Assessment of a COVID-19 vaccination protocol for unhoused patients in the emergency department.

BACKGROUND: We aimed to evaluate the feasibility of implementing an emergency department (ED)-based Coronavirus Disease of 2019 (COVID-19) vaccination protocol in a population of unhoused patients. METHODS: On June 10, 2021, a best practice alert (BPA) was implemented that fired when an ED provider opened the charts of unhoused patients and prompted the provider to order COVID-19 vaccination for eligible patients. We downloaded electronic medical record data of patients who received a COVID-19 vaccine in the ED between June 10, 2021 and August 26, 2021. The outcomes of interest were the number of unhoused, and the total number of patients vaccinated for COVID-19 during the study period. Data were described with simple descriptive statistics. RESULTS: There were 25,871 patient encounters in 19,992 unique patients (mean 1.3 visits/patient) in the emergency department during the study period. There were 1,474 (6% of total ED population) visits in 1,085 unique patients who were unhoused (mean 1.4 visits/patient). The BPA fired in 1,046 unhoused patient encounters (71% of PEH encounters) and was accepted in 79 (8%). Forty-three unhoused patients were vaccinated as a result of the BPA (4% of BPA fires) and 18 unhoused patients were vaccinated without BPA prompting. An additional 76 domiciled patients were vaccinated in the ED. CONCLUSIONS: Implementing an ED-based COVID-19 vaccination program is feasible, however, only a small number of patients underwent COVID-19 vaccination. Further studies are needed to explore the utility of using the ED as a setting for COVID-19 vaccination.

Aggressive Versus Conservative Initial Diuretic Dosing in the Emergency Department for Acute Decompensated Heart Failure.

BACKGROUND: Intravenous (IV) loop diuretics are recommended to relieve vascular congestion in patients with acute decompensated heart failure (ADHF); however, initial dosing is often empirical. Strong evidence supporting individualized diuretic dosing in the emergency department (ED) is lacking. OBJECTIVE: The purpose of this study was to compare the efficacy and safety of aggressive (≥2 daily home doses) and conservative (<2 daily home doses) initial doses of loop diuretic. METHODS: This was a retrospective cohort study in adult patients presenting to the ED with ADHF at an academic medical center from Apri 2015 to September 2015. The primary outcome was time to transition from IV to oral diuretics. RESULTS: A total of 91 patients were included (aggressive dosing, n = 44; conservative dosing, n = 47). Mean time to transition from IV to oral diuretics was 67.9 hours in the aggressive group compared with 88.1 hours in the conservative group ( P = 0.049). Mean hospital length of stay (LOS) was 119.5 hours in the aggressive group versus 123.0 hours in the conservative group ( P = 0.799). No differences were observed between the mean urine output ( P = 0.829), change in body weight ( P = 0.528), or serum creatinine ( P = 0.135). CONCLUSION: Patients who received an aggressive initial diuretic dose in the ED had a significantly faster time to oral diuretic therapy without any significant differences in hospital LOS, urine output, change in body weight, and renal function when compared with conservative dosing.

Superior mesenteric artery thrombosis after abrupt discontinuation of rivaroxaban.

We report a case of superior mesenteric artery thrombosis after the abrupt discontinuation of rivaroxaban in a 59-year-old male patient. The initial presentation was of sudden onset abdominal pain, nausea, vomiting, diarrhea, and hematochezia in the setting of recently holding rivaroxaban anticoagulation for an atrial flutter ablative procedure. Imaging revealed thrombosis of the superior mesenteric artery and acute mesenteric ischemia requiring emergent surgical intervention for embolectomy. Upon exploratory laparotomy, the bowel was found to be viable, and an embolectomy with patch angioplasty was successful without complication. This case illustrates the need for emergency medicine clinician familiarity with this possible medication adverse event with rivaroxaban.

Survey of Emergency Medicine Pharmacy Education Opportunities for Students and Residents.

