Abstract TP195: A Comprehensive Epidemiology Of Stroke In A Multi Ethnic Society: An Analysis Of A Nationwide Stroke Data From 2014 - 2020

Introduction: The prevalence of stroke is progressively increasing in developing countries owing to the increase in vascular risk factors in the population. Risk factors vary significantly in different population groups leading to variations in disease progression, management and outcomes. This study aims to describe the epidemiology, prevalent risk factors and outcomes in a multi ethnic society of Qatar.

Methods: We conducted a retrospective cohort study that included all patients with suspected stroke admitted to Hamad General Hospital, Doha Qatar between April 30, 2014 till September 15, 2020.

Results: A total of 11,892 patients were admitted during this period with suspected stroke. Of these, Ischemic stroke (IS; 48.8%), Transient ischemic attack (TIA; 10.3%), Intracerebral hemorrhage (ICH; 10.9%), Stroke mimics (28.6%) and Cerebral venous sinus thrombosis (CVST; 1.3%). Mean age was 53.1 + 14.1 and a male to female ratio of 3:1. Study population was majorly Asian (56.8%) and Arab (36%); while African (4.5%), Caucasian (2.6%) and Others (0.1%) formed minority of the population. Asian population (South Asian; 49.7 + 11.6 and Far Eastern; 47.4 + 9.9) were younger as compared to Arabs (58.9 + 15.9). Majority of the patients were hypertensive (66.8%), diabetic (47.9%) and dyslipidemic (45.9%) on admission, while cardiac diseases (14.7%) and DVT (0.3%) were observed in fewer patients. Patients with a history of prior stroke were 11.7%, while 0.9% had a prior TIA. In IS patients, 31.7% of the patients arrived ED within the 4.5-hour thrombolysis window, 12.5% received thrombolysis and 4.6% received thrombectomy. The average Door-to-Needle time for IS patients was 58.9 + 39.5 minutes. The average length of stay was 5.2 + 9.0 days with 71.5% discharged home, 13.8% transferred to rehabilitation, 9.3% to other specialties, 3% to long term care and 2.4% suffered in-hospital mortality.

Conclusion: The patients suffering Stroke in Qatar are relatively younger than western population. Highly prevalent vascular risk factors could explain younger presentation and relatively high burden of stroke. Further analysis of epidemiological differences between ethnic subgroups can help tailoring effective preventive and management policies to reduce the burden of disease.

Abstract TP71: Characteristics And Demographics Of Patients Using Emergency Medical Services For Suspected Acute Stroke And Its Impact On Long-term Outcomes In A Multi Ethnic Population

Introduction: Acute ischemic stroke (IS) patients who receive IV thrombolysis are more likely to have good long-term prognosis. Unfortunately, more than two-third of IS patients present outside the therapeutic window. The use of emergency medical services (EMS) can reduce pre-hospital delay and increase likelihood of treatment with t-PA. We aim to determine the characteristic variations amongst the suspected acute stroke patients using EMS.

Methods: In this retrospective observational study, all suspected acute stroke patients admitted to Hamad General Hospital from April 30, 2014 to September 15, 2020 were included. We evaluated demographics, clinical features, impact on treatment and associated factors in EMS versus non-EMS group.

Results: During the study period, 11892 patients presented as suspected acute stroke. Of these, 65.1% used EMS (EMS-group). Mean age in EMS group was 53.4 + 14.1 versus 52.6 + 14.0 in non-EMS group (p = 0.003). Male to female ratio in both groups was 3:1. The proportion of patients who used EMS were higher in the Asian (66.8%), African (66.8%) and Caucasian (66.6%) population as compared to Arabs (61.9%). EMS use in Qatari population (59.2%) was relatively low. Intracerebral hemorrhage patients (82.4%) had a significantly higher EMS use followed by IS (65.7%) and cerebral venous thrombosis (64.7%); p<0.001. Symptom onset time of less than 4.5 hours at presentation was reported by 41% in EMS-group versus 24.3% in Non-EMS group. Patients with prior stroke (65.5%) and transient ischemic attack (58.4%) preferred EMS as compared to Non-EMS group (34.5% and 41.5%). Patients with unilateral weakness (66.4%) aphasia (78.2%), neglect (78.2%), dysarthria (68.4%), loss of consciousness (83.3%) and seizures (83.9%) had a higher use of EMS versus non-EMS group. The thrombolysis rate in EMS group was high vs non-EMS (82.4% vs 17.6%; p<0.001) with a door-to-needle time significantly lower in the EMS group (56.4 + 38.2 vs 75.7 + 43.8; p<0.001).

