Return Rates for Opioid versus Nonopioid Management of Patients with Abdominal Pain in the Emergency Department.

BACKGROUND: Research suggests that opioid treatment for abdominal pain, which comprises a large proportion of patients presenting to the emergency department (ED), may contribute to long-term opioid use without significant benefits with regard to symptom management. OBJECTIVES: This study seeks to assess the association between opioid use for management of abdominal pain in the ED and return ED visits for abdominal pain within 30 days for patients discharged from the ED at initial presentation. METHODS: We conducted a retrospective, multicenter observational study of adult patients presenting to and discharged from 21 EDs with a chief concern of abdominal pain between November 2018 and April 2020. The proportion of 30-day return visits to the ED for patients who received opioid analgesics was compared with a reference group of patients who only received acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), or both. RESULTS: Of the 4745 patients, 1304 (27.5%) received opioids and 1101 (23.2%) only received either acetaminophen, NSAIDs, or both. Among those given opioids, 287 (22.0%) returned to the ED for abdominal pain within 30 days, compared with 162 (14.7%) of those in the reference group (odds ratio 1.57, 95% confidence interval 1.27-1.95, p-value < 0.001). CONCLUSION: Patients given opioids for abdominal pain in the ED had 57% increased odds of a return ED visit within 30 days compared with those given only acetaminophen or NSAIDs. This warrants further research on the use of nonopioid analgesics in the ED, especially in patients with anticipated discharge.

Stercoral Colitis in the Emergency Department: A Retrospective Review of Presentation, Management, and Outcomes.

STUDY OBJECTIVE: Stercoral colitis is inflammation of the bowel wall caused by fecal impaction. Despite reported high morbidity and risk of perforation, little research assessing outcomes is available. This study characterizes the presentation, management, and outcomes of emergency department patients with stercoral colitis. METHODS: We performed a retrospective chart review of ED patients with stercoral colitis identified on computed tomography (CT) scan. Of 814, 522 visits to multiple EDs across the US, 269 met the inclusion criteria. Variables regarding patient presentation, management, and outcomes were extracted from electronic medical records. Results were analyzed with percentages and 95% confidence intervals (CIs). RESULTS: Of 269 patients, the median age was 76 years. The most common chief concern was abdominal pain/distension (33.8%). However, abdominal pain was documented as absent in 62.1% of cases. The most common CT findings included fecal impaction (96.7%), bowel wall inflammation (72.9%), and fat stranding (48.3%). Eighty-four (31.2%) patients were discharged home from the ED, and over half of these (45/84, 53.6%) received no enema, laxatives, or disimpaction. Overall, 9 patients (3.3%, 95% CI 1.6% to 6.5%) required surgical management of a related complication within 3 months, 27 (10.0%, 95% CI 6.8% to 14.4%) returned to the ED within 72 hours, and 9 (3.3%, 95% CI 1.6% to 6.5%) died from a cause related to stercoral colitis within 3 months. CONCLUSION: Patients with stercoral colitis often present in a nonspecific manner, and short-term mortality is substantial. In this study, most discharged patients did not receive recommended treatment. This represents the largest ED study of stercoral colitis and provides further evidence linking this diagnosis with adverse outcomes.

Review of Cardiac Malpractice Cases Involving a Trainee.

Lawsuits involving medical trainees are underappreciated and poorly documented, including within cardiology-related fields. The purpose of this review was to characterize clinical characteristics and legal outcomes of cardiology- and cardiac surgery-related lawsuits involving trainees. Westlaw, an online legal research database containing legal records from around the United States, was retrospectively reviewed for malpractice cases involving medical students, residents, or fellows through November 2020. Cases included both cardiac and cardiac surgery cases. A total of 28 cases were identified, with 16 involving female patients (57%). In the 17 cases in which patient age was included, the median age was 51 years. A total of 22 (79%) cases resulted in death or permanent disability. The most common alleged errors included procedural issues (n = 14, 50%) and failure to diagnose (n = 7, 25%). A total of 14 cases (50%) ended in favor of the physicians, 9 (32%) ended in a settlement or verdict against the physician, and 5 cases had an unknown outcome. Of the 8 cases in which the settlement or verdict amount was reported, the median payment was $1,291,992 with a range of $220,507-$30,000,000. This review of cardiac and cardiac surgery malpractice cases involving a trainee suggests trainee involvement in procedures and diagnosis may confer relatively high liability risks for both trainees and their supervisors.

