Radiological Findings of Sexual Intercourse Related Emergency Department Admissions: A First Overview

Objectives

Sexuality is an essential aspect of human function, well-being and quality of life. Many people have sex without complications. However, there are some people who need to seek emergency medical help for related health problems. The aim of this study was to present a first overview of patients who received a radiological examination related to sexual intercourse based emergency department admission.

Methods

Our centralized electronic patient record database was reviewed for patients who had been admitted to our emergency department with an emergency after sexual intercourse between 2000 and 2011. The database was scanned for the standardized key words ‘sexual intercourse’ or ‘coitus’ retrospectively. For all patients identified in the electronic patient record database the radiological examinations were searched for manually in our Radiology Information System, and reviewed by three independent radiologists.

Results

One hundred and twenty nine out of 445 (29,0%) patients received a radiological examination after immediate emergency department admission related to sexual intercourse. Fifty two out of 129 (40.3%) patients had positive radiological findings while 77 (59.7%) did not. Eighty point seven percent (n = 42) of the radiological findings were a sexual intercourse-associated pathology and 19.2% (n = 10) were considered to be incidental findings. Age and male sex positively correlated with radiological imaging workup (p<0.001, respectively p<0.037). The most common sexual intercourse-associated pathology was headache attributed to cerebrovascular insult (n = 21, 40.3%) followed by epididymitis (n = 7, 16.6%) and obstructive uropathy (n = 5, 11.6%). Of the patients with headache attributed to non-traumatic intracranial hemorrhage, subarachnoid hemorrhage (n = 14, 66.6%) was the most common, followed by intracerebral bleeding (n = 4, 19.0%) and one subdural hemorrhage.

Conclusions

Pathological findings are manifold. Cerebral imaging is the most common type of radiological imaging performed. Further prospective and standardized studies should be performed to better evaluate the significance of radiological imaging in this patient collective with the aim to gain better knowledge on what patients profit from what type of radiological imaging when presenting with a sexual intercourse related emergency.

Advances in Knowledge

The present study provides a first overview on radiological findings of sexual intercourse related emergency department admissions.     

Complaints and Diagnoses of Emergency Department Patients in the Netherlands: A Comparative Study of Integrated Primary and Emergency Care

ObjectiveIn the Netherlands, an increasing number of emergency departments (EDs) and general practitioner cooperatives collaborate by creating one Emergency-Care-Access-Point (ECAP). This has resulted in fewer patients at ECAP EDs. The objective of this study was to explore differences in patient characteristics, presented complaints and ED discharge diagnoses between EDs with an ECAP and EDs without an ECAP.MethodsA retrospective observational study was performed with 1800 consecutive patient records sampled from six EDs spread over the Netherlands in 2013. We extracted data on time and date of presentation, sex, age, presenting complaint, discharge diagnosis, origin and follow up.ResultsAt ECAP EDs, the mean age was 47.8 years (95%CI 46.1-49.4) compared to 41.3 (95%CI 39.7-42.9). Compared to non-ECAP EDs, more patients were referred by medical professionals (74.7% versus 46.8%), more patients received hospital admission (45.2% versus 29.0%) and fewer patients received GP follow-up (4.1% versus 16.9%). There was no significant difference in presenting complaints between ECAP and non-ECAP EDs. Most prevalent complaints were trauma (25.7% versus 29.7%), abdominal pain (12.1% versus 10.9%) and general symptoms (7.8% versus 4.8%). The most prevalent ED diagnoses significantly differed with fractures and dislocations (10.8%), sprains and strains (10.4%) and respiratory infections (6.8%) at ECAP EDs versus fractures and dislocations (10.7%), wounds (9.3%) and sprains and strains (8.9%) at non-ECAP EDs.ConclusionCompared to non-ECAP EDs, patients at ECAP EDs were older, medical professionals referred more patients and more patients received a hospital admission. We found some small differences in discharge diagnoses between ECAP EDs compared to non-ECAP EDs, but no difference in presented complaints.     

Associations between Extending Access to Primary Care and Emergency Department Visits: A Difference-In-Differences Analysis

BackgroundHealth services across the world increasingly face pressures on the use of expensive hospital services. Better organisation and delivery of primary care has the potential to manage demand and reduce costs for hospital services, but routine primary care services are not open during evenings and weekends.Extended access (evening and weekend opening) is hypothesized to reduce pressure on hospital services from emergency department visits. However, the existing evidence-base is weak, largely focused on emergency out-of-hours services, and analysed using a before-and after-methodology without effective comparators.ConclusionsThe study found that extending access was associated with a reduction in emergency department visits in the first 12 months. The results of the research have already informed the decision by National Health Service England to extend primary care access across Greater Manchester from 2016. However, further evidence is needed to understand whether extending primary care access is cost-effective and sustainable.     