Conclusion: EMS use facilitate rapid transfer, timely stroke evaluation and management of patients who need time-critical care. Patient characteristics and demographics, clinical symptoms and stroke type are associated with early stroke recognition and EMS use leading to higher recanalization rate.

COVID-19 cases presenting to the Emergency Department predict Qatar National COVID-19 trends and numbers

In this short communication, we summarized the analyses, models, and interpretations of the corporate department of emergency medicine's (CDEM) COVID-19 numbers and their relationship to predict the national COVID-19 trends and numbers in Qatar. Data included in this analysis were obtained between March 1, 2020 and July 31, 2021. It included the number of COVID-19 cases that presented to four major EDs under the Hamad Medical Corporation CDEM umbrella and published data from the Qatar Ministry of public health (MoPH). On plotting weighted scatterplot smoothing (lowess) trend lines, there were striking similarities between CDEM and national COVID-19 n curves for overall trends and peaks. In conclusion, CDEM COVID-19 spike may be useful to predict national COVID-19 spike in 2-3 weeks.

Q-DEPICT: Qatar Determining Emergency Physician Incidence of COVID-Positive Testing

Despite protective measures such as personal protective equipment (PPE) and a COVID airway management program (CAMP), some emergency physicians will inevitably test positive for COVID. We aim to develop a model predicting weekly numbers of emergency physician COVID converters to aid operations planning.

The data were obtained from the electronic medical record (EMR) used throughout the national healthcare system. Hamad Medical Corporation's internal emergency medicine workforce data were used as a source of information on emergency physician COVID conversion and numbers of emergency physicians completing CAMP training. The study period included the spring and summer months of 2020 and started on March 7 and ran for 21 whole weeks through July 31. Data were extracted from the system's EMR database into a spreadsheet (Excel, Microsoft, Redmond, USA). The statistical software used for all analyses and plots was Stata (version 16.1 MP, StataCorp, College Station, USA). All data definitions were made a priori.

A total of 35 of 250 emergency physicians (14.0%, 95% CI 9.9%–19.9%) converted to a positive real-time reverse transcriptase-polymerase chain reaction (PCR) during the study's 21-week period. Of these. only two were hospitalized for having respiratory-only disease, and none required respiratory support. Both were discharged within a week of admission. The weekly number of newly COVID-positive emergency physicians was zero and was seen in eight of 21 (38.1%) weeks. The peak weekly counts of six emergency physicians with new COVID-positive were seen in week 14. The mean weekly number of newly COVID-positive emergency physicians was 1.7 ± 1.9, and the median was 1 (IQR, 0 to 3).

This study demonstrates that in the State of Qatar's Emergency Department (ED) system, knowing only four parameters allows the reliable prediction of the number of emergency physicians likely to convert COVID PCR tests within the next week. The results also suggest that attention to the details of minimizing endotracheal intubation (ETI) risk can eliminate the expected finding of the association between ETI numbers and emergency physician COVID numbers.

Qatar Prediction Rule Using ED Indicators of COVID-19 at Triage

INTRODUCTION

The presence of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) and its associated disease, COVID-19 has had an enormous impact on the operations of the emergency department (ED), particularly the triage area. The aim of the study was to derive and validate a prediction rule that would be applicable to Qatar's adult ED population to predict COVID-19-positive patients.

METHODS

This is a retrospective study including adult patients. The data were obtained from the electronic medical records (EMR) of the Hamad Medical Corporation (HMC) for three EDs. Data from the Hamad General Hospital ED were used to derive and internally validate a prediction rule (Q-PREDICT). The Al Wakra Hospital ED and Al Khor Hospital ED data formed an external validation set consisting of the same time frame. The variables in the model included the weekly ED COVID-19-positivity rate and the following patient characteristics: region (nationality), age, acuity, cough, fever, tachypnea, hypoxemia, and hypotension. All statistical analyses were executed with Stata 16.1 (Stata Corp). The study team obtained appropriate institutional approval.

