The sublethal effects of pesticide poisoning will have significant negative impacts on the foraging and learning of bees and bumblebees, so it has received widespread attention. However, little is known about the physiological effects of sublethal spinetoram and glyphosate exposure on bumblebees. We continuously exposed to sublethal (2.5 mg/L) spinetoram or glyphosate under controlled conditions for 10 days. The superoxide dismutase, glutathione-S-transferase, carboxylesterase, prophenoloxidase, α-amylase and protease activities, and changes in gut microbes were measured to understand the effects of sublethal pesticide exposure on the physiology and gut microbes of bumblebees. Sublethal pesticide exposure to significantly increased superoxide dismutase activity and significantly decreased gut α-amylase activity in bumblebees but had no significant effect on glutathione-S-transferase, carboxylesterase or gut protease activities. In addition, glyphosate increased the activity of prophenoloxidase. Interestingly, we observed that neither of the two pesticides had a significant effect on dominant gut bacteria, but glyphosate significantly altered the structure of the dominant gut fungal community, and reduced the relative abundance of associated with fat accumulation. These results suggest that sublethal spinetoram and glyphosate do not significantly affect the detoxification system of bumblebees, but may affect bumblebee health by inhibiting energy acquisition. Our results provide information on the sublethal effects of exposure to low concentrations of glyphosate and spinetoram on bumblebees in terms of physiology and gut microbes.

Myxomas are slowly growing benign neoplasms which are rare in children. Up to 80% can be located in the left atrium and generate symptoms such as embolism, cardiac failure, fever and weight loss. Rarely, myxomas can be detected in the right ventricle outflow tract, causing arrhythmias, pulmonary emboli and sudden death. We report the case of a 13-year-old healthy child brought to the Emergency Department (ED) of the Children's Hospital Bambino Gesù, Rome, for recent dyspnea, chest pain on exertion and new onset cardiac murmur. Patient underwent medical examination and echocardiogram with the finding of a rounded and lobulated voluminous mass in the right ventricle outflow tract (RVOT) which caused severe obstruction. The contrast computed tomography (CT) scan confirmed the presence of a heterogeneously enhancing soft-tissue mass occupying the RVOT with no evidence of pulmonary embolization. The mass was surgically excised, and the pathologic examination confirmed our suspicion of myxoma. Our experience suggests that myxoma can have mild clinical symptoms, the presentation may be non-specific, and diagnosis can be a challenge Careful examination and a diagnostic imaging workup, primarily with the transthoracic echocardiogram, are needful to make a rapid differential diagnosis and to better manage surgical treatment and follow-up.

Broad-spectrum antibiotics can kill both pathogens and gut microbiota. Reducing exposure to excess intestinal antibiotics could theoretically protect gut microbiota homeostasis. Recently, engineered charcoals, gel microparticles, and resin beads have demonstrated efficacy in intestinal antibiotic adsorption in animal studies. We report the first in vitro study evaluating human fecal antibiotic adsorption efficacy of conventional activated charcoal (AC). We collected fecal samples from eight patients who received intravenous (IV) ceftriaxone after admission to King Chulalongkorn Memorial Hospital, Thailand, during January−March 2020. Fecal ceftriaxone was measured by indirect competitive enzyme-linked immunoassays. Three different doses of AC were mixed with fecal samples under a specified protocol. The geometric mean reduction in fecal ceftriaxone concentration when mixed with AC 30 mg/g feces was 0.53 (95% CI 0.33−0.85, p-value < 0.001), meaning 47% adsorption efficacy. Increased adsorption was found with higher doses, 71% and 87% for AC 150 and 500 mg/g feces, respectively. In conclusion, the usual food-poisoning-care dose of conventional AC, 30 mg/g feces, demonstrated dose-dependent and significant fecal ceftriaxone adsorption. Conventional oral AC might be a pragmatic and inexpensive option for the protection of gut microbiota in patients receiving IV ceftriaxone. However, in vivo studies and microbiome analysis are needed for further evidence.