Newly Diagnosed Multiple Sclerosis Presenting as Brown-Séquard Syndrome: A Case Report.

INTRODUCTION: Brown-Séquard syndrome is a rare neurological disorder due to hemisection of the spinal cord that can occur from a variety of causes, most commonly trauma. CASE REPORT: We present a case of a 25-year-old woman presenting with Brown-Séquard syndrome as her first clinical presentation of multiple sclerosis. CONCLUSION: This case highlights the need to have demyelinating disease on the differential as an exceedingly rare, but important, possible cause of Brown-Séquard syndrome.

Lay knowledge and practices of methamphetamine use to manage opioid-related overdose risks.

AIM: Methamphetamine use has increased among individuals with opioid use disorder. The key aims of this study are to detail and contextualise lay knowledge, attitudes, and behaviours related to methamphetamine use in relation to opioid overdose risks in an area dominated by non-pharmaceutical fentanyl-type drugs (NPF). METHODS: The study recruited 41 individuals in Dayton, Ohio, who reported past 30-day use of methamphetamine and heroin/fentanyl. Interviews included structured and qualitative questions. Urine toxicology analysis was conducted to identify NPFs and other drugs. Open-ended interview sections were audio-recorded, transcribed, and analysed qualitatively using NVivo. RESULTS: The mean age was 38.3 years, 51% were female, and 100% non-Hispanic white. Participants described an exceedingly unpredictable local opioid market that became saturated with NPFs. The sample tested positive for 10 NPFs, including fentanyl (100%), acetyl fentanyl (61%), tetrahydrofuran fentanyl (29%), and carfentanil (12%). Most participants believed that methamphetamine could help prevent and/or reverse an opioid-related overdose. Nearly half had personally used it to help manage overdose risks related to NPF. These beliefs were embedded in a lay understanding of how methamphetamine works to stimulate the cardiovascular system. They were acted upon in the context of last resort situations that were determined by a lack of immediate access to naloxone, ambiguities surrounding overdose symptomatology, and easy access to plentiful and inexpensive methamphetamine. CONCLUSION: Lay efforts to rely on methamphetamine to manage NPF-related overdose risks highlight the need for a continuing expansion of take-home-naloxone programs and implementation of other novel harm reduction approaches in communities affected by NPFs.

Adult emergency department naloxone education and prescription program: Video and pamphlet education comparison.

OBJECTIVES: This study looked at the fill rate of naloxone prescriptions, after the implementation of an opioid overdose and naloxone education intervention for adult patients in the emergency department (ED). The study compared fill rates between recipients who received this education by video versus written format. METHODS: This was a prospective, randomized controlled study of patients seen in the adult ED for opioid-related complaints between August 1, 2017, and December 1, 2018. The study randomized patients to education through video or written pamphlet, and all patients received a prescription for a free naloxone kit redeemable at the discharge pharmacy. The study calculated and compared naloxone prescription fill rates for the respective education methods. RESULTS: Of the 770 patients reviewed for recruitment, the study excluded 703. Of the 67 patients enrolled, 59 were contacted at follow-up and eighteen (30.5%) had filled a naloxone prescription. Thirty-three percent (13/39) of patients who received video education and 25% (5/20) who received written pamphlet education filled naloxone prescriptions. The p-value of the chi-square for this data was 0.53. CONCLUSIONS: There is a large population affected by opioid overdose both nationally and locally in Arizona. Opioid overdose and naloxone distribution education for ED patients through both video and pamphlet is feasible but requires more research to determine which education method is superior. Legislative changes, improved identification of patients at high risk for opioid overdose, opiate education for medical providers, and naloxone availability from multiple venues are needed to create a holistic approach to improve naloxone access to those who need it most.