RESULTS

The study included 45,663 adult patients who were tested for COVID-19. Out of these, 47% (n = 21461) were COVID-19 positive. The derivation-set model had very good discrimination (c = 0.855, 95% Confidence intervals (CI) 0.847-0.861). Cross-validation of the model demonstrated that the validation-set model (c = 0.857, 95% CI 0.849-0.863) retained high discrimination. A high Q-PREDICT score ( ≥ 13) is associated with a nearly 6-fold increase in the likelihood of being COVID-19 positive (likelihood ratio 5.9, 95% CI 5.6-6.2), with a sensitivity of 84.7% (95% CI, 84.0%-85.4%). A low Q-PREDICT ( ≤ 6) is associated with a nearly 20-fold increase in the likelihood of being COVID-19 negative (likelihood ratio 19.3, 95% CI 16.7-22.1), with a specificity of 98.7% (95% CI 98.5%-98.9%).

CONCLUSION

The Q-PREDICT is a simple scoring system based on information readily collected from patients at the front desk of the ED and helps to predict COVID-19 status at triage. The scoring system performed well in the internal and external validation on datasets obtained from the state of Qatar.

Ethnic differences in out-of-hospital cardiac arrest among Middle Eastern Arabs and North African populations living in Qatar

Aims: There are very few studies comparing epidemiology and outcomes of out-of-hospital cardiac arrest (OHCA) in different ethnic groups. Previous ethnicity studies have mostly determined OHCA differences between African American and Caucasian populations. The aim of this study was to compare epidemiology, clinical presentation, and outcomes of OHCA between the local Middle Eastern Gulf Cooperation Council (GCC) Arab and the migrant North African populations living in Qatar.Methods: This was a retrospective cohort study of Middle Eastern GCC Arabs and migrant North African patients with presumed cardiac origin OHCA resuscitated by Emergency Medical Services (EMS) in Qatar, between June 2012 and May 2015.Results: There were 285 Middle Eastern GCC Arabs and 112 North African OHCA patients enrolled during the study period. Compared with the local GCC Arabs, univariate analysis showed that the migrant North African OHCA patients were younger and had higher odds of initial shockable rhythm, pre-hospital interventions (defibrillation and amioderone), pre-hospital scene time, and decreased odds of risk factors (hypertension, respiratory disease, and diabetes) and pre-hospital response time. The survival to hospital discharge had greater odds for North African OHCA patients which did not persist after adjustment. Multivariable logistic regression showed that North Africans were associated with lower odds of diabetes (OR 0.48, 95% CI 0.25-0.91, p = 0.03), and higher odds of initial shockable rhythm (OR 2.86, 95% CI 1.30-6.33, p = 0.01) and greater scene time (OR 1.02 95% CI 1.0-1.04, p = 0.02).Conclusions: North African migrant OHCA patients were younger, had decreased risk factors and favourable OHCA rhythm and received greater ACLS interventions with shorter pre-hospital response times and longer scene times leading to better survival.

The establishment of a medical toxicology consulting service for advancing care of poisoning and overdose in Qatar

Objectives: The State of Qatar, in recent decades, underwent rapid, and substantial population growth. The country's emergency medicine (EM) needs are met by government-operated facilities of the Hamad Medical Corporation (HMC), which see virtually all acute-care cases in adults and children. In 2017, emergency departments (ED) established the Medical Toxicology Consulting Service (MTCS). This report aims to outline the MTCS's initial 100 cases’ experience and report salient findings that can help ongoing national strategies in meeting Qatar's medical toxicology needs. Methods: The study setting is Qatar, and the clinical base for the MTCS was the country's sole level I center, Hamad General Hospital. The MTCS group is composed of six physicians, all with advanced training in medical toxicology. The study group is composed of the first 100 consecutive cases of the MTCS registry. Registry entry was triggered by in-person consultation, telephone consultation, or identification of cases by daily MTCS rounder surveillance of the ED's electronic tracking board. Results: The MTCS institution identified a significant number of medical toxicology cases within the national hospital system. The trends of poisoning in this study showed a median age of 30 years (range 1–81 years, IQR 22–36 years). Fourteen patients were < 18 years old. The median interval between exposure and ED presentation was 2 hours, with a range of 15 minutes to 24 hours (IQR 1–3 hours). Most patients (71%, 95% CI, 51%–80%) were symptomatic because they were exposed. The MTCS recommended therapeutic intervention in over a third of cases (36%, 95% CI, 27%–46%). Decontamination procedures were ordered in 8% of cases (95% CI, 4%–15%) and specific therapies recommended in 13 cases (13%, 95% CI, 7%–21%). Conclusions: The study highlighted that the availability of experts in medical toxicology, such as with a poison center or toxicology consultation service, results in significant resource conservation in the management of poisoned patients.

