Trends in advanced imaging and hospitalization for emergency department syncope care before and after ACEP clinical policy

ObjectivesTo describe recent trends in advanced imaging and hospitalization of emergency department (ED) syncope patients, both considered “low-value”, and examine trend changes before and after the publication of American College Emergency Physician (ACEP) syncope guidelines in 2007, compared to conditions that had no changes in guideline recommendations.MethodsWe analyzed 2002–2015 National Hospital Ambulatory Medical Care Survey data using an interrupted-time series with comparison series design. The primary outcomes were advanced imaging among ED visits with principal diagnosis of syncope and headache and hospitalization for ED visits with principal diagnosis of syncope, chest pain, dysrhythmia, and pneumonia. We adjusted annual imaging and hospitalization rates using survey-weighted multivariable logistic regression, controlling for demographic and visit characteristics. Using adjusted outcomes as datapoints, we compared linear trends and trend changes of annual imaging and hospitalization rates before and after 2007 with aggregate-level multivariable linear regression.ResultsFrom 2002 to 2007, advanced imaging rates for syncope increased from 27.2% to 42.1% but had no significant trend after 2007 (trend change: ?3.1%; 95%CI ?4.7, ?1.6). Hospitalization rates remained at approximately 37% from 2002 to 2007 but declined to 25.7% by 2015 (trend change: ?2.2%; 95%CI ?3.0, ?1.4). Similar trend changes occurred among control conditions versus syncope, including advanced imaging for headache (difference in trend change: ?0.6%; 95%CI ?2.8, 1.6) and hospitalizations for chest pain, dysrhythmia, and pneumonia (differences in trend changes: 0.1% [95%CI ?1.9, 2.0]; ?0.9% [95%CI ?3.1, 1.3]; and ?1.2% [95%CI ?5.3, 2.9], respectively).ConclusionsBefore and after the release of 2007 ACEP syncope guidelines, trends in advanced imaging and hospitalization for ED syncope visits had similar changes compared to control conditions. Changes in syncope care may, therefore, reflect broader practice shifts rather than a direct association with the 2007 ACEP guideline. Moreover, utilization of advanced imaging remains prevalent. To reduce low-value care, policymakers should augment society guidelines with additional policy changes such as reportable quality measures.     

Dissected Aorta Repair Through Stent Implantation trial: Canadian results

Objectives

We describe the Canadian results of the Ascyrus Medical Dissection Stent (AMDS), a novel partially uncovered aortic arch hybrid graft implanted antegrade during hypothermic circulatory arrest to promote true lumen expansion and enhance aortic remodeling.

Medical Child Abuse: An Unusual “Source” of Vaginal Bleeding

BackgroundMedical child abuse (MCA) is challenging to diagnose. Although young children are often affected, adolescents can be victims through caregiver coercion. Presentation is highly variable. Diagnosis is essential because of high associated morbidity and mortality.CaseWe describe the case of a 12-year-old girl who presented to multiple subspecialty clinics with reported menorrhagia. Despite reassuring clinical examinations, the family described menorrhagia that failed to respond to standard treatment. After an urgent evaluation for reported heavy bleeding revealed only scant blood, the diagnosis of MCA was made.Summary and ConclusionVaginal bleeding is a rare presentation of MCA, but must be considered whenever reported symptomatology does not follow physiologic patterns, respond to standard medical treatment, or correspond to clinical evaluation. Prompt identification is important to prevent further harm.     

Validity of SMART-COP score in prognosis and severity of community acquired pneumonia in the emergency department

BackgroundDetermining prognosis in community acquired pneumonia (CAP), is very important. Many scores are introduced up to now for prediction of pneumonia prognosis like SMART-COP.ObjectiveTo evaluate validity of SMART-COP score in prognosis and severity of CAP in emergency department (ED).MethodsAll patients older than 18 years old with clinical suspicion of CAP (meeting the inclusion criteria), were enrolled in our study. In this prospective study, patients were admitted to the ED of a tertiary referral center. Hospital length of stay, rate of intensive care unit (ICU) admission, mortality rate, number of intensive respiratory or vasopressor support (IRVS) use, patients' SMART-COP scores and all demographic data were recorded. Validity of SMART-COP in the prediction of IRVS rate and its correlation with other variables were determined.ResultsIn this study, 47.6% and 52.4% of patients were females and males respectively. The mean age of patients was 68.13 ± 16.60 years old. The mean hospital length of stay was 13.49 ± 5.62 days. Of all patients entered in our study, 55 cases (38.5%) needed ICU admission, 29 cases (20.3%) were expired within 1 month and 44 cases (30.8%) needed IRVS during their treatment. SMART-COP ≥5 (high risk CAP) accurately predicted the rate of ICU admission, one-month mortality and IRVS need (p-value = 0.001).ConclusionsSMART-COP≥5 had a high sensitivity and specificity in the prediction of patients' prognosis with severe CAP in the ED.     