Excessive vanadium (V) contamination is an attracting growing concern, which can negatively affect the health of human and ecosystems. But how V causes nephrotoxicity and the role of mitochondria-associated endoplasmic reticulum membrane (MAM) in V-induced nephrotoxicity have remained elusive. To explore the detailed mechanism and screen of potential effective drugs for V-evoked nephrotoxicity, a total of 72 ducks were divided into two groups, control group and V group (30 mg/kg V). Results showed that excessive V damaged kidney function of ducks including causing histopathological abnormality, biochemical makers derangement and oxidative stress. Then MAM of duck kidneys was extracted to investigate differentially expressed proteins (DEPs) under V exposure using proteomics analysis. Around 4240 MAM-localized proteins were identified, of which 412 DEPs showed dramatic changes, including 335 upregulated and 77 downregulated DEPs. On the basis of gene ontology (GO), string and KEGG database analysis, excessive V led to nephrotoxicity primarily by affecting MAM-mediated metabolic pathways, especially elevating the endoplasmic Reticulum (ER) proteostasis related pathway. Further validation analysis of the detected genes and proteins of ER proteostasis related pathway under V poisoning revealed a consistent relationship with proteome analysis, indicating that V disrupted MAM-mediated ER proteostasis. Accordingly, our data proved the critical role for MAM in V-evoked nephrotoxicity, particularly with MAM-mediated ER proteostasis, providing promising insights into the toxicological exploration mechanisms of V.

Hydrogen sulfide (HS) is a toxin affecting the cardiovascular, respiratory, and central nervous systems. Acute HS exposure is associated with a high rate of mortality and morbidity. The precise pathophysiology of HS-induced death is a controversial topic; however, inhibition of the respiratory center in the brainstem is commonly cited as a cause of death. There is a knowledge gap on toxicity and toxic mechanisms of acute HS poisoning on the brainstem, a brain region responsible for regulating many reflective and vital functions. Serotonin (5-HT), dopamine (DA), and γ-aminobutyric acid (GABA) play a role in maintaining a normal stable respiratory rhythmicity. We hypothesized that the inhibitory respiratory effects of HS poisoning are mediated by 5-HT in the respiratory center of the brainstem. Male C57BL/6 mice were exposed once to an LCt concentration of HS (1000 ppm). Batches of surviving mice were euthanized at 5 min, 2 h, 12 h, 24 h, 72 h, and on day 7 post-exposure. Pulmonary function, vigilance state, and mortality were monitored during exposure. The brainstem was analyzed for DA, 3,4-dehydroxyphenyl acetic acid (DOPAC), 5-HT, 5-hydroxyindoleatic acid (5-HIAA), norepinephrine (NE), GABA, glutamate, and glycine using HPLC. Enzymatic activities of monoamine oxidases (MAO) were also measured in the brainstem using commercial kits. Neurodegeneration was assessed using immunohistochemistry and magnetic resonance imaging. Results showed that DA and DOPAC were significantly increased at 5 min post HS exposure. However, by 2 h DA returned to normal. Activities of MAO were significantly increased at 5 min and 2 h post-exposure. In contrast, NE was significantly decreased at 5 min and 2 h post-exposure. Glutamate was overly sensitive to HS-induced toxicity manifesting a time-dependent concentration reduction throughout the 7 day duration of the study. Remarkably, there were no changes in 5-HT, 5-HIAA, glycine, or GABA concentrations. Cytochrome c oxidase activity was inhibited but recovered by 24 h. Neurodegeneration was observed starting at 72 h post HS exposure in select brainstem regions. We conclude that acute HS exposure causes differential effects on brainstem neurotransmitters. HS also induces neurodegeneration and biochemical changes in the brainstem. Additional work is needed to fully understand the implications of both the short- and long-term effects of acute HS poisoning on vital functions regulated by the brainstem.

Lead (Pb) can cause damages to the brain, liver, kidney, endocrine and other systems. Flammulina velutipes residues polysaccharide (FVRP) has been reported to exhibit anti-heavy metal toxicity on yeast, but its regulating mechanism is unclear. Therefore, the protective effect and the underlying mechanism of FVRP on Pb-intoxicated mice were investigated. The results showed that FVRP could reduce liver and kidney function indexes, serum inflammatory factor levels, and increase antioxidant enzyme activity of Pb-poisoned mice. FVRP also exhibited a protective effect on histopathological damages in organs of Pb-intoxicated mice. Furthermore, FVRP attenuated Pb-induced kidney injury by inhibiting apoptosis via activating the Akt/GSK3β/Nrf-2/HO-1 signaling pathway. In addition, based on 16 s rRNA and ITS-2 sequencing data, FVRP regulated the imbalance of gut microbiota to alleviate the damage of Pb-poisoned mice by increasing the abundance of beneficial microbiota (Lachnospiraceae, Lactobacillaceae, Saccharomyces and Mycosphaerella) and decreasing the abundance of harmful microbiota (Muribaculaceae and Pleosporaceae). In conclusion, FVRP inhibited kidney injury in Pb-poisoned mice by inhibiting apoptosis via activating Akt/GSK3β/Nrf-2/HO-1 signaling pathway, and regulating gut fungi and gut bacteria. This study not only revealed the role of gut fungi in Pb-toxicity, but also laid a theoretical foundation for FVRP as a natural drug against Pb-toxicity.