Increasing consultant-level staffing as a proportion of overall physician coverage improves emergency department length of stay targets

Objectives

One goal of Emergency Department (ED) operations is achieving an overall length of stay (LOS) that is less than four hours. The goal of the current study was to assess for association between increasing number of on-duty EM Consultants and LOS, while adjusting for overall (all-grade) on-duty emergency doctors’ numbers and other operational factors.

Methods

This was a retrospective analysis of three years (2016–2019) of data, employing a unit of analysis of 3276 eight-hour ED shifts. The study was conducted using a prospectively populated ED database in a busy (annual census 420,000) Middle Eastern ED with staffing by Consultants and multiple non-Consultant grades (Specialists, fellows, and residents). Using logistic regression, the main predictor variable of “on-duty Consultant n” was assessed for association with the study’s primary (dichotomous) endpoint: whether a shift’s median LOS met the target of < 240 min. Linear regression was used to assess for association between on-duty Consultant n and the study’s secondary (continuous) endpoint: median LOS for the ED shift.

Results

Multivariate logistic regression adjusting for a number of operations factors (including total EP on-duty complement) identified an association between increasing n of on-duty Consultants and the likelihood of a shift’s meeting the 4-h ED LOS target (OR 1.27, 95% CI 1.20 to 1.34, p < .0001). Multiple linear regression, which also adjusted for total on-duty EP n and other operational factors, also indicated LOS benefit from more on-duty Consultants: each additional on-duty Consultant was associated with a shift’s median LOS improving by 5.4 min (95% CI 4.3 to 6.5, p < .0001).

Conclusions

At the study site, in models that adjusted for overall on-duty EP numbers as well as myriad other operational factors, increasing numbers of on-duty Consultants was associated with a statistically and operationally significant reduction in ED LOS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-020-00399-8.

Randomized double-blinded placebo-controlled trial of hydroxychloroquine with or without azithromycin for virologic cure of non-severe Covid-19

BACKGROUND

Hydroxychloroquine (HC) ± azithromycin (AZ) is widely used for Covid-19. The Qatar Prospective RCT of Expediting Coronavirus Tapering (Q-PROTECT) aimed to assess virologic cure rates of HC±AZ in cases of low-acuity Covid-19.

METHODS

Q-PROTECT employed a prospective, placebo-controlled design with blinded randomization to three parallel arms: placebo, oral HC (600 mg daily for one week), or oral HC plus oral AZ (500 mg day one, 250 mg daily on days two through five). At enrollment, non-hospitalized participants had mild or no symptoms and were within a day of Covid-19 positivity by polymerase chain reaction (PCR). After six days, intent-to-treat (ITT) analysis of the primary endpoint of virologic cure was assessed using binomial exact 95% confidence intervals (CIs) and χ2 testing. (ClinicalTrials.gov NCT04349592, trial status closed to new participants.).

FINDINGS

The study enrolled 456 participants (152 in each of three groups: HC+AZ, HC, placebo) between 13 April and 1 August 2020. HC+AZ, HC, and placebo groups had 6 (3·9%), 7 (4·6%), and 9 (5·9%) participants go off study medications before completing the medication course (p = 0·716). Day six PCR results were available for all 152 HC+AZ participants, 149/152 (98·0%) HC participants, and 147/152 (96·7%) placebo participants. Day six ITT analysis found no difference (p = 0·821) in groups' proportions achieving virologic cure: HC+AZ 16/152 (10·5%), HC 19/149 (12·8%), placebo 18/147 (12·2%). Day 14 assessment also showed no association (p = 0·072) between study group and viral cure: HC+AZ 30/149 (20·1%,), HC 42/146 (28·8%), placebo 45/143 (31·5%). There were no serious adverse events.

