Antibiotic Prescriptions for Upper Respiratory Infection in the Emergency Department: A Population-Based Study

Study Objective. Antibiotics prescriptions for upper respiratory infections (URI) are not uncommon, but the benefits for these groups had seldom been evaluated. We aimed to utilize a sampled National Health Insurance (NHI) claims data containing one million beneficiaries to explore if the use of antibiotics could reduce the possibility of unscheduled returns. Methods. We identified patients presented to ambulatory clinics with the discharged diagnoses of URI. The prescriptions of antibiotics were identified. We further matched each patient in the antibiotic group to the patient in the control group by selected covariates using a standard propensity score greedy-matching algorithm. The risks of unscheduled revisits were compared between the two groups. Results. A total of 6915140 visits were identified between 2005 and 2010. The proportions of antibiotics prescriptions are similar among these years, ranging from 9.99% to 13.38 %. In the propensity score assignment, 9190 patients (4595 in each group) were further selected. The odds ratio of unscheduled revisits among antibiotics group and control group was 0.92 (95% CI, 0.70–1.22) with P value equal to 0.569. Conclusions. Overall, antibiotics prescriptions did not seem to decrease the unscheduled revisits in patients presented to the ED with URI. Emergency physicians should reduce the unnecessary prescriptions and save antibiotics to patients with real benefits.

Effects of Full-Moon Definition on Psychiatric Emergency Department Presentations

Objectives. The lunar cycle is believed to be related to psychiatric episodes and emergency department (ED) admissions. This belief is held by both mental health professionals and the general population. Previous studies analyzing the lunar effect have yielded inconsistent results. Methods. ED records from two tertiary care hospitals were used to assess the impact of three different definitions of the full-moon period, commonly found in the literature. The full-moon definitions used in this study were 6 hours before and 6 hours after the full moon (a 12-hour model); 12 hours before and 12 hours after the full moon (a 24-hour model); and 24 hours before and after the day of the full moon (a 3-day model). Results. Different significant results were found for each full-moon model. Significantly fewer patients with anxiety disorders presented during the 12-hour and 24-hour models; however, this was not true of the 3-day model. For the 24-hour model, significantly, more patients presented with a diagnosis of personality disorders. Patients also presented with more urgent triage scores during this period. In the 3-day model, no significant differences were found between the full-moon presentations and the non-full-moon presentations. Conclusions. The discrepancies in the findings of full moon studies may relate to different definitions of “full moon.” The definition of the “full moon” should be standardized for future research.

Acute Poisoning Surveillance in Thailand: The Current State of Affairs and a Vision for the Future

Acute poisoning is a major public health threat worldwide, including Thailand, a country in Southeast Asia with over 67 million inhabitants. The incidence and characteristics of poisoning in Thailand vary greatly depending on the reporting body. This systematic review aims to provide a comprehensive description of the state of poisoning in Thailand. It identifies common trends and differences in poisoning by reporting centers and regional studies. Almost half of the cases and three-fourths of the deaths involved pesticide poisonings associated with agricultural occupations. However, increasing urbanization has led to an increase in drug and household chemical poisoning. Though the majority of reported poisonings remain intentional, a trend towards unintentional poisonings in pediatric and geriatric populations should not be dismissed. Unique poisonings such as mushroom, botulism, and tetrodotoxin poisonings are also closely related to the Thai lifestyle. Following this extensive review of the Thai poisoning literature, it is apparent that further support of the poison control center in Thailand is needed to improve poisoning surveillance, research, prevention, and intervention.