Organophosphates (OPs) are inhibitors of acetylcholinesterase and have deleterious effects on the central nervous system. Clinical manifestations of OP poisoning include convulsions, which represent an underlying toxic neuro-pathological process, leading to permanent neuronal damage. This neurotoxicity is mediated through the cholinergic, GABAergic and glutamatergic (NMDA) systems. Pharmacological interventions in OP poisoning are designed to mitigate these specific neuro-pathological pathways, using anticholinergic drugs and GABAergic agents. Benactyzine is a combined anticholinergic, anti-NMDA compound. Based on previous development of novel GABA derivatives (such as prodrugs based on perphenazine for the treatment of schizophrenia and nortriptyline against neuropathic pain), we describe the synthesis and preliminary testing of a mutual prodrug ester of benactyzine and GABA. It is assumed that once the ester crosses the blood-brain-barrier it will undergo hydrolysis, releasing benactyzine and GABA, which are expected to act synergistically. The combined release of both compounds in the brain offers several advantages over the current OP poisoning treatment protocol: improved efficacy and safety profile (where the inhibitory properties of GABA are expected to counteract the anticholinergic cognitive adverse effects of benactyzine) and enhanced chemical stability compared to benactyzine alone. We present here preliminary results of animal studies, showing promising results with early gabactyzine administration.

Organophosphorus compounds (OPCs) are highly toxic compounds that can block acetylcholine esterase (AChE) and thereby indirectly lead to an overstimulation of muscarinic and nicotinic acetylcholine receptors (nAChRs). The current treatment with atropine and AChE reactivators (oximes) is insufficient to prevent toxic effects, such as respiratory paralysis, after poisonings with various OPCs. Thus, alternative treatment options are required to increase treatment efficacy. Novel therapeutics, such as the bispyridinium non-oxime MB327, have been found to reestablish neuromuscular transmission by interacting directly with nAChR, probably via allosteric mechanisms. To rationally design new, more potent drugs addressing nAChR, knowledge of the binding mode of MB327 is fundamental. However, the binding pocket of MB327 has remained elusive. Here, we identify a new potential allosteric binding pocket (MB327-PAM-1) of MB327 located at the transition of the extracellular to the transmembrane region using blind docking experiments and molecular dynamics simulations. MB327 forms striking interactions with the receptor at this site. The interacting amino acids are highly conserved among different subunits and different species. Correspondingly, MB327 can interact with several nAChR subtypes from different species. We predict by rigidity analysis that MB327 exerts an allosteric effect on the orthosteric binding pocket and the transmembrane domain after binding to MB327-PAM-1. Furthermore, free ligand diffusion MD simulations reveal that MB327 also has an affinity to the orthosteric binding pocket, which agrees with recently published results that related bispyridinium compounds show inhibitory effects via the orthosteric binding site. The newly identified binding site allowed us to predict structural modifications of MB327, resulting in the more potent resensitizers PTM0062 and PTM0063.

BACKGROUND:A host-protein score (BV score) that combines the circulating levels of TNF-related apoptosis-inducing ligand (TRAIL), interferon gamma-induced protein 10 (IP-10) and C-reactive protein (CRP) was developed for distinguishing bacterial from viral infection. This study assessed the potential of the BV score to impact decision making and antibiotic stewardship at the emergency department (ED), by comparing BV score's performance to physician's etiological suspicion at patient presentation. METHODS:Rosetta study participants, aged 3 months to 18 years with febrile respiratory tract infection or fever without source, were prospectively recruited in a tertiary care pediatric ED. 465 patients were recruited, 298 met eligibility criteria and 287 were enrolled. ED physician's etiological suspicion was recorded in a questionnaire. BV score was measured retrospectively with results interpreted as viral, bacterial or equivocal and compared to reference standard etiology, which was adjudicated by three independent experts based on all available data. Experts were blinded to BV scores. RESULTS:Median age was 1.3 years (interquartile range 1.7), 39.7% females. 196 cases were reference standard viral and 18 cases were reference standard bacterial. BV score attained sensitivity of 88.9% (95% confidence interval: 74.4-100), specificity 92.1% (88.1-96.0), positive predictive value 53.3% (35.5-71.2) and negative predictive value 98.8% (97.1-100). Positive likelihood ratio was 11.18 (6.59-18.97) and negative likelihood ratio was 0.12 (0.03-0.45). The rate of BV equivocal scores was 9.4%. Comparing physician's suspicion to BV score and to the reference standard, and assuming full adoption, BV score could potentially correct the physician's diagnosis and reduce error ~2-fold, from 15.9% to 8.2%. CONCLUSIONS:BV score has potential to aid the diagnostic process. Future studies are warranted to assess the impact of real-time BV results on ED practice.

