Clinical prediction rule for SARS-CoV-2 infection from 116 U.S. emergency departments 2-22-2021

Objectives

Accurate and reliable criteria to rapidly estimate the probability of infection with the novel coronavirus-2 that causes the severe acute respiratory syndrome (SARS-CoV-2) and associated disease (COVID-19) remain an urgent unmet need, especially in emergency care. The objective was to derive and validate a clinical prediction score for SARS-CoV-2 infection that uses simple criteria widely available at the point of care.

Methods

Data came from the registry data from the national REgistry of suspected COVID-19 in EmeRgency care (RECOVER network) comprising 116 hospitals from 25 states in the US. Clinical variables and 30-day outcomes were abstracted from medical records of 19,850 emergency department (ED) patients tested for SARS-CoV-2. The criterion standard for diagnosis of SARS-CoV-2 required a positive molecular test from a swabbed sample or positive antibody testing within 30 days. The prediction score was derived from a 50% random sample (n = 9,925) using unadjusted analysis of 107 candidate variables as a screening step, followed by stepwise forward logistic regression on 72 variables.

Results

Multivariable regression yielded a 13-variable score, which was simplified to a 13-point score: +1 point each for age>50 years, measured temperature>37.5°C, oxygen saturation<95%, Black race, Hispanic or Latino ethnicity, household contact with known or suspected COVID-19, patient reported history of dry cough, anosmia/dysgeusia, myalgias or fever; and -1 point each for White race, no direct contact with infected person, or smoking. In the validation sample (n = 9,975), the probability from logistic regression score produced an area under the receiver operating characteristic curve of 0.80 (95% CI: 0.79–0.81), and this level of accuracy was retained across patients enrolled from the early spring to summer of 2020. In the simplified score, a score of zero produced a sensitivity of 95.6% (94.8–96.3%), specificity of 20.0% (19.0–21.0%), negative likelihood ratio of 0.22 (0.19–0.26). Increasing points on the simplified score predicted higher probability of infection (e.g., >75% probability with +5 or more points).

Conclusion

Criteria that are available at the point of care can accurately predict the probability of SARS-CoV-2 infection. These criteria could assist with decisions about isolation and testing at high throughput checkpoints.

A 2.2 NEF Neural-Recording Amplifier Using Discrete-Time Parametric Amplification

This paper proposes a 2.2 noise efficiency factor (NEF) instrumentation amplifier for neural recording applications. A parametric amplifier based on the MOS C-V characteristic is designed as a pre-amplifier stage, lowering the input referred noise of the following stages by 3.4×. Sampling noise is minimized by oversampling the input signal and switching power is reduced by adopting an 8-phase soft-charging technique.

Molecular and morphological evidence for recognition of two species within Harpagonella (Amsinckiinae, Boraginaceae)

Recent taxonomic treatments of the genus Harpagonella have included only one lower taxon, Harpagonella palmeri A. Gray. However, a larger-fruited variety of Harpagonella palmeri from Arizona and Sonora was described by I.M. Johnston in 1924. He continued to recognize this taxon - Harpagonella palmeri var. arizonica - in his treatment of the genus in Kearney and Peebles's Arizona Flora in 1960. Here, we provide two lines of molecular evidence and quantitative morphological evidence from calyx characters showing that plants of Harpagonella from Arizona, Sonora, and central Baja California, corresponding to Johnston's var. arizonica, are distinct from Harpagonella palmeri of southern California and Baja California. We make the new combination Harpagonella arizonica (I.M. Johnston) Guilliams & B.G. Baldwin, comb. nov. for the plants from Arizona, Sonora, and central Baja California.

Integration of Ultrasound in Undergraduate Medical Education at the California Medical Schools: A Discussion of Common Challenges and Strategies From the UMeCali Experience

Since the first medical student ultrasound electives became available more than a decade ago, ultrasound in undergraduate medical education has gained increasing popularity. More than a dozen medical schools have fully integrated ultrasound education in their curricula, with several dozen more institutions planning to follow suit. Starting in June 2012, a working group of emergency ultrasound faculty at the California medical schools began to meet to discuss barriers as well as innovative approaches to implementing ultrasound education in undergraduate medical education. It became clear that an ongoing collaborative could be formed to discuss barriers, exchange ideas, and lend support for this initiative. The group, termed Ultrasound in Medical Education, California (UMeCali), was formed with 2 main goals: to exchange ideas and resources in facilitating ultrasound education and to develop a white paper to discuss our experiences. Five common themes integral to successful ultrasound education in undergraduate medical education are discussed in this article: (1) initiating an ultrasound education program; (2) the role of medical student involvement; (3) integration of ultrasound in the preclinical years; (4) developing longitudinal ultrasound education; and (5) addressing competency.