Multimorbidity in Adult Asylum Seekers: A First Overview

Principals

Over the last two decades, the total annual number of applications for asylum in the countries of the European Union has increased from 15,000 to more than 300,000 people. The aim of this study was to give a first overview on multimorbidity of adult asylum seekers.

Methods

Our retrospective Swiss single center data analysis examined multimorbidity of adult asylums seekers admitted to our ED between 1 January 2000 and 31 December 2012.

Results

A total of 3170 patients were eligible for the study; they were predominantly male (2392 male, 75.5% versus 778 female, 24.5). The median age of the patients was 28 years (range 28–82). The most common region of origin was Africa (1544, 48.7%), followed by the Middle East (736, 23.6%). 2144 (67.6%) of all patients were not multimorbid. A total of 1183 (37.7%) of our patients were multimorbid. The mean Charlson comorbidity index was 0.25 (SD 1.1, range 0–12). 634 (20%) of all patients sufferem from psychiatric diseases, followed by chronic medical conditions (12.6%, 399) and infectious diseases (4.7%, 150). Overall, 11% (349) of our patients presented as a direct consequence of prior violence. Patients from Sri Lanka/India most often suffered from addictions problems (50/240, 20.8%, p<0.0001). Infectious diseases were most frequent in patients from Africa (6.6%), followed by the Balkans and Eastern Europe/Russia (each 3.8%).

Conclusion

The health care problems of asylum seekers are manifold. More than 60% of the study population assessed in our study did not suffer from more than one disease. Nevertheless a significant percentage of asylum seekers is multimorbid and exhibits underlying psychiatric, infectious or chronic medical conditions despite their young age.     

Therapeutic Conflicts in Emergency Department Patients with Multimorbidity: A Cross-Sectional Study

Background

Patients with multimorbidity are an increasing concern in healthcare. Clinical practice guidelines, however, do not take into account potential therapeutic conflicts caused by co-occurring medical conditions. This makes therapeutic decisions complex, especially in emergency situations.

Objective

The aim of this study was to identify and quantify therapeutic conflicts in emergency department patients with multimorbidity.

Methods

We reviewed electronic records of all patients ≥18 years with two or more concurrent active medical conditions, admitted from the emergency department to the hospital ward of the University Hospital Zurich in January 2009. We cross-tabulated all active diagnoses with treatments recommended by guidelines for each diagnosis. Then, we identified potential therapeutic conflicts and classified them as either major or minor conflicts according to their clinical significance.

Results

166 emergency inpatients with multimorbidity were included. The mean number of active diagnoses per patient was 6.6 (SD±3.4). We identified a total of 239 therapeutic conflicts in 49% of the of the study population. In 29% of the study population major therapeutic conflicts, in 41% of the patients minor therapeutic conflicts occurred.

Conclusions

Therapeutic conflicts are common among multimorbid patients, with one out of two experiencing minor, and one out of three experiencing major therapeutic conflicts. Clinical practice guidelines need to address frequent therapeutic conflicts in patients with co-morbid medical conditions.     

Measuring Social Contacts in the Emergency Department

Background

Infectious individuals in an emergency department (ED) bring substantial risks of cross infection. Data about the complex social and spatial structure of interpersonal contacts in the ED will aid construction of biologically plausible transmission risk models that can guide cross infection control.

Methods and Findings

We sought to determine the number and duration of contacts among patients and staff in a large, busy ED. This prospective study was conducted between 1 July 2009 and 30 June 2010. Two 12-hour shifts per week were randomly selected for study. The study was conducted in the ED of an urban hospital. There were 81 shifts in the planned random sample of 104 (78%) with usable contact data, during which there were 9183 patient encounters. Of these, 6062 (66%) were approached to participate, of which 4732 (78%) agreed. Over the course of the year, 88 staff members participated (84%). A radiofrequency identification (RFID) system was installed and the ED divided into 89 distinct zones structured so copresence of two individuals in any zone implied a very high probability of contact <1 meter apart in space. During study observation periods, patients and staff were given RFID tags to wear. Contact events were recorded. These were further broken down with respect to the nature of the contacts, i.e., patient with patient, patient with staff, and staff with staff. 293,171 contact events were recorded, with a median of 22 contact events and 9 contacts with distinct individuals per participant per shift. Staff-staff interactions were more numerous and longer than patient-patient or patient-staff interactions.

Conclusions

We used RFID to quantify contacts between patients and staff in a busy ED. These results are useful for studies of the spread of infections. By understanding contact patterns most important in potential transmission, more effective prevention strategies may be implemented.     