STUDY OBJECTIVE:To evaluate the diagnostic performance of emergency physicians' interpretation of robotically acquired retinal optical coherence tomography images for detecting posterior eye abnormalities in patients seen in the emergency department (ED). METHODS:Adult patients presenting to Duke University Hospital emergency department from November 2020 through October 2021 with acute visual changes, headache, or focal neurologic deficit(s) who received an ophthalmology consultation were enrolled in this pilot study. Emergency physicians provided standard clinical care, including direct ophthalmoscopy, at their discretion. Retinal optical coherence tomography images of these patients were obtained with a robotic, semi-autonomous optical coherence tomography system. We compared the detection of abnormalities in optical coherence tomography images by emergency physicians with a reference standard, a combination of ophthalmology consultation diagnosis and retina specialist optical coherence tomography review. RESULTS:Nine emergency physicians reviewed the optical coherence tomography images of 72 eyes from 38 patients. Based on the reference standard, 33 (46%) eyes were normal, 16 (22%) had at least 1 urgent/emergency abnormality, and the remaining 23 (32%) had at least 1 nonurgent abnormality. Emergency physicians' optical coherence tomography interpretation had 69% (95% confidence interval [CI], 49% to 89%) sensitivity for any abnormality, 100% (95% CI, 79% to 100%) sensitivity for urgent/emergency abnormalities, 48% (95% CI, 28% to 68%) sensitivity for nonurgent abnormalities, and 64% (95% CI, 44% to 84%) overall specificity. In contrast, emergency physicians providing standard clinical care did not detect any abnormality with direct ophthalmoscopy. CONCLUSION:Robotic, semi-autonomous optical coherence tomography enabled ocular imaging of emergency department patients with a broad range of posterior eye abnormalities. In addition, emergency provider optical coherence tomography interpretation was more sensitive than direct ophthalmoscopy for any abnormalities, urgent/emergency abnormalities, and nonurgent abnormalities in this pilot study with a small sample of patients and emergency physicians.

Twenty-four blood serum samples from patients with acute methanol poisoning (M) from the mass methanol poisoning outbreak in the Czech Republic in 2012 were compared with 46 patient samples taken four years after poisoning (S) (overlap of 10 people with group M) and with a control group (C) of 24 samples of patients with a similar proportion of chronic alcohol abuse. When comparing any two groups, tens to hundreds of proteins with a significant change in concentration were identified. Fifteen proteins showed significant changes when compared between any two groups. The group with acute methanol poisoning showed significant changes in protein concentrations for at least 64 proteins compared to the other groups. Among the most important identified proteins closely related to intoxication are mainly those involved in blood coagulation, metabolism of vitamin A (increased retinol-binding protein), immune response (e.g., increased complement factor I, complement factors C3 and C5), and lipid transport (increased apolipoprotein A I, apolipoprotein A II, adiponectin). For blood coagulation, the most affected proteins with significant changes in the methanol poisoning group were von Willebrand factor, carboxypeptidase N, alpha-2-antiplasmin (all increased), inter-alpha-trypsin inhibitor heavy chain H4, kininogen-1, plasma serine protease inhibitor, plasminogen (all decreased). However, heparin administration used for the methanol poisoning group could have interfered with some of the changes in their concentrations. Data are available via ProteomeXchange with the identifier PXD035726.

Background:The frequent occurrence of major public health emergencies globally poses a threat to people's life, health, and safety, and the convergence development of digital technology is very effective and necessary to cope with the outbreak and transmission control of public epidemics such as COVID-19, which is essential to improve the emergency management capability of global public health emergencies. Methods:The published literatures in the Web of Science Core Collection database from 2003 to 2022 were utilized to analyze the contribution and collaboration of the authors, institutions, and countries, keyword co-occurrence analysis, and research frontier identification using the CiteSpace, VOSviewer, and COOC software. Results:The results are shown as follows: (1) Relevant research can be divided into growth and development period and rapid development period, and the total publications show exponential growth, among which the USA, China, and the United Kingdom are the most occupied countries, but the global authorship cooperation is not close; (2) clustering analysis of high-frequency keyword, all kinds of digital technologies are utilized, ranging from artificial intelligence (AI)-driven machine learning (ML) or deep learning (DL), and focused application big data analytics and blockchain technology enabled the internet of things (IoT) to identify, and diagnose major unexpected public diseases are hot spots for future research; (3) Research frontier identification indicates that data analysis in social media is a frontier issue that must continue to be focused on to advance digital and smart governance of public health events. Conclusion:This bibliometric study provides unique insights into the role of digital technologies in the emergency management of public health. It provides research guidance for smart emergency management of global public health emergencies.

