Physiological pacing to improve cardiac resynchronization therapy non-responder and a tryst with calcified septum-a case report.

BACKGROUND: As per the literature, patients with intraventricular conduction delay (IVCD) do not respond well to cardiac resynchronization therapy (CRT) alone. They need advanced technological approach and out of the box thinking for a good response. CASE: Ours is a case of ischemic cardiomyopathy with wide QRS-IVCD, a non-responder to CRT. While planning for replacement of the device for early replacement indicator (ERI), we decided to do His-optimized CRT/left bundle optimized CRT (HOT-CRT/LOT-CRT) for the patient. CONCLUSION: The challenges we faced with the present available hardware paved a way for insisting on the limitation of the available lumenless lead to penetrate calcified the septum and importance of the pre-procedure evaluation of intraventricular septum (IVS) for calcification by more than just echocardiography.

The Case for Observation Medicine Education and Training in Emergency Medicine.

BACKGROUND: Many hospitals have or will be opening an observation unit (OU), the majority managed by the emergency department (ED). Graduating emergency medicine (EM) residents will be expected to have the knowledge and skills necessary to appropriately identify and manage patients in this setting. Our objective is to examine the current state of observation medicine (OM) education and prevalence in EM training. METHODS: In a follow-up to the 2019 Society for Academic Emergency Medicine (SAEM) OM Interest Group meeting, we convened an expert panel of OM physicians who are members of both the SAEM OM Interest Group and the American College of Emergency Physicians Section of OM. The panel of six emergency physicians representing geographic diversity was formed. A structured literature review was performed yielding 16 educational publications and sources pertaining to OM education and training across all specialties. REPORT ON THE EXISTING LITERATURE: Only a small number of EM residencies have a required or elective OM rotation in an OU. An OM rotation in a protocol-driven ED OU gives residents experience managing patients in this setting and improves skills integral to EM and part of the EM milestones and Accreditation Council for Graduate Medical Education (ACGME) core competencies: reassessment, disposition decision making, risk stratification, team management, and practicing cost-appropriate care. Even without a formal rotation, multiple OM educational resources can be incorporated into EM resident education and didactics. Education research opportunity exists. CONCLUSIONS: This panel believes that OM is an important component of EM that should be incorporated into EM residency as the knowledge and skills learned such as risk stratification, disposition decision making, and team management augment those needed for the practice of EM. There is a distinct opportunity for EM educators to better equip their trainees for a career in EM by including OM education and experience in EM residency training.

Financial Viability of Emergency Department Observation Unit Billing Models.

BACKGROUND: Outpatients receive observation services to determine the need for inpatient admission. These services are usually provided without the use of condition-specific protocols and in an unstructured manner, scattered throughout a hospital in areas typically designated for inpatient care. Emergency department observation units (EDOUs) use protocolized care to offer an efficient alternative with shorter lengths of stay, lower costs, and higher patient satisfaction. EDOU growth is limited by existing policy barriers that prevent a "two-service" model of separate professional billing for both emergency and observation services. The majority of EDOUs use the "one-service" model, where a single composite professional fee is billed for both emergency and observation services. The financial implications of these models are not well understood. METHODS: We created a Monte Carlo simulation by building a model that reflects current clinical practice in the United States and uses inputs gathered from the most recently available peer-reviewed literature, national survey, and payer data. Using this simulation, we modeled annual staffing costs and payments for professional services under two common models of care in an EDOU. We also modeled cash flows over a continuous range of daily EDOU patient encounters to illustrate the dynamic relationship between costs and revenue over various staffing levels. RESULTS: We estimate the mean (±SD) annual net cash flow to be a net loss of $315,382 (±$89,635) in the one-service model and a net profit of $37,569 (±$359,583) in the two-service model. The two-service model is financially sustainable at daily billable encounters above 20, while in the one-service model, costs exceed revenue regardless of encounter count. Physician cost per hour and daily patient encounters had the most significant impact on model estimates. CONCLUSIONS: In the one-service model, EDOU staffing costs exceed payments at all levels of patient encounters, making a hospital subsidy necessary to create a financially sustainable practice. Professional groups seeking to staff and bill for both emergency and observation services are seldom able to do so due to EDOU size limitations and the regulatory hurdles that require setting up a separate professional group for each service. Policymakers and health care leaders should encourage universal adoption of EDOUs by removing restrictions and allowing the two-service model to be the standard billing option. These findings may inform planning and policy regarding observation services.

Care of Infectious Conditions in an Observation Unit.

Infectious conditions such as skin and soft tissue infections (SSTIs), Urogenital infections and peritonsillar abscesses frequently require care beyond emergency stabilization and are well-suited for short term care in an observation unit. SSTIs are a growing problem, partly due to emergence of strains of methicillin-resistant S. aureus (MRSA). Antibiotic choice is guided by the presence of purulence and site of infection. Purulent cellulitis is much more likely to be associated with MRSA. Radiographic imaging should be considered to aid in management in patients who are immunosuppressed, have persistent symptoms despite antibiotic therapy, recurrent infections, sepsis or diabetes.

Recommendations for the evaluation and management of observation services: a consensus white paper: the Society of Cardiovascular Patient Care.

