Guideline-Based Telemedicine Assessment of Orthopedic Low-Risk Conditions by General Practitioners is Not Inferior to that of Face-to-Face Consultations with Specialists in the Emergency Department: A Randomized Trial.

Background: There is a lack of randomized controlled trials focusing on orthopedic telemedicine (TM). The objective of this research was to compare the diagnostic accuracy and pattern of TM consultations of low-risk orthopedic patients performed by general practitioners (GPs) with those of face-to-face evaluations by orthopedists at an emergency department (ED). Methods: This randomized, single-center study was conducted between October 2021 and November 2022 on patients at an ED. Inclusion criteria were age >18 years, low back pain, extremity contusion, ankle sprain, or neck pain. Eligible patients were randomized 1:1 for TM consultations by generalist physicians with subsequent face-to-face orthopedic evaluations (TM-ED group) or face-to-face evaluations by orthopedic physicians (ED group). Primary outcomes were syndromic diagnosis, physical examination, and tests ordered. Secondary analysis included a satisfaction survey. Results: A total of 99 patients were enrolled; mean age was 41 ± 10.1 years, and 62.6% were female. The most common conditions were foot contusion (28.3%), ankle sprain (27.3%), hand contusion (19.2%), low back pain (19.2%), and neck pain (6.1%). Syndromic diagnosis showed no difference between groups (p = 0.231). In the TM-ED group (n = 51), self-examination demonstrated moderate to good agreement with face-to-face evaluations in several areas. Both groups showed similar tests practices. Patient satisfaction was higher in the TM-ED group across multiple measures. Conclusion: TM consultations for low-risk orthopedic patients by GPs are not inferior to face-to-face specialist evaluations at the ED. Virtual assessments are associated with higher patient satisfaction. Clinical Trial Identifier: NCT04981002.

Torsades de pointes and myocardial infarction following reversal of supraventricular tachycardia with adenosine: a case report.

Adenosine is an antiarrhythmic drug that slows conduction through the atrioventricular node and acts as a coronary blood vessel dilator. This case report highlights two unusual life-threatening events following the use of adenosine to revert supraventricular tachycardia in a structurally normal heart: non-sustained polymorphic ventricular tachycardia and myocardial infarction. A 46-year-old woman presented to the emergency department with a two-hour history of palpitations and was diagnosed with supraventricular tachycardia. Vagal maneuvers were ineffective, and after intravenous adenosine administration, the patient presented with chest pain and hypotension. The rhythm degenerated into non-sustained polymorphic ventricular tachycardia and spontaneously reverted to sinus rhythm with ST elevation in lead aVR and ST depression in the inferior and anterolateral leads. The patient spontaneously recovered within a few minutes. Despite successful arrhythmia reversal, the patient was admitted to the intensive care unit because of an infarction without obstructive atherosclerosis. This report aims to alert emergency physicians about the potential complications associated with supraventricular tachycardia and its reversal with adenosine.

Epipericardial fat necrosis as a differential diagnosis of acute chest pain: a case report and algorithm proposal for diagnostic approach.

Chest pain is a frequent, potentially life-threatening condition in the emergency department and requires immediate investigation and treatment. This case report highlights a rare differential diagnosis of pleuritic chest pain: epipericardial fat necrosis. A 29-year-old man presented with normal clinical evaluation, electrocardiography, point-of-care ultrasound, and unremarkable laboratory tests. The initial hypothesis was acute pleuritis. Chest radiography revealed peri-cardiac nonspecific findings, and computed tomography revealed epicardial fat necrosis. Despite the rarity of this condition, accurate diagnosis allows for better practices. An algorithm for a diagnostic approach is proposed.

Telemedicine diagnosis of acute respiratory tract infection patients is not inferior to face-to-face consultation: a randomized trial.

OBJECTIVE: To analyze telemedicine diagnostic accuracy in patients with respiratory infections during COVID-19 pandemic compared to face-to-face evaluation in the emergency department. METHODS: Randomized, unicentric study between September 2020 and November 2020 in patients with any respiratory symptom (exclusion criteria: age >65 years, chronic heart or lung diseases, immunosuppressed). Patients were randomized 1:1 for brief telemedicine followed by face-to-face consultation or direct face-to-face evaluation. The primary endpoint was the International Classification of Diseases code. The secondary analysis comprised length of stay, diagnostic test ordering, medical prescription, and proposed destination. RESULTS: Ninety-eight patients were enrolled. The mean age was 36.3±9.7 years old, 57.1% were women, and 81.6% had diagnostic test ordered. Mean grouped by International Classification of Diseases code for upper respiratory tract infection, pharyngotonsillitis, and sinusitis showed no difference between study groups or secondary endpoints. The Telemedicine Group was representative of the population usually evaluated in this center. In the Telemedicine Group (n=48), 18.7% patients would be referred for evaluation at the emergency department. The distribution of diagnoses by telemedicine was 67.4% for upper respiratory tract infection, 2.3% for pharyngotonsillitis, and 0% for sinusitis, being statistically similar to the subsequent face-to-face assessment, respectively: 72.1%, 11.6% and 7% (Kappa 0.386 [95%CI: 0.112-0.66]; p=0.536). Telemedicine ordered COVID-19 molecular (RT-PCR) tests in 76.5% versus 79.4% in face-to-face evaluation (Kappa 0.715 [95%CI: 0.413-1]; p>0.999). CONCLUSION: Diagnostic telemedicine consultation of low-risk patients with acute respiratory symptoms is not inferior to face-to-face evaluation at emergency department. Telemedicine is to be reinforced in the health care system as a strategy for the initial assessment of acute patients. ClinicalTrials.gov Identifier: NCT04806477.

Impact of the COVID-19 pandemic on emergency department visits: experience of a Brazilian reference center.

OBJECTIVE: To analyze the impact of COVID-19 on emergency department metrics at a large tertiary reference hospital in Brazil. METHODS: A retrospective analysis of consecutive emergency department visits, from January 1, 2020, to November 21, 2020, was performed and compared to the corresponding time frame in 2018 and 2019. The volume of visits and patients' demographic and clinic characteristics were compared. All medical conditions were included, except confirmed cases of COVID-19. RESULTS: A total of 138,138 emergency department visits occurred during the study period, with a statistically significant (p<0.01) reduction by 52% compared to both 2018 and 2019. This decrease was more pronounced for pediatric visits - a drop by 71% in comparison to previous years. Regarding clinical presentation, there was a decrease of severe cases by 34.7% and 37.6%, whereas mild cases decreased by 55.2% and 56.2% when comparing 2020 to 2018 and 2019, respectively. A 30% fall in the total volume of hospital admission from emergency department patients was observed during the study period, but accompanied by a proportional increase in monthly admission rates since April 2020. CONCLUSION: The COVID-19 pandemic led to a 52% fall in attendance at our emergency department for other conditions, along with a proportional increase in hospital admission rates of COVID-19 patients. Healthcare providers should raise patient awareness not to delay seeking medical treatment of severe conditions that require care at the emergency department.