BACKGROUND:The impact of the coronavirus disease 2019 (COVID-19) pandemic on the incidence and in-hospital mortality of emergency cardiovascular disease (CVD) has not been clarified in Japan. METHODS:We compared the number of admissions and in-hospital mortality for emergency CVD during the pandemic (from January to December 2020) with those of pre-pandemic periods (from January 2018 to December 2019), using quarterly data from the Tokyo Cardiovascular Care Unit Network. The incidence rate in 2020 is compared with the average incidence rate observed in the same quarter of 2018 and 2019 and is presented as an incidence rate ratio (IRR) with 95 % confidence interval (CI). RESULTS:The number of admissions for acute myocardial infarction during the pandemic was significantly lower than before the pandemic, with an IRR of 0.93 (95 % CI; 0.88-0.98). Similarly, the IRR for unstable angina was 0.78 (95 % CI; 0.72-0.83), for acute heart failure was 0.84 (95 % CI; 0.76-0.91), for acute aortic dissection was 0.88 (95 % CI; 0.78-0.98), and for ruptured aortic aneurysm was 0.75 (95 % CI; 0.62-0.88). In quarterly comparisons, the numbers of acute aortic diseases and emergency arrhythmia significantly decreased from July to September 2020, while those of other emergency CVDs significantly declined in the 2020 April-June period, which includes the first wave period in Japan. In-hospital mortality of emergency CVDs was unchanged from the pre-pandemic period, except for acute aortic dissection, which increased in odds ratio of 1.31 (95 % CI 1.10-1.57). CONCLUSIONS:The COVID-19 pandemic significantly reduced the number of admissions for all emergency CVDs in all or part of the year. In-hospital mortality was unchanged from the pre-pandemic period, except for acute aortic dissection, which increased.

Background:One of the most critical decisions that emergency department (ED) physicians make is the discharge versus admission of patients. We aimed to study the association of the decision in the ED to admit patients with chest pain and/or breathlessness to a ward with risk assessment using the Rapid Emergency Triage and Treatment System (RETTS), the National Early Warning Score (NEWS), and plasma levels of the biomarkers copeptin, midregional proadrenomedulin (MR-proADM), and midregional proatrial natriuretic peptide (MR-proANP). Methods:Patients presenting at the ED with chest pain and/or breathlessness with less than one week onset were enrolled. Patients were triaged according to RETTS. NEWS was calculated from the vital signs retrospectively. Results:Three hundred and thirty-four patients (167 males), mean age 63.8 ± 16.8 years, were included. Of which, 210 (62.8%) patients complained of chest pain, 65 (19.5%) of breathlessness, and 59 (17.7%) of both. Of these, 176 (52.7%) patients were admitted to a ward, and 158 (47.3%) patients were discharged from the ED. In binary logistic models, age, gender, vital signs (O saturation and heart rate), NEWS class, and copeptin were associated with admission to a ward from the ED. In receiver-operating-characteristics (ROC) analysis, copeptin had an incremental predictive value compared to NEWS alone ( = 0.002). Conclusions:Emergency physicians' decisions to admit patients with chest pain and/or breathlessness from the ED to a ward are related to age, O saturation, heart rate, NEWS category, and copeptin. As an independent predictive marker for admission, early analysis of copeptin might be beneficial when improving patient pathways at the ED.