Assessment of emergency physician-performed ultrasound in evaluating nonspecific abdominal pain

STUDY OBJECTIVE

The objective of this pilot study was to lay the groundwork for future studies assessing the impact of emergency physician-performed ultrasound (EPUS) on diagnostic testing and decision making in emergency department (ED) patients with nonspecific abdominal pain (NSAP).

METHODS

This was a prospective, noninterventional study using a consecutive sample of patients presenting to the ED with NSAP as determined by nursing triage when a participating physician was available. Nonspecific abdominal pain was defined as abdominal pain for which the patient was seeking evaluation without a presumed diagnosis or referral for specific evaluation. Patients were evaluated by a physician who documented their differential diagnosis and planned diagnostic workup. Then, the physician performed EPUS, recorded their findings, and documented their post-EPUS differential diagnosis and planned diagnostic workup. This was compared with the patient's final diagnosis as determined by 2 emergency physicians blinded to the EPUS results.

RESULTS

A total of 128 patients were enrolled. Fifty-eight (45%; 95% confidence interval [CI], 36%-54%) had an improvement in diagnostic accuracy and planned diagnostic workup using EPUS. Sixty-four (50%; 95% CI, 41%-59%) would have been treated without further radiographic imaging. Fifty (39%; 95% CI, 31%-48%) would have been treated without any further laboratory testing or imaging.

DISCUSSION

Based on our findings, a future trial of 164 consecutive patients would have 90% power to confirm a 25% reduction in testing and a 25% improvement in decision making.

CONCLUSION

Emergency physician-performed ultrasound appears to positively impact decision making and diagnostic workup for patients presenting to the ED with NSAP and should be studied further.

Reduction of gate leakage current on AlGaN/GaN high electron mobility transistors by electron-beam irradiation

This study examined the effect of electron-beam (E-beam) irradiation on the AIGaN/GaN HEMTs for the reduction of gate leakage. After E-beam irradiation, the gate leakage current significantly decreased from 2.68 x 10(-8) A to 4.69 x 10(-9) A at a drain voltage of 10 V. The maximum drain current density of the AIGaN/GaN HEMTs with E-beam irradiation increased 14%, and the threshold voltage exhibited a negative shift, when compared to that of the AIGaN/GaN HEMTs before E-beam irradiation. These results strongly suggest that the reduction of gate leakage current resulted from neutralization nitrogen vacancies and removing of oxygen impurities.

Prehospital Spirituality: How Well Do We Know Ambulance Patients?

Objective:

To assess the religious spirituality of EMS personnel and their perception of the spiritual needs of ambulance patients.

Methods:

Emergency medical technicians (EMTs) and paramedics presenting to an urban, academic emergency department (ED) were asked to complete a three-part survey relating to demographics, personal practices, and perceived patient needs. Their responses were compared to those of ambulance patients presenting to an ED during a previous study period and administered a similar survey.

Results:

A total of 143 EMTs and 89 paramedics returned the surveys. There were 161 (69.4%) male and 71 (30.6%) female respondents with a median age range of 26–35 years old. Eighty-seven percent believed in God, 82% practiced prayer or meditation, 62% attended religious services occasionally, 55% belonged to a religious organization, 39% felt that their beliefs affected their job, and 18% regularly read religious material. This was similar to the characteristics of ambulance patients.

However, only 43% felt that occasionally ambulance patients presented with spiritual concerns and 78% reported never or rarely discussing spiritual issues with patients. Contrastingly, &gt;40% of ambulance patients reported spiritual needs or concerns at the time of ED presentation, and &gt;50% wanted their providers to discuss their beliefs. Twenty-six percent of respondents reported praying or meditating with patients, while 50% reported praying or meditating for patients.

Females were no more religious or spiritual than males, but were more likely to engage in prayer with (OR = 2.38,p= 0.0049) or for (OR = 6.45,p&lt;0.0001) patients than their male counterparts.

Conclusion:

EMTs and paramedics did not perceive spiritual concerns as often as reported by ambulance patients, nor did they commonly inquire about the religious/spiritual needs of patients.

