Volume 23

Emergency Department Treatment of Elevated Blood Pressure in the Headache Patient

Original Articles, Volume 23, Issue 2, Pages 53 – 96 (2024)

Headache accounts for 1 – 3% of emergency department (ED) visits globally and is associated with elevated blood pressure (BP). It is unclear if anti-hypertensive therapy provides benefits. This retrospective study assessed effects of anti-hypertensive therapy in ED headache patients on rescue analgesic need, hospital admissions, and length of stay (LOS). 1385 patients were included. 366 received anti-hypertensive therapy. The anti-hypertensive therapy cohort was older (p < 0.001) with increased odds of admission (p < 0.001) and 2.385 hrs longer ED LOS (p < 0.001). No difference in rescue analgesia was found (p < 0.429). Anti-hypertensive therapy in hypertensive ED headache patients is associated with increased hospital admission and ED LOS, but no difference in rescue analgesia utilization.

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Performance of AI-powered chatbots in diagnosing acute pulmonary thromboembolism from given clinical vignettes

Original Articles, Volume 23, Issue 2, Pages 53 – 96 (2024)

Background: Chatbots hold great potential to serve as support tool in diagnosis and clinical decision process. In this study, we aimed to evaluate the accuracy of chatbots in diagnosing pulmonary embolism (PE). Furthermore, we assessed their performance in determining the PE severity.
Method: 65 case reports meeting our inclusion criteria were selected for this study. Two emergency medicine (EM) physicians crafted clinical vignettes and introduced them to the Bard, Bing, and ChatGPT-3.5 with asking the top 10 diagnoses. After obtaining all differential diagnoses lists, vignettes enriched with supplemental data redirected to the chatbots with asking the severity of PE.
Results: ChatGPT-3.5, Bing, and Bard listed PE within the top 10 diagnoses list with accuracy rates of 92.3%, 92.3%, and 87.6%, respectively. For the top 3 diagnoses, Bard achieved 75.4% accuracy, while ChatGPT and Bing both had 67.7%. As the top diagnosis, Bard, ChatGPT-3.5, and Bing were accurate in 56.9%, 47.7% and 30.8% cases, respectively. Significant differences between Bard and both Bing (p=0.000) and ChatGPT (p=0.007) were noted in this group. Massive PEs were correctly identified with over 85% success rate. Overclassification rates for Bard, ChatGPT-3.5 and Bing at 38.5%, 23.3% and 20%, respectively. Misclassification rates were highest in submassive group.
Conclusion: Although chatbots aren’t intended for diagnosis, their high level of diagnostic accuracy and success rate in identifying massive PE underscore the promising potential of chatbots as clinical decision support tool. However, further research with larger patient datasets is required to validate and refine their performance in real-world clinical settings.

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The intensive care population profile in Denmark before and during the first wave of the SARS-CoV-2 pandemic; a national register-based study

Original Articles, Volume 23, Issue 2, Pages 53 – 96 (2024)

Objective: To describe the change in admission rate and demographic profile of patients admitted to ICUs throughout Denmark before and during first wave of the SARS-CoV-2 pandemic.
Methods: A register-based national observational study of all patients admitted to ICU from December 2019 until April 2020, comparing ICU admission before and after lockdown.
Results: The number of admissions declined, especially in the age groups below 18 and above 70. The sex distribution and the comorbidity-level remained unchanged. The length of hospital stay prior to ICU admission increased. Overall fewer patients were admitted electively.
Conclusion: Fewer patients were admitted to ICU and waited longer for admission during the first wave of the COVID-19 pandemic.

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Optimising Cardiology Ambulatory Care Pathways: A Comprehensive Approach to Admission Avoidance and Timely Intervention in a Post-Pandemic Healthcare Landscape

Original Articles, Volume 23, Issue 2, Pages 53 – 96 (2024)

Introduction: Cardiovascular diseases are a substantial burden on healthcare systems, contributing significantly to avoidable hospital admissions. We propose a Cardiology Ambulatory Care Pathway.
Methods: Conducted a 1 month study redirecting admission streams from primary and emergency care, into a Cardiology Ambulatory Care Hub providing triage in Hot Clinic, and access to a Multi-Modal Testing Platform.
Results: 98 patients were referred to the Ambulatory Care Hub, 91 of which avoided admission. 52 patients received care in the cardiology hub, 38 of which required further testing.
Conclusion: We successfully streamlined various service streams, reducing admissions, and improving patient outcomes. Outpatient CTCA, ambulatory ECG, and echocardiography proved instrumental. We project a cost saving of £53,379 per month in bed days (£640,556 annual saving).