BACKGROUND:Adult cancer patients are at higher risk of morbidity and mortality following COVID-19 infection. Being on the front lines, it is crucial for emergency physicians to identify those who are at higher risk of mortality. The aim of our study was to determine the predictors of in-hospital mortality in COVID-19 positive cancer patients who present to the emergency department. METHODS:This is a retrospective cohort study conducted on adult cancer patients who presented to the ED of the American university of Beirut medical center from February 21, 2020, till February 21, 2021, and were found to have COVID-19 infection. Relevant data was extracted and analyzed. The association between different variables and in-hospital mortality was tested using Student's t test and Fisher's exact test or Pearson's Chi-square where appropriate. Logistic regression was applied to factors with p <0.2 in the univariate models. RESULTS:The study included 89 distinct patients with an average age of 66 years (± 13.6). More than half of them were smokers (52.8%) and had received chemotherapy within 1 month of presentation (52.8%). About one third of the patients died (n = 31, 34.8%). Mortality was significantly higher in patients who had recently received chemotherapy (67.7% vs 44.8%, p = .039), a history of congestive heart failure (CHF)(p = .04), higher levels of CRP (p = 0.048) and/or PCT(p<0.04) or were tachypneic in the ED (P = 0.016). CONCLUSIONS:Adult cancer patients with COVID-19 infection are at higher risks of mortality if they presented with tachypnea, had a recent chemotherapy, history of CHF, high CRP, and high procalcitonin levels at presentation.

Since early identification of potential critical patients in the Emergency Department (ED) can lower mortality and morbidity, this study seeks to develop a machine learning model capable of predicting possible critical outcomes based on the history and vital signs routinely collected at triage. We compare emergency physicians and the predictive performance of the machine learning model. Predictors including patients' chief complaints, present illness, past medical history, vital signs, and demographic data of adult patients (aged ≥ 18 years) visiting the ED at Shuang-Ho Hospital in New Taipei City, Taiwan, are extracted from the hospital's electronic health records. Critical outcomes are defined as in-hospital cardiac arrest (IHCA) or intensive care unit (ICU) admission. A clinical narrative-aware deep neural network was developed to handle the text-intensive data and standardized numerical data, which is compared against other machine learning models. After this, emergency physicians were asked to predict possible clinical outcomes of thirty visits that were extracted randomly from our dataset, and their results were further compared to our machine learning model. A total of 4,308 (2.5 %) out of the 171,275 adult visits to the ED included in this study resulted in critical outcomes. The area under the receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (AUPRC) of our proposed prediction model is 0.874 and 0.207, respectively, which not only outperforms the other machine learning models, but even has better sensitivity (0.95 vs 0.41) and accuracy (0.90 vs 0.67) as compared to the emergency physicians. This model is sensitive and accurate in predicting critical outcomes and highlights the potential to use predictive analytics to support post-triage decision-making.

BACKGROUND:For COVID-19 patients evaluated in the Emergency Department (ED), decision on hospital admission vs. home discharge is challenging. The 4C mortality score (4CMS) is a prognostication tool integrating key demographic/clinical/biochemical data validated for COVID-19 inpatients. We sought to derive and validate a dichotomic rule based on 4CMS identifying patients with mild outcomes, suitable for safe ED discharge. METHODS:Derivation was performed in a prospective cohort of ED patients with suspected COVID-19 from two centers (April 2020). Validation was pursued in a prospective multicenter cohort of ED patients with confirmed COVID-19 from 6 centers (October 2020 to January 2021). Chest X-ray (CXR) images were independently scored. The primary composite outcome was all-cause 30-day mortality or hospital admission. Secondary outcomes were ED re-visit, oxygen therapy and ventilation. RESULTS:In a derivation cohort of 838 ED patients with suspected COVID-19, 4CMS≤8 was associated with low outpatient mortality (0.4%) and was thus selected as a feasible discharge rule. In a validation cohort of 521 COVID-19 outpatients, the mean age was 51±17 years; 97 (18.6%) patients had ≥1 CXR infiltrate. The 4CMS had an AUC of 0.82 for the primary outcome and 0.93 for mortality, outperforming other scores (CURB-65, qCSI, qSOFA, NEWS) and CXR. In 474 (91%) patients with 4CMS≤8, the mortality rate was 0.2% and the hospital admission rate was 6.8%, versus 12.8% and 36.2% for 4CMS≥9 (P<0.001). CXR did not provide additional discrimination. CONCLUSIONS:COVID-19 outpatients with 4CMS≤8 have mild outcomes and can be safely discharged from the ED. [NCT0462918].