The technical errors of physicians learning to perform focused assessment with sonography in trauma

OBJECTIVES

The objective was to assess the incidence of various technical errors committed by emergency physicians (EPs) learning to perform focused assessment with sonography in trauma (FAST).

METHODS

This was a retrospective review of the first 75 consecutive FAST exams for each EP from April 2000 to June 2005. Exams were assessed for noninterpretable views, misinterpretation of images, poor gain, suboptimal depth, an incomplete exam, or backward image orientation.

RESULTS

A total of 2,223 FAST exams done by 85 EPs were reviewed. Multiple noninterpretable views or misinterpreted images occurred in 24% of exams for those performing their first 10 exams, 3.6% for those performing their 41st to 50th exams, and 0% for those performing their 71st to 75th exams (Cochran-Armitage trend test = 10.5, p < 0.0001). A single noninterpretable view, poor gain, suboptimal depth, incomplete exam, or backward image orientation occurred in 48% of exams for those performing their first 10 exams, 17% for those performing their 41st to 50th exams, and 5% for those performing their 71st to 75th exams (Cochran-Armitage trend test = 11.6, p < 0.0001).

CONCLUSIONS

The incidence of specific technical errors of EPs learning to perform FAST at our institution improved with hands-on experience. Interpretive skills improved more rapidly than image acquisition skills.

Jugular venous distension on ultrasound: sensitivity and specificity for heart failure in patients with dyspnea

BACKGROUND

Accurately diagnosing congestive heart failure (CHF) in patients with dyspnea can be difficult because clinical history and physical examination are often nondiagnostic and may be inaccurate, especially when patients have complicated comorbid conditions.

OBJECTIVE

To prospectively assess jugular venous distension on ultrasound (JVD-US) performed by emergency physicians for identifying CHF on echocardiography by the department of cardiology (C-ECHO) in patients with dyspnea.

MEASUREMENTS

This was a secondary analysis of a previously collected data set from a prospective study of JVD-US in ED patients with dyspnea due to suspected CHF. C-ECHO results were obtained and used as the criterion standard.

RESULTS

Jugular venous distension on ultrasound had a sensitivity of 99% (95% confidence interval [CI], 92.2%-100%), specificity of 59% (95% CI, 40.9%-74.4%), positive likelihood ratio of 2.4 (95% CI, 1.6-3.6), and negative likelihood ratio of 0.01 (95% CI, 0.0007-0.20) for identifying CHF on C-ECHO in patients with dyspnea.

CONCLUSION

This initial study suggests that JVD-US by emergency physicians is predictive of CHF using echocardiography performed by the department of cardiology as the criterion standard.

Operator confidence correlates with more accurate abdominal ultrasounds by emergency medicine residents

The purpose of this study was to assess whether greater operator confidence correlates with more accurate focused abdominal ultrasounds (FAUS) by residents. This was a prospective study of novice residents performing FAUS in patients with abdominal pain. FAUS included focused assessment with sonography for trauma, gall bladder, renal, and aortic examinations. Residents answered the question, "How confident are you of your findings?" using a visual scale from 1 (doubtful) to 5 (certain). The results of the resident-performed FAUS were compared to subsequent criterion evaluations. Thirty-eight residents with an average experience of 27 (95% confidence interval [CI] 18-36) prior US examinations evaluated 504 patients. Greater operator confidence correlated with improved accuracy of FAUS (R(2) = 0.858, p = 0.0369). Sensitivity and specificity were 14% (95% CI 4-37 %) and 71% (95% CI 48-88 %) with a confidence level of 2/5 but 85% (95% CI 73-93 %) and 100% (95% CI 97-100 %) with a confidence level of 5/5. Greater operator confidence correlates with improved accuracy in FAUS. This should be considered in the development of training guidelines.

Point-of-care Urine Trypsinogen Testing for the Diagnosis of Pancreatitis

OBJECTIVES

To assess a point-of-care (POC) urine trypsinogen (UT) test for the diagnosis of pancreatitis in the emergency department (ED).

METHODS

This was a prospective cohort study of a convenience sample of patients presenting to the ED with abdominal pain or symptoms suggestive of pancreatitis. A 3-minute POC UT test (Actim Pancreatitis; Medix Biochemica, Kauniainen, Finland) was compared with plasma lipase and amylase measurements, imaging results when performed, and final discharge diagnoses. The criterion standard was a final discharge diagnosis of acute pancreatitis.