The Relationship between Same-Day Access and Continuity in Primary Care and Emergency Department Visits

We examined how emergency department (ED) visits for potentially preventable, mental health, and other diagnoses were related to same-day access and provider continuity in primary care using administrative data from 71,296 patients in 22 VHA clinics over a three-year period. ED visits were categorized as non-emergent; primary care treatable; preventable; not preventable; or mental health-related. We conducted multi-level regression models adjusted for patient and clinic factors. More same-day access significantly predicted fewer non-emergent and primary care treatable ED visits while continuity was not significantly related to any type of ED visit. Neither measure was related to ED visits for mental health problems.     

Reducing Frequent Visits to the Emergency Department: A Systematic Review of Interventions

Objective

The objective of this study was to establish the effectiveness of interventions to reduce frequent emergency department (ED) use among a general adult high ED-use population.

Methods

Systematic review of the literature from 1950-January 2015. Studies were included if they: had a control group (controlled trials or comparative cohort studies), were set in an ED or acute care facility, and examined the impact of an intervention to reduce frequent ED use in a general adult population. Studies reporting non-original data or focused on a specific patient population were excluded. Study design, patient population, intervention, the frequency of ED visits, and costs of frequent ED use and/or interventions were extracted and narratively synthesized.

Results

Among 17 included articles, three intervention categories were identified: case management (n = 12), individualized care plans (n = 3), and information sharing (n = 2). Ten studies examining case management reported reductions in mean (-0.66 to -37) or median (-0.1 to -20) number of ED visits after 12-months; one study reported an increase in mean ED visits (+2.79); and one reported no change. Of these, 6 studies also reported reduced hospital costs. Only 1 study evaluating individualized care plans examined ED utilization and found no change in median ED visits post-intervention. Costs following individualized care plans were also only evaluated in 1 study, which reported savings in hospital costs of $742/patient. Evidence was mixed regarding information sharing: 1 study reported no change in mean ED visits and did not examine costs; whereas the other reported a decrease in mean ED visits (-16.9) and ED cost savings of $15,513/patient.

Conclusions

The impact of all three frequent-user interventions was modest. Case management had the most rigorous evidence base, yielded moderate cost savings, but with variable reductions in ED use. Future studies evaluating non-traditional interventions, tailoring to patient subgroups or socio-cultural contexts, are warranted.     

Spontaneous Thyroid Nodule Hemorrhage in the Emergency Department

Objective: Spontaneous thyroid gland hemorrhage is a rare event. The present retrospective study considered its clinical impact and management in a referral center.Methods: Clinical records of adult patients accessed in the last 10 years (2009–2018) in the Emergency Department of Policlinico Gemelli IRCCS were reviewed to study patients with spontaneous thyroid nodule hemorrhage. All demographic and radiologic or surgical parameters were included, with special attention to the characteristics of thyroid disease and clinical management.Results: Among the 631,129 adults who were registered during the period considered, 59 consecutive patients were included in the study. The mean age was 48.3 ± 14.3 years, with a prevalence of females. The main symptoms were acute neck pain, dyspnea, and dysphagia. All patients underwent ultrasound evaluation; computed tomography scan was performed on only 3 patients, finding one case of active intranodular bleeding requiring urgent surgery. Six patients required hospitalization; the others were discharged and referred for ambulatory endocrinology follow-up. Among them, 7 patients underwent surgery in the next 6 months, with malignant disease found in 3 cases (5.1%).Conclusion: Intrathyroidal spontaneous hemorrhage is a rare event, occurring in multinodular as well as in single-nodule thyroid disease. Although the clinical course is mostly benign, this condition should be carefully evaluated as, in rare circumstances, active bleeding could induce airway obstruction with the need for emergency surgery. Patients should be referred to endocrinology ambulatory follow-up because bleeding could arise as the first sign of malignant lesions in some cases.Abbreviations: CT = computed tomography; ED = emergency department; FNA = fine-needle aspiration; US = ultrasound     

Overview of the First Phylogenomics Conference

The First Phylogenomics Conference was held in Ste-Adèle (Québec, Canada) in March 2006. Selected papers appear in this special issue of BMC Evolutionary Biology. Here, we give an introduction to the field and provide an overview of the articles presented in this issue.     