OBJECTIVE:This study aims to assess the incidence of Emergency Department (ED) visits for benign paroxysmal positional vertigo (BPPV), describe patient characteristics, management practices and predictors of inpatient admission of BPPV patients. METHODS:This was a retrospective chart review of patients presenting with BPPV to a single ED between November 2018 and August 2020. Patients' characteristics, ED management, discharge medications, disposition and unscheduled return visits were determined. RESULTS:In total, 557 patients were included. Average age was 49 years, 54.2% were females and 12.4% required hospital admission. In the ED, 51.1% received intravenous hydration, 33.8% received anti-emetics, 10.1% received benzodiazepines, 31.8% underwent canalith repositioning maneuvers (CRMs) and 56.7% were discharged on acetyl-leucine. Of discharged patients, 2.5% had unscheduled return visits. A higher likelihood of admission was associated with age above 54 years (aOR = 4.86, p<0.001, 95% CI [2.67, 8.86]), home use of proton pump inhibitors (PPIs) (aOR = 2.44, p = 0.03, 95% CI [1.08, 5.53]), use of anti-emetics and benzodiazepines in the ED (aOR = 2.34, p = 0.003, 95% CI [1.34, 4.07]) and (aOR = 2.18, p = 0.04, 95% CI [1.03, 4.64]), respectively. CONCLUSION:While BPPV is a benign diagnosis, a significant number of patients presenting to the ED require admission. Predictors of admission include older age, PPIs use and ED treatment with anti-emetics and benzodiazepines. Although CRMs are the gold standard for management, CRMs usage did not emerge as protective from admission, and our overall usage was low.

The first clinical impression of emergency patients conveys a myriad of information that has been incompletely elucidated. In this prospective, observational study, the value of the first clinical impression, assessed by 18 observations, to predict the need for timely medical attention, the need for hospital admission, and in-hospital mortality in 1506 adult patients presenting to the triage desk of an emergency department was determined. Machine learning models were used for statistical analysis. The first clinical impression could predict the need for timely medical attention [area under the receiver operating characteristic curve (AUC ROC), 0.73; p = 0.01] and hospital admission (AUC ROC, 0.8; p = 0.004), but not in-hospital mortality (AUC ROC, 0.72; p = 0.13). The five most important features informing the prediction models were age, ability to walk, admission by emergency medical services, lying on a stretcher, breathing pattern, and bringing a suitcase. The inability to walk at triage presentation was highly predictive of both the need for timely medical attention (p < 0.001) and the need for hospital admission (p < 0.001). In conclusion, the first clinical impression of emergency patients presenting to the triage desk can predict the need for timely medical attention and hospital admission. Important components of the first clinical impression were identified.

INTRODUCTION:Multiple studies have validated the Emergency Surgery Score (ESS) as a tool which reliably predicts outcomes after emergency general surgery. The purpose of this study was to assess the performance of the ESS for lower-extremity endovascular procedures in nonelective setting (neLEE). METHODS:The American College of Surgeons' National Surgical Quality Improvement Program database was retrospectively analyzed for patients undergoing neLEE between 2015 and 2019. The performance of the ESS in predicting mortality in each procedure was assessed using receiver operating characteristic analyses. RESULTS:Four thousand five hundred and eighty three patients underwent neLEE with median age 68 (±12.3 SD), with 1802 females (39.3%). The ESS correlated with 30-day mortality (area under the curve [AUC] was 0.729), discharge to rehab (AUC 0.638), renal failure (AUC 0.667), postintervention ventilation requirement (AUC 0.680), and stroke (AUC 0.656). The predictive ability of the ESS decreased with increasing age, with the ESS performing best for patients between 60 and 69 y in age (AUC 0.735) and worst for patients above 80 y (AUC 0.650). A Cochran-Armitage test showed linear trend towards increased 30-day mortality among the quartiles with increasing ESS (P < 0.001), with patients with ESS ≥10 having 10 times odds of increased 30-day mortality compared to reference quartile of patients with ESS ≤4 on multivariate analysis. CONCLUSIONS:The ESS score is associated with 30-day mortality and other complications after neLEE procedures. It can potentially be used as a predictive tool for preoperative risk stratification and can also be used for equitably evaluating standards and outcomes after lower extremity endovascular procedures.

Objectives:To understand the current status of smoking behavior among emergency physicians in China and to explore its determinants. Background:The emergency department is considered a more appropriate setting for tobacco interventions. However, the smoking behavior of emergency physicians can reduce the effectiveness of interventions for patient smoking behavior. Methods:From July to August 2018, we conducted a structured online questionnaire among Chinese emergency medicine physicians. We used descriptive analysis with binary logistic regression to analyze the current smoking status of Chinese emergency physicians and its determinants. Results:A total of 10,457 emergency physicians were included in this study. The prevalence of smoking among physicians was 25.35% (with 34.15 and 1.59% among male and female physicians, respectively). Results of logistic regression showed that postgraduate education (OR = 0.52, 95% CI: 0.41-0.66), chief-level title (OR = 0.79, 95% CI: 0.65-0.97), and regular exercise habits (OR = 0.83, 95% CI: 0.76-0.92) were associated with a lower risk of smoking behavior. However, being over 50 years old (OR = 1.71, 95% CI: 1.29-2.27), being fixed-term (OR = 1.25, 95% CI: 1.10-1.42), and having depressive symptoms (OR = 1.43, 95% CI: 1.28-1.61) were associated with a higher risk of smoking. Conclusion:The prevalence of smoking behavior among emergency physicians in China is high. Hospital management could reduce the incidence of smoking behavior among emergency physicians by strengthening smoking cessation training, paying attention to physicians' psychological health, reducing pressure on physicians in fixed-term positions, and encouraging physicians to develop regular exercise habits.