BACKGROUND: Pharmacy services in the emergency department (ED) have been shown to decrease medication adverse events and improve patient outcomes. Anecdotally, there has been expansion of emergency medicine (EM) educational opportunities for pharmacy students and postgraduate year 1 (PGY1) pharmacy residents, however the extent of this expansion is currently unknown. OBJECTIVE: The objective of this survey study is to determine the prevalence and nature of EM pharmacy training available to pharmacy students and residents. METHODS: Electronic surveys were distributed to chairs of departments of pharmacy practice and experiential education representatives at Accreditation Council for Pharmacy Education-accredited colleges or schools of pharmacy as well as residency program directors at American Society of Health-System Pharmacists-accredited postgraduate year 1 (PGY1) programs. Questions were asked related to demographics, EM introductory or advanced pharmacy practice experiences (IPPE or APPE), and PGY1 and non-EM postgraduate year 2 (PGY2) rotations. Five reminder e-mails and weekly and grand prize drawings were offered. Data that were gathered are presented utilizing descriptive statistics. RESULTS: Overall, 57/110 (52%) colleges or schools of pharmacy representatives and 286/831 (34%) residency program representatives completed the survey. Colleges or schools of pharmacy reported EM IPPEs and APPEs at 12/57 (21.1%) and 44/53 (83%), respectively. EM pharmacy rotations were available for PGY1 and non-EM PGY2 residents at 212/286 (74.1%) and 83/157 (52.9%) of institutions, respectively. CONCLUSIONS: Survey results represent the prevalence and characteristics of EM-related education opportunities for pharmacy students and residents.

Craniopharyngiomas.

Craniopharyngiomas are rare, mainly sellar/parasellar, epithelial tumors diagnosed during childhood or adult life. Histologically, two primary subtypes have been recognized (adamantinomatous and papillary) with an as yet, unclarified pathogenesis. They may present with a variety of manifestations (neurological, visual, and hypothalamo-pituitary). Despite their benign histological appearance, they often show an unpredictable growth pattern, which, combined with the lack of randomized studies, poses significant difficulties in the establishment of an optimal therapeutic protocol. This should focus on the prevention of recurrence(s), improvement of survival, reduction of the significant disease and treatment-related morbidity (endocrine, visual, hypothalamic, neurobehavioral, and cognitive), and preservation of the quality of life. Currently, surgical excision followed by external beam irradiation, in cases of residual tumor, is the main treatment option. Intracystic irradiation or bleomycin, stereotactic radiosurgery, or radiotherapy and systemic chemotherapy are alternative approaches; their place in the management plan remains to be assessed in adequately powered long-term trials. Apart from the type of treatment, the identification of clinical and imaging parameters that will predict patients with a better prognosis is difficult. The central registration of patients with these challenging tumors may provide correlates between treatments and outcomes and establish prognostic factors at the pathological or molecular level that may further guide us in the future.

Lawrence of Arabia, Sir Hugh Cairns, and the origin of motorcycle helmets.

When Colonel T.E. Lawrence ("Lawrence of Arabia") was fatally injured in a motorcycle accident in May 1935, one of the several doctors attending him was a young neurosurgeon, Hugh Cairns. He was moved by the tragedy in a way that was to have far-reaching consequences. At the beginning of the Second World War, he highlighted the unnecessary loss of life among army motorcycle dispatch riders as a result of head injuries. His research concluded that the adoption of crash helmets as standard by both military and civilian motorcyclists would result in considerable saving of life. It was 32 years later, however, that motorcycle crash helmets were made compulsory in the United Kingdom. As a consequence of treating T.E. Lawrence and through his research at Oxford, Sir Hugh Cairns' work largely pioneered legislation for protective headgear by motorcyclists and subsequently in the workplace and for many sports worldwide. Over subsequent decades, this has saved countless lives.

Lombalgia: algumas informaçöes de ordem prática para os pacientes / Backache: some practical informations for the patients

De uma maneira sumária, utilizando termos que possam ser entendidos pelo grande público, e sobretudo pelos pacientes, uma série de conceitos säo emitidos e uma padronizaçäo dos exercícios é estabelecida. Essa série de condutas representa a rotina no departamento de cirurgia neurológica em Oxford e que é usada na recuperaçäo de pacientes com lombalgia