INTERPRETATION

HC±AZ does not facilitate virologic cure in patients with mild or asymptomatic Covid-19.

FUNDING

The study was supported by internal institutional funds of the Hamad Medical Corporation (government health service of the State of Qatar).

The Role of Point-of-Care Ultrasound (POCUS) in Envenomation by a Desert Viper

Patient: Male, 53-year-old

Final Diagnosis: Snakebite envenomation

Symptoms: Pain • swelling

Medication: —

Clinical Procedure: Antivenom administration • Point of care ultrasound (POCUS)

Specialty: Critical Care Medicine • Radiology • Toxicology

Evaluation of Electronic Medical Record Downtime in a Busy Emergency Department

Objectives: This study aimed to investigate electronic medical record (EMR) implementation in a busy urban academic emergency department (ED) and to determine the frequency, duration, and predictors of EMR downtime episodes.

Materials and Methods: This study retrospectively analyzed data collected real time by the EMR and by the operations group at the study ED from May 2016 to December 2017. The study center has used the First Net Millennium EMR (Cerner Corporation, Kansas City, Missouri, USA). The ED operations data have been downloaded weekly from the EMR and transferred to the analytics software Stata (version 15MP, StataCorp, College Station, Texas, USA).

Results: During the study period, 12 episodes of EMRD occurred, with a total of 58 hours and a mean of 4.8 ± 2.7 hours. The occurrence of EMRD event has not been associated with on-duty physician coverage levels (p = 0.831), month (p = 0.850), or clinical shift (morning, evening, or night shift) (p = 0.423). However, EMRD occurrence has been statistically significantly associated with weekdays (p = 0.020).

Discussion: In a real-world implementation of EMR in a busy ED, EMRD episodes averaging approximately 5 hours occurred at unpredictable intervals, with a frequency that remained unchanged over the first 20 months of the EMR deployment.

Conclusion: The study could define downtime characteristics at the study center. The EMRD episodes have been associated with inaccuracies in hourly census reporting, with a rebound phenomenon of over-reporting in the first hour or two after restoration of EMR operations.

Characterizing Agreement in the Level of Interarm Blood Pressure Readings of Adults in the Emergency Department (CALIBRATE Study)

Background: Increased interarm systolic blood pressure difference (IASBPD) is one of the major predictors of cardiovascular disease. An IASBPD of >10 mmHg is of clinical significance. However, studies have reported a high number of patients visiting the emergency department (ED) with high IASBPD and varying correlation of IASBPD to age, ethnic background, and comorbidities such as hypertension and diabetes. Objective: The CALIBRATE study aimed to measure the IABPDs in the multiethnic patient population presenting to the ED in Qatar and to assess the distribution of IASBPD in this population. Methods: In a sitting position, two consecutive blood pressure (BP) measurements were recorded from the right and left arms for each participant using a calibrated automated machine and appropriate cuff sizes. The data were recorded using predefined data fields, including patient demographics, past medical, and social and family history. The continuous variables were reported as mean or median based on the distribution of data. The data were analyzed using Stata MP 14.0. Results: A total of 1800 patients, with a mean age of 34 (10) years, were prospectively recruited from the ED. The median absolute systolic BP difference (ΔSBP) between the right and left arms was 6 (3-10) mmHg, and it was the same for the first (ΔSBP1) and the second readings (ΔSBP2). The absolute average of ΔSBP1 and ΔSBP2 was 7 (4-10) mmHg. The difference in systolic BP difference (SBP) of < 20 mmHg for interarm blood pressure was seen in the 95th percentile of the population. No meaningful association could be detected between the IABPD and the study variables such as age, demographics, regions of interest, and risk factors. Conclusion: In population presenting to the ED, the IASBPD of at least 20 mmHg reached at the 95th percentile, validating the known significant difference. The utility of SBP difference can be improved further by taking the average of two individual readings.