Evaluation of Serum Creatine Kinase and Urinary Myoglobin as Markers in Detecting Development of Acute Renal Failure in Severely Injured Trauma Patients

Background. Presence of myoglobinuria, particularly in the early phases of renal failure, and elevation of creatinine kinase are seen to correlate with the development of acute renal failure. Aim. To evaluate the efficiency of serum creatine kinase (CK) and urine myoglobin in assessing development of renal failure. Materials and Method. We prospectively studied trauma patients over a period of 3 months. Samples of 107 patients were routinely analyzed on the 1st, 3rd, and 5th days post trauma, for myoglobinuria and serum CK concentration. Results. 107 patients with median age 28 (4–83) yrs were studied, of which 83.2% were males. 56% had head injury, and 17.1% had high injury severity (ISS > 24). Incidence of renal failure was 9.3%. Myoglobinuria was present in 57 patients on admission, 33 on 3rd day and 22 on the 5th day. The association of myoglobinuria with renal failure was statistically insignificant. The cutoff values of serum CK on the 1st, 3rd, and 5th days were ≥1320 IU/L, ≥1146 IU/L, and ≥1754 IU/L, respectively. Mortality rate was 24 (22.4%), of which 6 had renal failure. Conclusion. Myoglobin is clinically insignificant in the detection of renal failure; serum CK is a sensitive predicting marker for the progression of renal failure following traumatic injury.

Early and Rapid Diagnosis with Multislice CT Reduces Lethality in Trauma Patients Requiring Intensive Care: Findings of a Prospective Study

Objective. The objective of this study was to investigate if short diagnostic times by MSCT have an influence on lethal outcomes. Methods. In three different patient populations, hospital mortality was examined. Group 1: retrospective data derived from conventional diagnostic methods in the trauma room between 2002 and 2003; group 2: data from the same centre taken prospectively between 2004 and 2010 after modification of the trauma room algorithm; group 3: a reference population from the TraumaRegister DGU (TR-DGU) from 2004 to 2010. Injury severity was determined using the ISS and lethality was predicted on the basis of the RISC. Results. At the singular centre, data from 943 polytraumatised patients requiring intensive care between 2002 and 2010 were examined. With the new trauma room algorithm, lethality was likewise significantly lower (9.1% versus 15%; P<0.05) compared to the population from 2002 to 2003, with a comparable ISS (28.5 versus 30.2). The ISS (28.5) was comparable with the TR-DGU (24.9) population and lethality was significantly lower. Conclusion. Early diagnostic approaches using MSCT during the first minutes of trauma room treatment, as an integral part of a stringently timed, highly structured concept, have been found to reduce lethality as compared to the TR-DGU and our own retrospective historical data. This trial is registered with DRKS00005055; TR-DGU-Projekt-ID: 2009-005.

Detecting Substance Abuse in the Emergency Department: A 10-Year Comparative Study

Aims. We have retrospectively analyzed the variations in the clinical profile of patients with a positive consumption of alcohol and/or drugs of abuse that have been confirmed and treated in the Emergency Department of a Virgen de La Arrixaca University Hospital in Murcia (Spain) after a period of 10 years. Secondly, we have assessed if the use of urine toxicology screen tests had any influence on the improvement of the management and/or referral of these patients to specialized services from the Emergency Department or at the time of discharge from hospital, regardless of the specialist or service where they had been treated. Method. 415 patients were selected in the year 2000 and 452 in the year 2010 who had tested positive for alcohol and drugs, assessing the reason for consultation, specific symptoms, drug used, record, diagnosis, and patient management. Results. The most frequent reasons for going to the Emergency Department was common illness, mainly psychiatric disorders, and the type of drug taken, alcohol. There were no significant differences between both groups, but approximately 50% of the patients were not referred for treatment of the abuse or dependency. Conclusions. The clinical profession should consider measures to improve detection and referral of patients with substance abuse disorders.