Diagnostic Radiation Exposure of Injury Patients in the Emergency Department: A Cross-Sectional Large Scaled Study

In contrast to patients with underlying cancer or chronic disease, injury patients are relatively young, and can be expected to live their natural lifespan if injuries are appropriately treated. Multiple and repeated diagnostic scans might be performed in these patients during admission. Nevertheless, radiation exposure in injury patients has been overlooked and underestimated because of the emergent nature of such situations. Therefore, we tried to assess the cumulative effective dose (cED) of injury patients in the emergency department. We included patients who visited the emergency department (ED) of a single tertiary hospital due to injury between February 2010 and February 2011. The cED for each patient was calculated and compared across age, sex and injury mechanism. A total of 11,676 visits (mean age: 28.0 years, M:F = 6,677:4,999) were identified. Although CT consisted of only 7.8% of total radiologic examinations (n=78,025), it accounted for 87.1% of the total cED. The mean cED per visit was 2.6 mSv. A significant difference in the cED among injury mechanisms was seen (p<0.001) and patients with traffic accidents and fall down injuries showed relatively high cED values. Hence, to reduce the cED of injury patients, an age-, sex- and injury mechanism-specific dose reduction strategy should be considered.     

High-Sensitive Troponin Measurement in Emergency Department Patients Presenting with Syncope: A Retrospective Analysis

Objective

To study the relevance of high-sensitive troponin measurements in the acute workup in patients admitted to the emergency department of a large university hospital due to syncope.

Methods

In this retrospective study all patients admitted to the emergency department because of syncope of the Inselspital, University Hospital Bern between 01 August 2010 and 31 October 2012, with serial determination of high-sensitive troponin (baseline and three hours control) were included. Of all identified patients we obtained data on demographics, laboratory data, ECG as well as on outcome. A change in high-sensitive troponin in the three hours control of +/−30% compared to baseline was considered significant.

Results

A total of 121 patients with a mean age of 67 years (SD 16) were included in the study. 79 patients (65%) were male and 42 (35%) were female. There was no significant difference in the median high sensitive-troponin level at baseline and in the three hours control (0.01 mcg/L [0.003 to 0.022] versus 0.011 mcg/L [0.003 to 0.022], p = 0.47). Median percent change in high-sensitive troponin level between baseline and control was 0% (−9.1 to 5). 51 patients (42%) had elevated high-sensitive troponin levels at baseline with 7 patients (6%) showing a dynamic of +/−30% change from the baseline measurement in the 3 hours control. 3 of these patients received coronary angiography due to the dynamic in high-sensitive troponin, none of whom needed intervention for coronary revascularization.

Conclusions

On basis of the current study, where no single patient took benefit from determination of high-sensitive troponin, measurement of cardiac troponins should be reserved for patients with syncope presenting with symptoms suggestive for the presence of an acute cardiac syndrome.     

Understanding Low-Acuity Visits to the Pediatric Emergency Department

Background

Canadian pediatric emergency department visits are increasing, with a disproportionate increase in low-acuity visits locally (33% of volume in 2008-09, 41% in 2011-12). We sought to understand: 1) presentation patterns and resource implications; 2) parents’ perceptions and motivations; and 3) alternate health care options considered prior to presenting with low-acuity problems.

Methods

We conducted a prospective cohort study at our tertiary pediatric emergency department serving two provinces to explore differences between patients with and without a primary care provider. During four, 2-week study periods over 1 year, parents of low-acuity visits received an anonymous survey. Presentation times, interventions, diagnoses and dispositions were captured on a data collection form linked to the survey by study number.

Results

Parents completed 2,443 surveys (74.1% response rate), with survey-data collection form pairs available for 2,146 visits. Overall, 89.7% of respondents had a primary care provider; 68% were family physicians. Surprisingly, 40% of visits occurred during weekday office hours and 27.3% occurred within 4 hours of symptom onset; 67.5% of those early presenters were for injuries. Few parents sought care from their primary care provider (25%), health information line (20.7%), or urgent care clinic (18.5%); 36% reported that they believed their child’s problem required the emergency department. Forty-five percent required only a history, physical exam and reassurance; only 11% required an intervention not available in an office setting. Patients without a primary care provider were significantly more likely to present during weekday office hours (p = 0.003), have longer symptom duration (p<0.001), and not know of other options (p = 0.001).

Conclusions

Many parents seek pediatric emergency department care for low-acuity problems despite their child having a primary care provider. Ensuring timely access to these providers may help reduce pediatric emergency department overuse. Educational initiatives should inform parents about low-acuity problems and where appropriate care can/should be accessed.     