不完全契约理论视阈下某跨区域医联体核心医院运行效率评价研究

目的对某跨区域医联体核心医院的运行效率进行评价，以不完全契约理论为分析视角探讨影响因素，为深化医联体建设提供借鉴和参考。方法收集2014年-2021年核心医院相关数据，采用DEA数据分析方法，计算运行效率变化情况。结果核心医院各项投入明显增加，医疗业务产出同步增长，医院运行效率经历了动态波动后持续向好。结论通过构建管理共同体，逐步优化契约，争取医保政策支持，合作共建初见成效。     

Distribution and Surgical Management of Visceral Ewing Sarcoma Among Children and Adolescents

IntroductionEwing sarcoma (EWS) is a highly malignant tumor of bone and soft tissue that occasionally arises from viscera. Visceral EWS (V-EWS) is challenging to manage given its varied organ distribution and often late-stage presentation. We aimed to characterize our institutional experience with V-EWS, focusing on its surgical management, and to compare V-EWS outcomes against those with osseous (O-EWS) and soft tissue EWS (ST-EWS).MethodsRetrospective review of all EWS patients ≤21 years presenting to a single institution between 2000 and 2022. Patient- and disease-specific characteristics were compared. Overall and relapse-free survival were estimated using Kaplan Meier methods and log-rank test.Results156 EWS patients were identified: 117 O-EWS, 20 ST-EWS, and 19 V-EWS. V-EWS arose in the kidney (n = 5), lung (n = 5), intestine (n = 2), esophagus (n = 1), liver (n = 1), pancreas (n = 1), adrenal gland (n = 1), vagina (n = 1), brain (n = 1), and spinal cord (n = 1). No significant demographic differences were detected between EWS groups. V-EWS was more frequently metastatic at presentation (63.2%; p = 0.005), yet no significant overall or relapse-free survival differences emerged between EWS groups, with similar follow-up intervals. While V-EWS required multiple unique operative strategies to gain primary control, no significant difference in treatment strategies appeared between groups. Surgery-only primary control was associated with improved overall and relapse-free survival in all groups.ConclusionsV-EWS presents unique management challenges in children and adolescents given its variable sites of origin. This large cohort is the first to describe the surgical management and outcomes of V-EWS, demonstrating more frequent metastatic presentation, while achieving similar survival across groups.Level of evidenceLevel 2 – Cohort Study.     

A retrospective analysis comparing set up errors from standard versus customised headrests for head and neck radiotherapy

IntroductionIn response to advice from The National Institute for Health and Care Excellence ⁽¹⁾ to reduce hospital visits during COVID-19, standard headrests were introduced for head and neck radiotherapy within Northern Centre for Cancer Care (NCCC). The standard headrest requires one mould room appointment compared to 3 appointments with customised headrests.MethodsTwo groups of 10 patients treated between December 2019 and June 2020 were retrospectively analysed by 1 observer. Groups were stratified according to age, sex and tumour site. One group had customised headrest and the other had standard headrest. Five hundred and forty seven cone beam computed tomography images were reviewed. A 6 Degree of Freedom match was performed then chin, shoulder and spine position were assessed using dosimetrist drawn structures. Structures out of the tolerance were recorded. A chi-squared test was used for statistical analysis.ResultsThe out of tolerance chin position count recorded was 21 for customised headrest and 36 for standard headrest, p-value 0.046. The shoulder position count was 13 for customised headrest and 77 for standard headrest p-value <0.001. The spine position count was 3 for CHR and 21 for standard headrest, p-value <0.001. This means the headrests compared are not equivalent in terms of set up reproducibility. Overall the standard headrest group had 10 set-up re-scans and no set up re-scans were recorded in the customised headrest group.ConclusionFewer hospital visits with SHR reduce patient exposure to COVID-19. However, CHR provided a more reliable level of immobilisation in this study.Implications for practiceThe radiotherapy service will be reviewed in line with these findings.