Depression Symptoms and Risk Factors in Adult Emergency Department Patients: A Multisite Cross-Sectional Prevalence Survey

Objectives. To identify the proportion of adult emergency department (ED) patients who screen positive for depression. Secondary aims were to identify factors associated with a positive depression screen and determine predictors of a positive depression screen. Methods. This cross-sectional, prevalence survey of ED patients was conducted at two inner-city hospitals. 350 ED patients were screened for depression using the Patient Health Questionnaire-9 (PHQ-9). Clinical and demographic risk factors were examined through medical records and additional questionnaires. Results. Of 350 participants screened, 50 (14.3%; 95% CI = 11.0–18.4%) screened positive. Independent predictors of depression risk included self-reported depression and/or a previous diagnosis of depression (OR = 8.345; 95% CI = 3.524–19.762), seeing a mental health service provider in the past 6 months (OR = 4.518; 95% CI = 2.107–9.690), and previous discussion about mental health with a local doctor (OR = 2.369; 95% CI = 1.025–5.475). Conclusion. ED patients were found to be at a higher risk of depression than the general population. ED-based depression screening, particularly of high-risk populations, has the potential to increase case detection rates and allow earlier management of these patients. Further research and validation of an ED-based depression screening tool are required.

The Mortality in Emergency Department Sepsis Score as a Predictor of 1-Month Mortality among Adult Patients with Sepsis: Weighing the Evidence

Objective. To evaluate the performance of Mortality in Emergency Department Sepsis (MEDS) score in comparison to biomarkers as a predictor of mortality in adult emergency department (ED) patients with sepsis. Methods. A literature search was performed using PubMed, ScienceDirect, SpringerLink, and Ovid databases. Studies were appraised by using the C2010 Consensus Process for Levels of Evidence for prognostic studies. The respective values for area under the curve (AUC) were obtained from the selected articles. Results. Four relevant articles met the selection process. Three studies defined the 1-month mortality as death occurring within 28 days of ED presentation, while the remaining one subcategorised the outcome measure as (5-day) early and (6- to 30-day) late mortality. In all four studies, the MEDS score performed better than the respective comparators (C-reactive protein, lactate, procalcitonin, and interleukin-6) in predicting mortality with an AUC ranging from 0.78 to 0.89 across the studies. Conclusion. The MEDS score has a better prognostic value than the respective comparators in predicting 1-month mortality in adult ED patients with suspected sepsis.

Early Endoscopy Can Shorten the Duration of Hospitalization in Suspected Variceal Hemorrhage

Background. Endoscopic treatment in patients with acute variceal hemorrhage should be performed within 12 hours, but the recommendation is based on the experts’ opinion. Objective. Our study investigated if time to endoscopy was a significant factor that could alter the outcomes of patients with suspected variceal hemorrhage. The primary outcome was the length of hospital stay and the mortality. The secondary outcomes were complications during observation periods. Methods. Patients were included if variceal hemorrhage was suspected in the emergency department. Patients were further divided into early (receiving endoscopy within 12 hours) and delayed groups (receiving endoscopy after 12 hours), and each patient was matched using a standard propensity score greedy-matching algorithm. The primary and secondary outcomes were compared accordingly. Results. 1442 patients met our inclusion criteria and therefore were enrolled for further analysis. In the Cox regression model, log time to endoscopy was not a significant factor. In the propensity score assignment, 566 patients (283 in each group) were further selected into the subcohort (P value = 0.8001). Kaplan-Meier curves showed a discharge benefit favoring the early endoscopy over the control group. The mortality rates and complications were not statistically different between the two groups (P value = 0.0045). Conclusion. Early endoscopy before 12 hours in patients with suspected variceal hemorrhage could result in shorter length of hospitalization without increasing the mortalities and complications. The results would help emergency physicians in decisions making when these patients are encountered.

Management of Pain in the Emergency Department

Since pain is a primary impetus for patient presentation to the Emergency Department (ED), its treatment should be a priority for acute care providers. Historically, the ED has been marked by shortcomings in both the evaluation and amelioration of pain. Over the past decade, improvements in the science of pain assessment and management have combined to facilitate care improvements in the ED. The purpose of this review is to address selected topics within the realm of ED pain management. Commencing with general principles and definitions, the review continues with an assessment of areas of controversy and advancing knowledge in acute pain care. Some barriers to optimal pain care are discussed, and potential mechanisms to overcome these barriers are offered. While the review is not intended as a resource for specific pain conditions or drug information, selected agents and approaches are mentioned with respect to evolving evidence and areas for future research.