Observation Services (OS) was founded by emergency physicians in an attempt to manage "boarding" issues faced by emergency departments throughout the United States. As a result, OS have proven to be an effective strategy in reducing costs and decreasing lengths of stay while improving patient outcomes. When OS are appropriately leveraged for maximum efficiency, patients presenting to emergency departments with common disease processes can be effectively treated in a timely manner. A well-structured observation program will help hospitals reduce the number of inappropriate, costly inpatient admissions while avoiding the potential of inappropriate discharges. Observation medicine is a complicated multidimensional issue that has generated much confusion. This service is designed to provide the best possible patient care in a value-based purchasing environment where quality, cost, and patient satisfaction must continually be addressed. Observation medicine is a service not a status. Therefore, patients are admitted to the service as outpatients no matter whether they are placed in a virtual or dedicated observation unit. The key to a successful observation program is to determine how to maximize efficiencies. This white paper provides the reader with the foundational guidance for observational services. It defines how to set up an observational service program, which diagnoses are most appropriate for admission, and what the future holds. The goal is to help care providers from any hospital deliver the most appropriate level of treatment, to the most appropriate patient, in the most appropriate location while controlling costs.

State of the art: emergency department observation units.

Hospitals and emergency departments face the challenges of escalating healthcare costs, mismatched resource utilization, concern over avoidable admissions, and hospital and emergency department overcrowding. One approach that has been used by hospitals to address these issues is the use of emergency department observation units. Research in this setting has increased in recent years, leading to a better understanding of the role of these units and their unique benefits. These benefits have been proven for health systems as a whole and for several acute conditions including chest pain, asthma, syncope, transient ischemic attack, atrial fibrillation, heart failure, abdominal pain, and more. Benefits include a decrease in diagnostic uncertainty, lower cost and resource utilization, improved patient satisfaction, and clinical outcomes that are comparable to admitted patients. As more hospitals begin to use observation units, there is a need for further education and research in how to optimize the use of emergency department observation units. The purpose of this article is to provide a general overview of observation units, including advancements and research in this field.

Aortic dissection presenting as isolated lower leg ischemia.

BACKGROUND: Aortic dissections that present only with symptoms of lower extremity ischemia are rare. Few case reports exist documenting this phenomenon. OBJECTIVES: We report an unusual case of aortic dissection presenting as unilateral lower extremity pain. CASE REPORT: A 56-year-old man presented with left lower extremity pain of 1 h duration. He had no associated complaints. Doppler imaging revealed decreased flow in the left iliac artery, thus, initial treatment with anticoagulation was begun for presumptive obstruction. Subsequent imaging with arteriography revealed a Stanford type A/DeBakey type 1 aortic dissection. This was confirmed by computer-assisted tomography angiography, and the patient was taken to surgery for repair. CONCLUSION: It is important to consider the connection between lower extremity symptoms and possible aortic dissection.

Clinical confounder: an incarcerated appendix masquerading as epididymitis.

BACKGROUND: Acute appendicitis can have various unusual presentations. Detection of this entity is often confounded by its presence in the company of symptoms consistent with distinctly different etiologies. OBJECTIVES: This article highlights an extremely rare presentation of appendicitis. CASE REPORT: The case of a man presenting to an urban Emergency Department complaining of scrotal swelling and pain is discussed. On surgical exploration, the patient's symptomatology was diagnosed as acute appendicitis within an Amyand hernia. CONCLUSION: Appendicitis can sometimes be a challenging diagnosis. Thorough examination and maintenance of a wide differential diagnosis with common complaints can assist the emergency physician in reaching the correct diagnosis.

Correlation of hepatic venous pressure gradient with variceal bleeding, size of esophageal varices, etiology, ascites and degree of liver dysfunction in cirrhosis of liver.

An elevated hepatic venous pressure gradient (HVPG) has been associated with risk of variceal bleeding, and outcome and survival after variceal bleeding. In this pilot study, we measured HVPG in 40 patients with liver cirrhosis and studied its relationship with etiology of liver disease, esophageal variceal size, history of variceal bleeding or ascites, biochemical liver tests and Child-Pugh class. There was no procedurerelated complication. The mean (SD) HVPG was similar in patients who had history of variceal bleeding as compared to those who did not (15.4 [2.8] mmHg vs. 13.9 [2.7] mmHg, p=0.1); HVPG had no significant association with etiology of cirrhosis (p=0.4). HVPG levels were significantly higher in patients with larger esophageal varices (grade III/IV vs. I/II: 15.2 [2.7] mmHg vs.13.1 [2.8] mmHg, p=0.04), poorer Child-Pugh class (B or C versus A), and presence of ascites (p=0.04). Thus, HVPG correlated with variceal size, Child-Pugh class, and presence of ascites, but not with variceal bleeding status.

Brugada syndrome.

The syndrome of right bundle branch block, ST segment elevation from VI-V3 and syncopal episodes and/or sudden death in a patient with structurally normal heart is a new entity, named Brugada syndrome in 1992. In some individuals, the presentation may be asymptomatic with only abnormal electrocardographs while in others a history of sudden death in the family and electrocardiographic criteria are observed. This disease is genetically determined caused by a defect in the myocardial sodium channel (SCN5A). Sudden death in individuals with this syndrome can only be prevented by implanting a cardioverter-defibrillator.