Electronic Cigarette or Vaping-Associated Lung Injury Case Report.

Electronic cigarette (e-cigarette) or vaping associated lung injury (EVALI) cases have increased with the popularity of e-cigarettes in the mostly young, healthy population. Some common symptoms associated with EVALI include shortness of breath and chest pain, and the most common diagnostic imaging findings are organizing pneumonia and diffuse alveolar damage seen on computed tomography (CT). Pneumomediastinum is a known sequela of EVALI.1 In the setting of pneumomediastinum in EVALI, EVALI is a diagnosis of exclusion, so other sources of pneumomediastinum need to be evaluated. EVALI has diverse presentations, and this case is a unique representation of a disease process that is becoming more commonplace with the increase in popularity of vaping. It is important to be aware of the clinical symptoms of EVALI, which can be nonspecific and can include gastrointestinal symptoms along with respiratory symptoms. It is equally important to recognize the diverse image findings of EVALI, which can include subcutaneous emphysema and pneumomediastinum. In this case, pneumomediastinum is seen in EVALI, and the patient was successfully treated with empiric antibiotic coverage, steroids, and conservative measures- making sure to limit any coughing or increases in intrathoracic pressure that can cause worsening of pneumomediastinum. Topics: EVALI, vaping, pneumomediastinum, E-cigarette, ground-glass opacity.

Worsening of emergency department length of stay during the COVID-19 pandemic.

OBJECTIVE: Our study sought to determine whether there was a change in emergency department (ED) length of stay (LOS) during the coronavirus disease 2019 (COVID-19) pandemic compared to prior years. METHODS: We performed a retrospective analysis using ED performance data 2018-2020 from 56 EDs across the United States. We used a generalized estimating equation (GEE) model to assess differences in ED LOS for admitted (LOS-A) and discharged (LOS-D) patients during the COVID-19 pandemic period compared to prior years. RESULTS: GEE modeling showed that LOS-A and LOS-D were significantly higher during the COVID-19 period compared to the pre-COVID-19 period. LOS-A during the COVID-19 period was 10.3% higher compared to the pre-COVID-19 time period, which represents a higher geometric mean of 28 minutes. LOS-D during the COVID-19 period was 2.8% higher compared to the pre-COVID-19 time period, which represents a higher geometric mean of 2 minutes. CONCLUSIONS: ED LOS-A and LOS-D were significantly higher in the COVID-19 period compared to the pre-COVID-19 period despite a lower volume of patients in the COVID-19 period.

Do Automated Reminders for Emergency Department Resident Physicians to Review Their Patient List Improve Efficiency?

OBJECTIVES: Navigating the emergency department (ED) workflow in an efficient manner is an important skill every emergency physician or advanced provider must master. There is a paucity of research into ways to improve how efficiently an ED provider works amid these distractions. This study seeks to determine whether the addition of an hourly automated reminder for resident physicians to review their patient list improves throughput metrics. METHODS: This a double-blinded randomized controlled trial in which resident physicians at a single community ED were randomly assigned to two groups: the intervention group, which received automated hourly notifications within the electronic medical record (EMR) to review their patient list for those whose workup is completed, and the control group, which received no notifications. We prospectively analyzed records for 25,255 encounters with 19,264 individual patients seen by 64 residents over the study period. Three-level mixed-effects regression models were used to examine whether notifications improved ED length of stay (ED-LOS), turnaround time to discharge (TAT-D), or turnaround time to admission (TAT-A). RESULTS: There was no statistically significant difference in ED-LOS or TAT-D between groups, but the average TAT-A was 20.00 minutes longer in the intervention group compared to the control group (p < 0.001), after accounting for patient- and resident-specific effects. Secondary analysis demonstrated no statistically significant effect of residency specialty on the effect of notifications on ED-LOS, TAT-D, or TAT-A. CONCLUSIONS: Automated hourly notifications within the EMR reminding residents in the ED to review their patient list did not reduce the ED-LOS, TAT-D, or TAT-A. However, the TAT-A was 20.00 minutes longer in the intervention group compared to the control group. It is unclear whether this represents an unintended effect of the automated reminders or is simply a spurious correlation.

A 23-year-old man with acute lung injury after using a tetrahydrocannabinol-containing vaping device: a case report.

BACKGROUND: Vaping-associated lung injury is a newly emerging disease process with the potential for serious health implications and high mortality, even despite the lack of underlying lung disease. We present a case of a young, otherwise healthy patient with tetrahydrocannabinol vaping-associated lung injury. CASE PRESENTATION: A 23-year-old Caucasian man with a past history of tetrahydrocannabinol vaping and benzodiazepine and methamphetamine abuse presented to the emergency department of our institution with a complaint of "feeling malnourished" over the past 5 days, along with associated fevers, cough, and vomiting. His past medical, surgical, family, and social histories were significant only for the recent use of marijuana vaping pens. Upon initial presentation, the patient appeared to be in significant respiratory distress. A computed tomographic scan of his chest demonstrated diffuse central predominant interstitial opacities, and he was admitted to the medical intensive care unit, where he was eventually intubated for hypoxic respiratory failure. No other cause of his respiratory failure was found, and it was ultimately believed that the patient had sustained a vaping-associated lung injury. CONCLUSION: Tetrahydrocannabinol-containing vaping-associated lung injury is still poorly understood overall and is currently being investigated by the Centers for Disease Control and Prevention. In the meantime, physicians should consider vaping to be a public health emergency. We summarize the appropriate history, physical examination, appropriate workup, and therapies that physicians should be aware of in order to appropriately manage and treat patients presenting with suspected vaping-associated lung injury.

Underutilization of the Emergency Department During the COVID-19 Pandemic.

INTRODUCTION: The novel coronavirus 2019 (COVID-19) pandemic in the United States (US) prompted widespread containment measures such as shelter-in-place (SIP) orders. The goal of our study was to determine whether there was a significant change in overall volume and proportion of emergency department (ED) encounters since SIP measures began. METHODS: This was a retrospective, observational, cross-sectional study using billing data from January 1, 2017-April 20, 2020. We received data from 141 EDs across 16 states, encompassing a convenience sample of 26,223,438 ED encounters. We used a generalized least squares regression approach to ascertain changes for overall ED encounters, hospital admissions, and New York University ED visit algorithm categories. RESULTS: ED encounters decreased significantly in the post-SIP period. Overall, there was a 39.6% decrease in ED encounters compared to expected volume in the pre-SIP period. Emergent encounters decreased by 35.8%, while non-emergent encounters decreased by 52.1%. Psychiatric encounters decreased by 30.2%. Encounters related to drugs and alcohol decreased the least, by 9.3% and 27.5%, respectively. CONCLUSION: There was a significant overall reduction in ED utilization in the post-SIP period. There was a greater reduction in lower acuity encounters than higher acuity encounters. Of all subtypes of ED encounters, substance abuse- and alcohol-related encounters reduced the least, and injury-related encounters reduced the most.