Due to its widespread availability, low cost, feasibility at the patient's bedside and accessibility even in low-resource settings, chest X-ray is one of the most requested examinations in radiology departments. Whilst it provides essential information on thoracic pathology, it can be difficult to interpret and is prone to diagnostic errors, particularly in the emergency setting. The increasing availability of large chest X-ray datasets has allowed the development of reliable Artificial Intelligence (AI) tools to help radiologists in everyday clinical practice. AI integration into the diagnostic workflow would benefit patients, radiologists, and healthcare systems in terms of improved and standardized reporting accuracy, quicker diagnosis, more efficient management, and appropriateness of the therapy. This review article aims to provide an overview of the applications of AI for chest X-rays in the emergency setting, emphasizing the detection and evaluation of pneumothorax, pneumonia, heart failure, and pleural effusion.

Background:Since January 2020, the continuous and severe COVID-19 epidemic has ravaged various countries around the world and affected their emergency medical systems (EMS). The total number of emergency calls and the number of emergency calls for central nervous system (CNS) symptoms during the 2020 COVID-19 outbreak in Hangzhou, China (January 20-March 20) were investigated, and it was investigated whether these numbers had decreased as compared with the corresponding period in 2019. Methods:The number of daily emergency calls, ambulance dispatches, and rescues at the Hangzhou Emergency Center (HEC) was counted. The CNS symptoms considered in this study included those of cerebrovascular diseases, mental and behavioral disorders, and other neurological diseases. Results:It was found that, during the 2020 study period, the number of emergency calls was 33,563, a decrease of 19.83% (95% CI: 14.02-25.41%) as compared to the 41,863 emergency calls in 2019 ( < 0.01). The number of ambulances dispatched was 10,510, a decrease of 25.55% (95 %CI: 18.52-35.11%) as compared to the 14,117 ambulances dispatched in 2019 ( < 0.01). The number of rescues was 7,638, a decrease of 19.67% (95% CI: 16.12-23.18%) as compared with the 9,499 rescues in 2019 ( < 0.01). It was also found that the number of emergency calls related to CNS symptoms, including symptoms of cerebrovascular diseases, mental and behavioral disorders, and other neurological diseases, was significantly reduced ( < 0.01). Conclusion:The total number of medical emergency calls and the number of emergency calls for CNS symptoms occurring in a large city in China decreased significantly during the COVID-19 epidemic.

OBJECTIVE:The objective was to identify the most important and impactful peer-reviewed global emergency medicine (GEM) articles published in 2021. The top articles are summarized in brief narratives and accompanied by a comprehensive list of all identified articles that address the topic during the year to serve as a reference for clinicians, researchers, and policy makers. METHODS:A systematic PubMed search was carried out to identify all GEM articles published in 2021. Title and abstract screening was performed by trained reviewers and editors to identify articles in one of three categories based on predefined criteria: disaster and humanitarian response (DHR), emergency care in resource-limited settings (ECRLS), and emergency medicine development (EMD). Included articles were each scored by two reviewers using established rubrics for original (OR) and review (RE) articles. The top 5% of articles overall and the top 5% of articles from each category (DHR, ECRLS, EMD, OR, and RE) were included for narrative summary. RESULTS:The 2021 search identified 44,839 articles, of which 444 articles screened in for scoring, 25% and 22% increases from 2020, respectively. After removal of duplicates, 23 articles were included for narrative summary. ECRLS constituted the largest category (n = 16, 70%), followed by EMD (n = 4, 17%) and DHR (n = 3, 13%). The majority of top articles were OR (n = 14, 61%) compared to RE (n = 9, 39%). CONCLUSIONS:The GEM peer-reviewed literature continued to grow at a fast rate in 2021, reflecting the continued expansion and maturation of this subspecialty of emergency medicine. Few high-quality articles focused on DHR and EMD, suggesting a need for further efforts in those fields. Future efforts should focus on improving the diversity of GEM research and equitable representation.