RESULTS

Of 191 patients included in this study, 17 patients were diagnosed with either acute or acute-on-chronic pancreatitis. The sensitivity and specificity of UT for acute pancreatitis were, respectively, 100% (95% confidence interval [CI] = 77% to 100%) and 96% (95% CI = 92% to 98%). Seven of the 17 patients with pancreatitis (41%) had diagnostic findings on CT and positive UT tests but had nondiagnostic plasma lipase and amylase levels.

CONCLUSIONS

A POC UT screening test for pancreatitis in the ED compared favorably with plasma lipase and amylase levels. Future studies should be performed to explore whether this test in the ED setting has better clinical utility than plasma lipase or amylase.

Ultrasonography of the internal jugular vein in patients with dyspnea without jugular venous distention on physical examination

STUDY OBJECTIVE

Accurate physical examination of patients with dyspnea is important. Jugular venous distention, however, can be difficult to assess in patients. The purpose of this case series is to serve as a pilot study of how ultrasonographic examination of the internal jugular vein compares with other measures of dyspnea.

METHODS

This was a case series of 8 patients presenting with dyspnea without jugular venous distention on physical examination. Each patient underwent ultrasonographic examination of the internal jugular vein and inferior vena cava by an emergency physician sonographer blinded to all other clinical information after initial evaluation by another emergency physician for dyspnea. Results of ultrasonographic examination of the internal jugular vein and inferior vena cava were subsequently compared with initial emergency physician physical examination findings, initial chest radiography interpreted by radiologists, initial B-type natriuretic peptide levels, and final hospital discharge diagnosis.

RESULTS

Ultrasonographic examination of the internal jugular vein compared more favorably with B-type natriuretic peptide levels and chest radiographic findings than ultrasonographic examination of the inferior vena cava in these patients with dyspnea but not jugular venous distention on physical examination. It was able to identify every patient diagnosed with cardiogenic pulmonary edema on hospital discharge.

CONCLUSION

Ultrasonographic examination of the internal jugular vein appears to be helpful in patients who present with dyspnea but do not have evidence of jugular venous distention on physical examination.

Minimum training for right upper quadrant ultrasonography

The objective of this study was to assess if 10 right upper quadrant (RUQ) ultrasound (US) examinations could be used as a minimum standard for training. This was a retrospective review of patients with suspected gallbladder pathology who underwent resident-performed RUQ US before operative or department of radiology evaluation. Two hundred twenty-four patients were examined using resident-performed RUQ US followed by gold standard evaluations. One hundred seventy-eight patients were evaluated by 13 residents who met the "minimum training" standard of 10 prior examinations. The results of resident-performed RUQ US for gallstones and/or cholecystitis are shown subsequently. Previous suggestions that 10 examinations could be used as a minimum standard for training in focused abdominal sonography for trauma examinations cannot be used for RUQ US. The ACEP 2001 guidelines for 25 examinations are more consistent with the learning curve suggested by our data.

Residents should not independently perform focused abdominal sonography for trauma after 10 training examinations

OBJECTIVES

To assess whether 10 focused abdominal sonography for trauma (FAST) examinations could be used as a minimum standard for training, as suggested previously.

METHODS

This was a retrospective review of patients with abdominal trauma who underwent resident-performed FAST examinations before surgical or Department of Radiology evaluation.

RESULTS

Six hundred ninety-eight patients were examined by resident-performed FAST followed by reference standard evaluations. Four hundred twelve patients were evaluated by residents who previously performed 10 FAST examinations; 154 were evaluated by 29 residents performing their 11th through 30th examinations; and 258 were evaluated by 10 residents performing their 31st and subsequent examinations. The results of resident-performed FAST for intraperitoneal free fluid were as follows: 11 to 20 examinations--sensitivity, 73.9% (95% confidence interval, 51.3%-88.9%); specificity, 98.8% (92.5%-99.9%); true-positive findings, 17; true-negative, 81; false-positive, 1; false-negative, 6; total patients, 105; 21 to 30 examinations--sensitivity, 100% (73.2%-100%); specificity, 97.1% (83.3%-99.9%); true-positive, 14; true-negative, 34; false-positive, 1; false-negative, 0; total patients, 49; 31 and more examinations--sensitivity, 94.8% (88.6%-97.9%); specificity, 98.6% (94.5%-99.8%); true-positive, 110; true-negative, 140; false-positive, 2; false-negative, 6; total patients, 258.

CONCLUSIONS

The suggestion that 10 examinations could be used as a minimum standard for training in FAST examinations was not validated.