Meloidogyne aegracyperi n. sp. (Nematoda: Meloidogynidae), a root-knot nematode parasitizing yellow and purple nutsedge in New Mexico

Meloidogyne aegracyperi n. sp. is described from roots of purple nutsedge in southern New Mexico, USA. Mature females are small (310–460 µm), pearly white, with their egg masses completely contained inside root galls. The neck is often at a 90 to 130° angle to the protruding posterior end with the perineal pattern. The distance of the dorsal esophageal gland orifice (DGO) to the base of the stylet is relatively long (4.0–6.1 µm), and the excretory pore is level with the base of the stylet. The anterior portion of the rounded lumen lining of the metacorpus contains 3 to 10 small vesicles. The perineal pattern has a rounded dorsal arch with a tail terminal area that is smooth or marked with rope-like striae. Only two males were found. The body twists 90° throughout its length. The DGO to the base of the stylet is long (3.0–3.3) µm. The cephalic framework of the second-stage juvenile is weak, and the stylet is short (10.1–11.8 µm). The DGO to the base of the stylet is long (3–5 µm). The tail is very long (64–89 µm) and the hyaline portion of the tail is very narrow, making the tail finely pointed. Eggs are typical for the genus and vary in length (85.2–99.8 µm) and width (37.1–48.1 µm), having a L/W ratio of (2.1–2.6). Maximum likelihood phylogenetic analyses of the different molecular loci (partial 18S rRNA, D2-D3 of 28S rRNA, internal transcribed spacer (ITS) rRNA, cytochrome oxidase subunit II (COII)-16S rRNA of mitochondrial DNA gene fragments and partial Hsp90 gene) placed this nematode on an independent branch in between M. graminicola and M. naasi and a cluster of species containing M. chitwoodi. M. fallax, and M. minor. Greenhouse tests showed that yellow and purple nutsedge were the best hosts, but perennial ryegrass, wheat, bentgrass, and barley were also hosts.

Intramuscular versus oral diclofenac for acute pain in adults with acute musculoskeletal injuries presenting to the ED setting: a prospective, double-blind, double-dummy, randomised controlled trial

OBJECTIVE

The current study aimed to ascertain differences in early postmedication pain reduction in participants presenting with acute musculoskeletal injuries (MSI) to the ED receiving intramuscular (IM) versus per oral (PO) diclofenac.

METHODS

This was a prospective, double-blinded, randomised controlled trial conducted between January and June 2018 at the ED of Hamad General Hospital in Doha, Qatar. Adults (18-65 years of age) presenting to the ED within 24 hours of an acute MSI, who had a triage pain score measured using numerical rating scale of at least five or above were enrolled in this trial. Participants randomised to either IM (75 mg) with oral placebo, or oral (100 mg) diclofenac group with IM placebo using a computer-generated randomised concealed list in blocks of six and eight. The primary objective was to compare the proportion of IM versus PO participants attaining a 50% reduction in pain score at 30 min from t0.

RESULTS

300 participants were enrolled (150 in the IM diclofenac group and 150 in the PO diclofenac group) in the trial. The primary outcome was achieved in 99.3 (95% CI 96.3 to 100) in the IM group and 86.7 (95% CI 80.2 to 91.7) in PO group. There was an absolute risk difference of 12.7%. This corresponds to a number needed to treat of 8 cases (95% CI 6 to 14) receiving IM rather than the PO diclofenac in order to achieve one additional case of 50% pain reduction within 30 min of drug administration. There were no adverse events experienced in any treatment groups.

CONCLUSION

IM diclofenac injection provides rapid analgesia over PO administration of diclofenac. However, given the preparation needed for an IM injection, oral administration may be preferable when and if clinical circumstances allow a choice in non-steroidal anti-inflammatory drug administration route.

Helicopter Emergency Medical Services Literature 1972-2017: Characteristics and Trends

Since its inception in the latter part of the 20th century, the rapid expansion of helicopter emergency medical services (HEMS) has been accompanied by remarkable growth in the relevant evidence base. There are many review articles describing lessons contained within the various arenas of HEMS literature, but there is little or no characterization of the numbers and types of publications comprising the HEMS-related evidence base. This study analyzed all indexed publications mentioning HEMS (with abstract included) in the United States National Library of Medicine's PubMed collection. The aims of the analysis were to provide quantitative, qualitative, and longitudinal trend information regarding the 1972 to 2017 evidence base relevant to HEMS.