Risk Prediction of Emergency Department Revisit 30 Days Post Discharge: A Prospective Study

BackgroundAmong patients who are discharged from the Emergency Department (ED), about 3% return within 30 days. Revisits can be related to the nature of the disease, medical errors, and/or inadequate diagnoses and treatment during their initial ED visit. Identification of high-risk patient population can help device new strategies for improved ED care with reduced ED utilization.ConclusionsOur ED 30-day revisit model was prospectively validated on the Maine State HIN secure statewide data system. Future integration of our ED predictive analytics into the ED care work flow may lead to increased opportunities for targeted care intervention to reduce ED resource burden and overall healthcare expense, and improve outcomes.     

Difficult Behaviors in the Emergency Department: A Cohort Study of Housed,Homeless and Alcohol Dependent Individuals

Background

This study contrasted annual rates of difficult behaviours in emergency departments among cohorts of individuals who were homeless and low-income housed and examined predictors of these events.

Methods

Interviews in 1999 with men who were chronically homeless with drinking problems (CHDP) (n = 50), men from the general homeless population (GH) (n = 61), and men residing in low-income housing (LIH) (n = 58) were linked to catchment area emergency department records (n = 2817) from 1994 to 1999. Interview and hospital data were linked to measures of difficult behaviours.

Results

Among the CHDP group, annual rates of visits with difficult behaviours were 5.46; this was 13.4 (95% CI 10.3–16.5) and 14.3 (95% CI 11.2–17.3) times higher than the GH and LIH groups. Difficult behaviour incidents included physical violence, verbal abuse, uncooperativeness, drug seeking, difficult histories and security involvement. Difficult behaviours made up 57.54% (95% CI 55.43–59.65%), 24% (95% CI 19–29%), and 20% (95% CI 16–24%) of CHDP, GH and LIH visits. Among GH and LIH groups, 87% to 95% were never involved in verbal abuse or violence. Intoxication increased all difficult behaviours while decreasing drug seeking and leaving without being seen. Verbal abuse and violence were less likely among those housed, with odds ratios of 0.24 (0.08, 0.72) and 0.32 (0.15, 0.69), respectively.

Conclusions

Violence and difficult behaviours are much higher among chronically homeless men with drinking problems than general homeless and low-income housed populations. They are concentrated among subgroups of individuals. Intoxication is the strongest predictor of difficult behaviour incidents.     

Factors Associated with the Occurrence of Cardiac Arrest after Emergency Tracheal Intubation in the Emergency Department

Objectives

Emergency tracheal intubation has achieved high success and low complication rates in the emergency department (ED). The objective of this study was to evaluate the incidence of post-intubation CA and determine the clinical factors associated with this complication.

Methods

A matched case-control study with a case to control ratio of 1∶3 was conducted at an urban tertiary care center between January 2007 and December 2011. Critically ill adult patients requiring emergency airway management in the ED were included. The primary endpoint was post-intubation CA, defined as CA within 10 minutes after tracheal intubation. Clinical variables were compared between patients with post-intubation CA and patients without CA who were individually matched based on age, sex, and pre-existing comorbidities.

Results

Of 2,403 patients who underwent emergency tracheal intubation, 41 patients (1.7%) had a post-intubation CA within 10 minutes of the procedure. The most common initial rhythm was pulseless electrical activity (78.1%). Patients experiencing CA had higher in-hospital mortality than patients without CA (61.0% vs. 30.1%; p<0.001). Systolic hypotension prior to intubation, defined as a systolic blood pressure ≤90 mmHg, was independently associated with post-intubation CA (OR, 3.67 [95% CI, 1.58–8.55], p = 0.01).

Conclusion

Early post-intubation CA occurred with an approximate 2% frequency in the ED. Systolic hypotension before intubation is associated with this complication, which has potentially significant implications for clinicians at the time of intubation.     

Magnesium Sulfate in Emergency Department Patients with Hypertension

To compare the effect of IV magnesium with other antihypertensives in emergency department (ED) patients with hypertension. ED patients with a systolic BP > 135 mmHg or diastolic BP > 85 were approached for entry into the study. Those granting consent were randomly placed into one of three treatment groups: (1) 1.5 gm IV MgSO₄ (n = 42), (2) a parenteral or oral antihypertensive agent (n = 41), (3) both IV MgSO₄ and an antihypertensive agent (n = 44). Systolic and diastolic blood pressures were measured at entry into the study and at 15, 30, 45, and 60 min after magnesium or other antihypertensive medications were given. The main outcome measure was blood pressure at 60 min, and results were compared using one-way analysis of variance with the post hoc Tukey HSD test. Compared to systolic and diastolic blood pressures at time 0, both were lower at 15, 30, 45, and 60 min in all groups (p < 0.05). No significant difference in systolic or diastolic BP at any time point was observed when response to treatment was compared between the three groups. Intravenous MgSO₄ is as effective as antihypertensives at lowering BP in emergency department patients.