Current Issue : April - June Volume : 2020 Issue Number : 2 Articles : 6 Articles
Background: The Japan Coma Scale (JCS) score has been widely used to assess patientsâ?? consciousness level in\nJapan. JCS scores are divided into four main categories: alert (0) and one-, two-, and three-digit codes based on an\neye response test, each of which has three subcategories. The purpose of this study was to investigate the utility of\nthe JCS score on hospital arrival in predicting outcomes among adult trauma patients.\nMethods: Using the Japan Trauma Data Bank, we conducted a nationwide registry-based retrospective cohort\nstudy. Patients 16 years old or older directly transported from the trauma scene between January 2004 and\nDecember 2017 were included. Our primary outcome was in-hospital mortality. We examined outcome prediction\naccuracy based on area under the receiver operating characteristic curve (AUROC) and multiple logistic regression\nanalysis with multiple imputation.\nResults: A total of 222,540 subjects were included; their in-hospital mortality rate was 7.1% (n = 15,860). The 10-\npoint scale JCS and the total sum of Glasgow Coma Scale (GCS) scores demonstrated similar performance, in which\nthe AUROC (95% CIs) showed 0.874 (0.871â??0.878) and 0.878 (0.874â??0.881), respectively. Multiple logistic regression\nanalysis revealed that the higher the JCS score, the higher the predictability of in-hospital death. When we focused\non the simple four-point scale JCS score, the adjusted odds ratio (95% confidence intervals [CIs]) were 2.31 (2.12â??\n2.45), 4.81 (4.42â??5.24), and 27.88 (25.74â??30.20) in the groups with one-digit, two-digit, and three-digit scores,\nrespectively, with JCS of 0 as a reference category.\nConclusions: JCS score on hospital arrival after trauma would be useful for predicting in-hospital mortality, similar\nto the GCS score....
Background: Occult hemorrhagic shock secondary to uterine rupture represents a true obstetric emergency and\ncan result in significant morbidity and mortality for both the patient and the fetus. Multiparity and prior cesarean\nsections are known risk factors. Typically, these patients present late in gestation, often secondary to the physiologic\nstresses on the uterus related to contractions. This pathology is less common earlier in pregnancy and can often be\noverlooked in the acute setting.\nCase presentation: We present the case of a 31-year-old female with three prior gestations, two parities and two\nprior cesarean sections, resulting in three live births, who presented to the Emergency Department (ED) 22-weeks\npregnant with acute onset dyspnea and an episode of syncope. Due to her altered mental status there was\nconcern for occult shock, despite normal vital signs. Large amounts of free fluid in the abdomen were noted on\nbedside ultrasonography with a high suspicion for uterine pathology. She was resuscitated with blood and taken\nimmediately to the operating room for surgical management where she was found to have had a uterine rupture.\nConclusion: This case highlights a rare presentation of a well-known obstetric emergency, due to the patientâ??s\ndevelopment of uterine rupture early in gestation. Consequently, emergency physicians should consider atraumatic\nhypovolemic shock, secondary to this obstetric catastrophe, even at a stage that far precedes its expected presentation.\nIn addition, we make note of how this case validated our departmentâ??s integrated emergency medicine model, the\nfirst in the State of Israel....
Background: Academic and non-academic emergency departments (EDs) are regularly compared in clinical\noperations benchmarking despite suggestion that the two groups may differ in their clinical operations\ncharacteristics. and outcomes. We sought to describe and compare clinical operations characteristics of academic\nversus non-academic EDs.\nMethods: We performed a descriptive, comparative analysis of academic and non-academic adult and general EDs\nwith 40,000+ annual encounters, using the Academy of Academic Administrators of Emergency Medicine (AAAEM)/\nAssociation of Academic Chairs of Emergency Medicine (AACEM) and Emergency Department Benchmarking\nAlliance (EDBA) survey results. We defined academic EDs as primary teaching sites for emergency medicine (EM)\nresidencies and non-academic EDs as sites with minimal resident involvement. We constructed the academic and\nnon-academic cohorts from the AAAEM/AACEM and EDBA surveys, respectively, and analyzed metrics common to\nboth surveys.\nResults: Eighty and 454 EDs met inclusion criteria for academic and non-academic EDs, respectively. Academic EDs\nhad more median annual patient encounters (73,001 vs 54,393), lower median proportion of pediatric patients (6.3%\nvs 14.5%), higher median proportion of EMS patients (27% vs 19%), and were more commonly designated as Level I\nor II Trauma Centers (94% vs 24%). Median patient arrival-to-provider times did not differ (26 vs 25 min). Median\nlength-of-stay was longer (277 vs 190 min) for academic EDs, and left-before-treatment-complete was higher (5.7%\nvs 2.9%). MRI utilization was higher for academic EDs (2.2% patients with at least one MRI vs 1.0 MRIs performed\nper 100 patients). Patients-per-hour of provider coverage was lower for academic EDs with and without\nconsideration for advanced practice providers and residents.\nConclusions: Demographic and operational performance measures differ between academic and non-academic\nEDs, suggesting that the two groups may be inappropriate operational performance comparators. Causes for the\ndifferences remain unclear but the differences appear not to be attributed solely to the academic mission....
