The impact of month and season on the incidence of giant cell arteritis: an Intelligent Research in Sight (IRIS) Registry analysis.

PURPOSE: Previous investigations into the relationship between season and the incidence of giant cell arteritis (GCA) have produced conflicting results. This study aimed to explore the impact of season and new diagnoses of GCA in a more definitive sense by employing the large dataset of the Intelligent Research in Sight (IRIS) database. METHODS: The IRIS Registry was queried to identify new cases of GCA from 2013 to 2021. Statistical analyses were performed to determine the significance of the relationship between the time of year and the incidence of GCA on regional and nationwide bases via Cochran's Q statistical test. RESULTS: A total of 27,339 eyes with a new diagnosis of GCA were identified. Neither the month nor the season of the year correlated with the incidence of GCA, regardless of geographic location within the USA (p > 0.05 for each variable). CONCLUSIONS: In the USA, the incidence of GCA does not appear to vary by month or season. While this finding contradicts certain previous studies that identified a relationship, the cohort of patients identified from the IRIS Registry is much larger than that of previous investigations. Clinicians should be mindful of the possibility of GCA, regardless of the time of the year.

Neutrophil-to-Lymphocyte Ratios Distinguish Idiopathic Orbital Inflammation From Orbital Infectious Disease.

PURPOSE: The neutrophil-to-lymphocyte ratio (NLR) is a relatively novel biomarker to distinguish between acute stresses. This study was performed to determine whether the NLR may discern infectious orbital maladies from idiopathic orbital inflammation (IOI). METHODS: The NLR was calculated by a review of the initial blood draws of adult patients who presented to the emergency department at a single academic medical center. Statistical comparisons were performed to identify the significance of these results. RESULTS: Ten patients with IOI, 12 patients with necrotizing fasciitis (NF), and 12 patients with orbital cellulitis (OC) presented to the emergency department. The groups were not statistically significantly different in terms of age or gender. The mean NLRs were 3.48 (standard deviation = 1.80), 13.5 (standard deviation = 14.5), and 8.15 (standard deviation = 6.56) for IOI, NF, and OC, respectively. Patients with IOI had statistically significantly lower NLRs than patients with NF ( p = 0.037) and OC ( p = 0.034). However, the NLRs of patients with OC were not statistically significantly different from those of patients with NF ( p = 0.27). CONCLUSIONS: The NLR appears to distinguish IOI from infectious etiologies, but does not discern between variants of infection. These results should be juxtaposed against appropriate imaging and clinical evaluations, but elevated NLR values may heighten clinicians' concerns for an infectious process and encourage them to initiate appropriate management steps.

Blueprint for the development of resuscitation and emergency critical care fellowships.

The volume of critically ill patients presenting to the emergency department (ED) is increasing rapidly. Continued growth will likely further stress an already strained U.S. health care system. Numerous studies have demonstrated an association with worsened outcomes for critically ill patients boarding in the ED. To address the increasing volume and complexity of critically ill patients presenting to EDs nationwide, resuscitation and emergency critical care (RECC) fellowships were developed. RECC programs teach a general approach to the management of the undifferentiated critically ill patient, advanced management of critically ill patients by disease presentation, and ongoing supportive care of the critically ill patient boarding in the ED. The result is critical care training beyond that of a typical emergency medicine (EM) residency with a focus on the unique features and challenges of caring for critically ill patients in the ED not normally found in critical care fellowships. Graduates from RECC fellowships are well suited to practicing in any ED practice model and may be especially well prepared for EDs that distinguish acuity between zones (e.g., resuscitative care units, ED-based intensive care units). In addition to further developing clinical acumen, RECC fellowships provide graduates with a niche in EM education, research, and administration. In this article, we describe the philosophical principles and practical components necessary for the creation of future RECC fellowships.

Characteristics of Retrobulbar Hemorrhage Presentation in the Emergency Department.

PURPOSE: To describe demographic and clinical features of emergency department patients presenting with fracture-associated (FA) or fracture-independent retrobulbar hemorrhage (RBH). METHODS: The Nationwide Emergency Department Sample database 2018 and 2019 was used to compare demographic and clinical features of patients with fracture-independent RBH and FA RBH. RESULTS: A total of 444 fracture-independent and 359 FA RBH patients were identified. Demographics such as age distribution, gender, and payer type differed significantly, with young (21-44 years), privately insured males more likely to develop FA RBH and the elderly (65+ years) more likely to develop fracture-independent RBH. Prevalence of hypertension and anticoagulation did not differ, but substance use and ocular-related injuries were more prevalent in the FA RBH. CONCLUSION: Presentations of RBH differ in demographic and clinical features. Further research is needed to explore trends and guide decision-making in the emergency department.

