActive substances (IONA) study since March 2015. Demographic and clinical features are recorded and blood and/or urine samples analysed using high-resolution accurate mass liquid chromatography-mass spectrometry. Results By December 2021, analytical data were available for 1279 IONA participants and ADB-BUTINACA was detected in at least one sample from 10 (9 males, age range 16–51 median 45 years), all presenting since February 2021. Smoking ‘spice’ was reported by four patients, two had ingested edible “cannabis” gums and four reported heroin use (2 intravenous, 1 smoked, 1 route not known). Co-use of pregabalin (oral) and crack cocaine (smoked) were also reported. In 3 cases ADB-BUTINACA was the only substance detected, while in seven other substances of misuse were also detected including other SCRA, opioids, benzodiazepines cocaine and pregabalin. Clinical features reported in these 2 groups respectively included reduced level of consciousness (3/3, 6/7), agitation (0/3, 4/7), tachycardia (0/3, 3/7), seizures (1/3, 1/7), hallucinations (1/3, 1/7), hypotension (1/3, 1/7). Metabolic acidosis (1/3, 0/7) and respiratory acidosis (1/3, 0/7), All 10 patients recovered with supportive care, including intubation and ventilation for one case. The median length of hospital stay was 19 h (range 2.6–131 h). Conclusions ADB-BUTINACA has recently emerged as a drug of misuse in England. Clinical features of toxicity are consistent with those of other SCRA and include reduced level of consciousness, respiratory and/or metabolic acidosis, seizures, confusion and hallucinations.

Management strategies and outcomes of acute coronary syndrome (ACS) during Covid-19 pandemic

BackgroundThe COVID-19 outbreak represents a significant challenge to international health. Several studies have reported a substantial decrease in the number of patients attending emergency departments with acute coronary syndromes (ACS) and there has been a concomitant rise in early mortality or complications during the COVID-19 pandemic. A modified management system that emphasizes nearby treatment, safety, and protection, alongside a closer and more effective multiple discipline collaborative team was developed by our Chest Pain Center at an early stage of the pandemic. It was therefore necessary to evaluate whether the newly adopted management strategies improved the clinical outcomes of ACS patients in the early stages of the COVID-19 pandemic.MethodsPatients admitted to our Chest Pain Center from January 25th to April 30th, 2020 based on electronic data in the hospitals ACS registry, were included in the COVID-19 group. Patients admitted during the same period (25 January to 30 April) in 2019 were included in the pre-COVID-19 group. The characteristics and clinical outcomes of the ACS patients in the COVID-19 period group were compared with those of the ACS patients in the pre-COVID-19 group. Multivariate logistic regression analyses were used to identify the risk factors associated with clinical outcomes.ResultsThe number of patients presenting to the Chest Pain Center was reduced by 45% (p = 0.01) in the COVID-19 group, a total of 223 ACS patients were included in the analysis. There was a longer average delay from the onset of symptom to first medical contact (FMC) (1176.9 min vs. 625.2 min, p = 0.001) in the COVID-19 period group compared to the pre-COVID-19 group. Moreover, immediate percutaneous coronary intervention (PCI) (80.1% vs. 92.3%, p = 0.008) was performed less frequently on ACS patients in the COVID-19 group compared to the pre-COVID-19 group. However, more ACS patients received thrombolytic therapy (5.8% vs. 0.6%, p = 0.0052) in the COVID-19 group than observed in the pre-COVID-19 group. Interestingly, clinical outcome did not worsen in the COVID-19 group when cardiogenic shock, sustained ventricular tachycardia, ventricular fibrillation or use of mechanical circulatory support (MCS) were compared against the pre-COVID-19 group (13.5% vs. 11.6%, p = 0.55). Only age was independently associated with composite clinical outcomes (HR = 1.3; 95% CI 1.12–1.50, p = 0.003).ConclusionThis retrospective study showed that the adverse outcomes were not different during the COVID-19 pandemic compared to historical control data, suggesting that newly adopted management strategies might provide optimal care for ACS patients. Larger sample sizes and longer follow-up periods on this issue are needed in the future.