Objectives: We investigated an approach for the diagnosis of traumatic axonal injury\n(TAI) of the spinothalamic tract (STT) that was based on diffusion tensor tractography (DTT)\nresults and a statistical comparison of individual patients who showed central pain following mild\ntraumatic brain injury (mTBI) with the control group. Methods: Five right-handed female patients\nin their forties and with central pain following mTBI and 12 age-, sex-, and handedness-matched\nhealthy control subjects were recruited. After DTT reconstruction of the STT, we analyzed the STT\nin terms of three DTT parameters (fractional anisotropy (FA), mean diffusivity (MD), and fiber\nnumber (FN)) and its configuration (narrowing and tearing). To assess narrowing, we determined\nthe area of the STT on an axial slice of the subcortical white matter. Results: the FN values were\nsignificantly lower in at least one hemisphere of each patient when compared to those of the control\nsubjects (p < 0.05). Significant decrements from the STT area in the control group were observed in\nat least one hemisphere of each patient (p < 0.05). Regarding configurational analysis, the STT\nshowed narrowing and/or partial tearing in at least one hemisphere of each of the five patients.\nConclusions: Herein, we demonstrate a DTT-based approach for the diagnosis of TAI of the STT.\nThe approach involves a statistical comparison between DTT parameters of individual patients\nwho show central pain following mTBI and those of an age-, gender-, and handedness-matched\ncontrol group. We think that the method described in this study can be useful in the diagnosis of\nTAI of the STT in individual mTBI patients....
Background: The diagnosis of pediatric pancreatitis has been increasing over the last 15 years but the etiology of\nthis is uncertain. The population of pre-adolescent patients with pancreatitis in the emergency department has not\nbeen specifically described. Our objective was to determine the characteristics of these patients to illuminate this\npopulation and disease in order to better identify them and avoid a delay in diagnosis and treatment.\nMethods: This was a retrospective descriptive study of consecutive pediatric patients under the age of 13 years\nbetween 2006 and 2016 who presented to our pediatric emergency department with a diagnosis of atraumatic\npancreatitis. Patient characteristics, lab and imaging results, identified etiology of pancreatitis, and recurrence rates\nwere recorded and evaluated.\nResults: There were 139 visits, of which 85 were for a first episode of acute pancreatitis, and 54 were patients with\nan episode of recurrent pancreatitis. The median age for all visits was 8 years (IQ range 5â??11). Of the acute cases,\n26% had uncertain or undetermined etiologies of which half were thought to likely be viral related; 20% had systemic\ninflammatory or autoimmune diseases; 19% were associated with medications, with the most common being valproic\nacid; 16% were cholelithiasis-related; and 15% were found to have a genetic, congenital or structural etiology.\nNo patients had elevated triglycerides. Those with cholelithiasis and genetic or structural defects were found\nto have a higher recurrence rate than those with other etiologies. There were only four patients diagnosed\nwith chronic pancreatitis.\nConclusions: The etiology of pancreatitis in pre-adolescent children has a different distribution than in adolescents\nand adults, with gallstone disease less frequent and concurrent contributing illness more common. Patients\non pancreatitis-causing medications or with known genetic risk or structural pancreatic problems should be\ntested for pancreatitis if presenting with concerning symptoms. Hypertriglyceridemia and chronic pancreatitis\nwith evidence of pancreatic exocrine insufficiency is uncommon in this population....
Background: The number of Global Emergency Medicine (GEM) Fellowship training programs are increasing\nworldwide. Despite the increasing number of GEM fellowships, there is not an agreed upon approach for\nassessment of GEM trainees.\nMain body: In order to study the lack of standardized assessment in GEM fellowship training, a working group was\nestablished between the International EM Fellowship Consortium (IEMFC) and the International Federation for\nEmergency Medicine (IFEM). A needs assessment survey of IEMFC members and a review were undertaken to\nidentify assessment tools currently in use by GEM fellowship programs; what relevant frameworks exist; and\ncommon elements used by programs with a wide diversity of emphases. A consensus framework was developed\nthrough iterative working group discussions. Thirty-two of 40 GEM fellowships responded (80% response). There is\nvariability in the use and format of formal assessment between programs. Thirty programs reported training GEM\nfellows in the last 3 years (94%). Eighteen (56%) reported only informal assessments of trainees. Twenty-seven (84%)\nreported regular meetings for assessment of trainees. Eleven (34%) reported use of a structured assessment of any\nsort for GEM fellows and, of these, only 2 (18%) used validated instruments modified from general EM residency\nassessment tools. Only 3 (27%) programs reported incorporation of formal written feedback from partners in other\ncountries. Using these results along with a review of the available assessment tools in GEM the working group\ndeveloped a set of principles to guide GEM fellowship assessments along with a sample assessment for use by GEM\nfellowship programs seeking to create their own customized assessments.\nConclusion: There are currently no widely used assessment frameworks for GEM fellowship training. The working\ngroup made recommendations for developing standardized assessments aligned with competencies defined by the\nprograms, that characterize goals and objectives of training, and document progress of trainees towards achieving\nthose goals. Frameworks used should include perspectives of multiple stakeholders including partners in other\ncountries where trainees conduct field work. Future work may evaluate the usability, validity and reliability of\nassessment frameworks in GEM fellowship training....
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