Association of open globe injury characteristics with outcome measures in the emergency department.

PURPOSE: To evaluate the association of demographic and clinical features of emergency department (ED) patients presenting with open globe injuries (OG) with outcomes such as inpatient admission rate, length of stay (LOS), and total cost. METHODS: The Nationwide Emergency Department Sample database 2018 and 2019 was used to analyze the association of demographic and clinical features of OG patients with outcome measures. RESULTS: 8404 OG patients were identified. Medicaid patients were associated with higher ED costs and a higher frequency of extended LOS. The 70+ age group was associated with higher inpatient admission. Frail patients were associated with significantly increased likelihood of inpatient admission, higher likelihood of extended LOS and higher total combined ED cost. Falls and being struck were associated with shorter LOS. CONCLUSION: This study describes the most common demographic and clinical characteristics of OGIs that present to the ED, as well as the association of these characteristics with outcome measures such as inpatient admission rates, LOS, and total cost. The study further identified potential high-risk patients for prolonged length of stay. The findings will better optimize patient care protocols to improve outcomes.

Impact of Season on Incidence of Sinusitis-related Orbital Cellulitis.

PURPOSE: To explore the impact of season on the incidence of presentation to emergency departments with sinusitis-related orbital cellulitis in the United States. METHODS: The National Emergency Department Sample was queried to identify cases of patients with sinusitis-related orbital cellulitis. Patient's age, location, and the month of presentation were recorded. Statistical correlations were analyzed via a dedicated software package. RESULTS: A total of 439 patients with sinusitis-related orbital cellulitis were identified. The overall incidence was higher during the winter months ( p < 0.05); while children were more likely to develop this disease during the winter ( p < 0.05), season was not statistically correlated with its incidence among adults ( p = 0.16). The incidence of orbital cellulitis was higher during the winter in the midwest and south regions of the United States ( p < 0.05 for each region), although this correlation did not apply in the northeast and west ( p = 0.60 and 0.99, respectively). CONCLUSIONS: While sinusitis incidence increases during the winter, the relationship between season and orbital cellulitis is complex and varies by age and geographic location. These findings may help to facilitate screening protocols for this disease and to define staffing issues for emergent ophthalmic care.

Measles investigation: a moving target.

Measles is a highly contagious respiratory infection with significant transmission risk once thought to be on the verge of elimination. Outbreaks in Europe have resulted in resurgence; however, experience with measles is limited in the United States. We describe the impact of 2 measles cases presenting to our emergency department in May 2011. Exposure criteria were defined and revised. Guidance documents were developed and distributed. Suspect cases were masked and escorted to negative pressure. Lack of prompt IgM and polymerase chain reaction testing resulted in delayed disease confirmation. Computerized flagging systems were established. Exposed individuals were screened to determine the need for prophylaxis. Investigation costs were calculated. A total of 171 patients and visitors and 94 employees met exposure criteria. Employees had proof of immunity to measles. Of these, 43 patients and visitors returned for prophylaxis. No subsequent transmission occurred. The conservative cost for these investigations was $63,176.39. Multiple challenges were identified. Inexperience with measles can result in significant outbreaks. Although transmission did occur at another facility, it was prevented at our facility because of rapid case recognition, isolation, health care worker immunity, and multidisciplinary response. Discordance between the Healthcare Infection Control Practices Advisory Committee and public health guidelines for measles control created unnecessary challenges.

Emergency management of blunt chest trauma in children: an evidence-based approach.

Pediatric trauma is commonly encountered in the emergency department, and trauma to the head, chest, and abdomen may be a source of significant morbidity and mortality. As children have unique thoracic anatomical and physiological properties, they may present with diagnostic challenges that the emergency clinician must be aware of. This review examines the effects of blunt trauma to the pediatric chest, as well as its relevant etiologies and associated mortality. Diagnostic and treatment options for commonly encountered injuries such as pulmonary contusions, rib fractures, and pneumothoraces are examined. Additionally, this review discusses rarely encountered--yet highly lethal--chest wall injuries such as blunt cardiac injuries, commotio cordis, nonaccidental trauma, and aortic injuries.