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Guest Editorial – Shifting Dynamics: ICU Admissions in Denmark during the First Wave of the COVID-19 Pandemic

Guest Editorial, Volume 23, Issue 2, Pages 53 – 96 (2024)

The advent of the SARS-CoV-2 pandemic brought unprecedented challenges to healthcare systems worldwide. As the virus spread across continents, hospitals faced a surge in patient admissions, particularly to intensive care units (ICUs). Understanding the impact of the pandemic on the sickest patients admitted to hospital is crucial for enhancing preparedness for future outbreaks. In this edition of the journal, authors from Denmark report on a register-based national observational study that sheds light on the changes in ICU admission rates and demographic profiles of patients during the initial phase of the pandemic.

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Guest Editorial – Ambulatory Care: Turning Urgent and Emergency Care inside out

Guest Editorial, Volume 23, Issue 2, Pages 53 – 96 (2024)

Emergency departments are under year-round pressure, driven by high hospital bed occupancy and compounded by increasing attendances and admissions.1 In 2023, 1.5 million people waited 12 hours or more for a bed.2 Long waits are associated with increased mortality and there is a disproportionate impact on people living in more deprived areas.3,4 Addressing this problem begins with unity of purpose and vision, such that we all view emergency department performance as our responsibility, whatever our place in the healthcare system.

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ORF disease: a case report with images

Case Reports, Volume 23, Issue 1, Pages 1 – 52 (2024)

This article presents the case of a 25-year-old Moroccan male who contracted Orf disease (Ecthyma contagiosum), a common zoonotic viral infection in sheep and goats. The disease, caused by a parapoxvirus, can be transmitted to humans through contact with infected animals. The patient developed painful lesions on his fingers after interacting with a sheep during the Feast of Sacrifice. Diagnosis was clinically established considering exposure history and lesion characteristics. Treatment involved local antiseptics and 2% fusidic acid cream. The lesions resolved spontaneously over a few weeks without functional impairment

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An unexpected case of acute intermittent porphyria

Case Reports, Volume 23, Issue 1, Pages 1 – 52 (2024)

Acute Intermittent Porphyria (AIP) can be a challenging diagnosis to make, due to its rarity in actual practice and presenting symptoms often being attributed to more common conditions. This is particularly the case, since many patients will likely present to acute and general hospitals where the diagnosis may often not be considered. However, it remains pivotal to diagnose the condition as early as possible to prevent significant morbidity and even death. Here we present an unexpected case of AIP, illustrating the diagnostic delay that is commonly seen with the condition and yet emphasise the importance of its detection to commence urgent treatment.

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Point-of-care ultrasound for the diagnosis of an atypical small bowel obstruction in a cannabis user: a case report

Case Reports, Volume 23, Issue 1, Pages 1 – 52 (2024)

This case report describes an atypical small bowel obstruction in a 71- years old cannabis user and how point-of-care of ultrasound (PoCUS) helped to its management by further orientating the physician toward the bowel obstruction etiology, namely intussusception. Intussusception is the invagination of an intestinal segment into the adjacent segment. The acute clinical presentation of intussusception often has non-specific symptoms, and the diagnosis can be challenging. While the most common etiology is neoplasm, intussusception also occurs in bowel motility disorder such as after cannabis use. Although this case report illustrates intussusception PoCUS findings, these should nevertheless be integrated into the clinical picture and CT-scan should remain the gold standard complementary examination in case of a suspected bowel obstruction.

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Point of Care Ultrasound Bladder Volume Calculation on the Acute Medical Unit

Original Articles, Volume 23, Issue 1, Pages 1 – 52 (2024)

Nursing staff, healthcare assistants (HCAs) and other healthcare professionals on the Acute Medical Unit (AMU) at Royal Berkshire Hospital (RBH) were taught a Point of Care Ultrasound (POCUS) skill during a twenty minute session. Practitioners learned how to take bladder volume measurements with the Butterfly iQ, a portable ultrasound device which provides a visually-aided method of volume measurement. A Likert scale was used to measure the confidence that staff had in performing volume measurements with the AMU automated scanners, and with the semi-automated Butterfly iQ. After the teaching session, confidence reported by practitioners in using the semi-automated visual method was significantly higher than confidence reported in using the automated non-visual scanners (t < 0.001). Minimal time and expense was required to teach practitioners how to perform this skill. Training nurses in POCUS for bladder visualisation and bladder volume calculation is easy and practicable.

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