Implementation of a Novel Prehospital Clinical Decision Tool and ECG Transmission for STEMI Significantly Reduces Door-to-Balloon Time and Sex-Based Disparities.

BACKGROUND: An important method employed to reduce door to balloon time (DTBT) for ST segment elevation Myocardial Infarctions (STEMIs) is a prehospital MI alert. The purpose of this retrospective study was to examine the effects of an educational intervention using a novel decision support method of STEMI notification and prehospital electrocardiogram (ECG) transmission on DTBT. METHODS: An ongoing database (April 4, 2000 - present) is maintained to track STEMI alerts. In 2007, an MI alert program began; emergency medicine physicians could activate a "prehospital MI alert". In October 2015, modems were purchased for Emergency Medical Services personnel to transmit ECGs. There was concurrent implementation of a decision support tool for identifying STEMI. Sex was assigned as indicated in the medical record. Data were analyzed in two groups: Pre-2016 (PRE) and 2016-2022 (POST). RESULTS: In total, 3,153 patients (1,301 PRE; 1,852 POST) were assessed; the average age was 65.2 years, 32.6% female, 87.7% white with significant differences in age and race between the two cohorts. Of the total 3,153 MI alerts, 239 were false activations, leaving 2,914 for analysis. 2,115 (72.6%) had cardiac catheterization while 16 (6.7%) of the 239 had a cardiac catheterization. There was an overall decrease in DTBT of 27.5% PRE to POST of prehospital ECG transmission (p < 0.001); PRE median time was 74.5 min vs. 55 min POST. There was no significant difference between rates of cardiac catheterization PRE and POST for all patients. After accounting for age, race, and mode of arrival, DTBT was 12.2% longer in women, as compared to men (p < 0.001) PRE vs. POST. DTBT among women was significantly shorter when comparing PRE to POST periods (median 77 min vs. 60 min; p = 0.0001). There was no significant sex difference in the proportion of those with cardiac catheterization between the two cohorts (62.5% vs. 63.5%; p = 0.73). CONCLUSION: Introduction of a decision support tool with prehospital ECG transmission with prehospital ECG transmission decreased overall DTBT by 20 min (27.5%). Women in the study had a 17-minute decrease in DTBT (22%), but their DTBT remained 12.2% longer than men for reasons that remain unclear.

A Case of Cutaneous Leishmaniasis with Mucosal Involvement in the Northern United States.

BACKGROUND: Cutaneous leishmaniasis (CL) is a vector-borne parasitic infection endemic to many sub-tropical regions worldwide. In the Americas, Leishmania braziliensis is responsible for most reported CL cases. Variable symptom presentation and susceptibility to secondary infection make diagnosing CL a difficult proposition for physicians who may not encounter cases frequently. CASE REPORT: We present the case of a 50-year-old man with multiple progressive lesions, diagnosed initially as a bacterial infection, who presented to a North American emergency department after several unsuccessful trials of antibiotic therapy. Eventually, polymerase chain reaction testing of a wound biopsy sample confirmed the presence of L. braziliensis. After a complicated course, the patient's infection resolved after tailored antiparasitic therapy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case highlights the need to include travel history in the evaluation of atypical dermatologic infections.

Identifying Biopsychosocial Characteristics of Emergency Youth Shelter Residents With Psychiatric Diagnoses.

Background In the United States, homelessness is an issue that may affect a significant portion of the adolescent population. There is no consensus on the extent to which this population has been impacted by poor mental health and lack of resources. This study aimed to characterize trends among those who struggle with housing insecurity and mental illness to provide a clearer picture of mental health needs among this population. Methods Data from 641 adolescents who presented to a local adolescent homeless shelter between 2015 and 2021 were utilized to determine if there were significant associations between specific mental illness diagnoses and biopsychosocial characteristics. A chi-square test of independence was performed on demographic and psychosocial variables for categories with a frequency greater than five. For continuous variables, an unpaired t-test was utilized to assess significance (p<0.05). Results Among the study population, 61.3% (369) had at least one psychiatric diagnosis, which is higher than even the most conservative estimates of mental illness among the general public. Having one or more psychiatric diagnoses was significantly associated with suicide attempts, documented aggressive behavior, and tobacco use. Contrary to our initial hypothesis, there were no significant correlations between psychiatric diagnoses and demographic characteristics or drug use other than tobacco. Conclusions Our findings indicate that though the particular reasons for homelessness among adolescents may vary, the prevalence of mental illness among these young individuals was roughly uniformly distributed and vastly above normal levels. Future research must focus on developing interventions to mitigate the effects of mental illness among homeless adolescents, as they are at a vulnerable point in their formative years.