Emergency Physician Interpretation of Point-of-care Ultrasound for Identifying and Grading of Hydronephrosis in Renal Colic Compared With Consensus Interpretation by Emergency Radiologists

OBJECTIVE

The ability of emergency physicians (EPs) to identify hydronephrosis using point-of-care ultrasound (POCUS) has been assessed in the past using computed tomography (CT) scans as the reference standard. We aimed to determine the ability of EPs to identify and grade hydronephrosis on POCUS using the consensus interpretation of POCUS by emergency radiologists as the reference standard.

METHODS

The study was conducted at an urban academic emergency department (ED) as a secondary analysis of previously collected ultrasound data from the EP-performed POCUS databank. Patients were eligible for inclusion if they had both POCUS and CT scanning performed during the index ED visit. Two board-certified emergency radiologists and six EPs interpreted each POCUS study independently. The interpretations were compared with the consensus interpretation by emergency radiologists. Additionally, the POCUS interpretations were also compared with the corresponding CT findings. Institutional approval was obtained for conducting this study. All the analyses were performed using Stata MP 14.0 (StataCorp).

RESULTS

A total of 651 patient image-data sets were eligible for inclusion in this study. Hydronephrosis was reported in 69.6% of POCUS examinations by radiologists and 72.7% of CT scans (p = 0.22). Using the consensus radiology interpretation of POCUS as the reference standard, EPs had an overall sensitivity of 85.7% (95% confidence interval [CI] = 84.3%-87.0%), specificity of 65.9% (95% CI = 63.1%-68.7%), positive likelihood ratio of 2.5 (95% CI = 2.3-2.7), and negative likelihood ratio of 0.22 (95% CI = 0.19-0.24) for hydronephrosis. When using CT scan as the reference standard, the EPs had an overall sensitivity of 81.1% (95% CI = 79.6% to 82.5%), specificity of 59.4% (95% CI = 56.4%-62.5%), positive likelihood ratio of 2.0 (95% CI = 1.8-2.2), and negative likelihood ratio of 0.32 (95% CI = 0.29-0.35) for hydronephrosis. The specificity of EPs was improved to 94.6% (95% CI = 93.7%-95.4%) for categorizing the degree of hydronephrosis as "moderate or severe" versus "none or mild," with positive likelihood ratio of 6.33 (95% CI = 5.3-7.5) and negative likelihood ratio of 0.69 (95% CI = 0.66-0.73).

CONCLUSIONS

Emergency physicians were found to have moderate to high sensitivity for identifying hydronephrosis on POCUS when compared with the consensus interpretation of the same studies by emergency radiologists. These POCUS findings by EPs produced more definitive results when at least moderate degree of hydronephrosis was present.

Assessing the Effect of a Medical Toxicologist in the Care of Rattlesnake-envenomated Patients

BACKGROUND

Rattlesnake envenomation is an important problem in the United States, and the management of these envenomations can be complex. Despite these complexities, however, the majority of such cases are managed without the involvement of a medical toxicologist. The primary objective of this study was to evaluate the impact of a medical toxicology service (MTS) on the length of stay (LOS) of such patients.

METHODS

The authors conducted a retrospective study at six centers in California. Patients were included if they were admitted in the 2 years before the establishment of a MTS (pre-MTS) or in the 2 years after the creation of a MTS (post-MTS).

RESULTS

A total of 300 subjects were included (169 pre-MTS, 131 post MTS). Baseline characteristics between the pre-MTS and post-MTS groups were very similar. The creation of a MTS was associated with a significant reduction in the mean (95% confidence interval) LOS (69.5 [59.1-79.9] hours vs. 48.1 [41.4-54.8] hours). This reduced LOS was not associated with any statistically significant change in readmission rates.

CONCLUSION

Rattlesnake bite patients treated by a medical toxicologist have a significantly reduced LOS compared to those without direct involvement of a medical toxicologist.