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When Pain Puts Your Heart in the Fast Lane: A Case of Ventricular Tachycardia Induced by Pain From Rib Fracture
No full textRepetitive monomorphic ventricular tachycardia (RMVT) is the most common form of idiopathic ventricular tachycardia. It usually happens in patients with no history of cardiac disease. Many triggers have been described in the literature, specifically high catecholamine states such as surgery or acute illness. Here, we present a young patient with no past medical history who presented with acute onset right-sided upper back pain. An electrocardiogram (ECG) in the emergency room showed a wide QRS complex tachycardia with a left bundle branch morphology. The echocardiogram was significant for a reduced ejection fraction (EF) with severe global hypokinesis. She was evaluated by electrophysiology, who recommended initiating metoprolol tartrate, as the working diagnosis was thought to be RMVT. She underwent cardiac catheterization, which showed non-obstructive coronary artery disease (CAD). Upon further evaluation, she was found to have right-sided rib fractures that were not seen on the initial workup. Pain from the rib fracture was thought to be the triggering factor for her arrhythmia. Her tachycardia was resolved with beta blockers. The patient was discharged in a stable condition with electrophysiology follow-up for considering ablation
Treatment Patterns of Patients With Mitral Valve Disease and Critical Neo-LVOT Obstruction
No full textBACKGROUND AND AIMS: Among patients with severe mitral valve (MV) disease and predicted high-risk of left ventricular outflow track obstruction (LVOTO), the patterns of treatment and clinical outcomes have not previously described. The aim of this study was to explore outcomes of this patient population.
METHODS: We conducted a single-center study including all consecutive patients with severe MV disease who were evaluated by a multidisciplinary structural heart disease team for MV therapies between 2018 and 2023. All patients underwent pre-procedural contrast cardiac computed tomography (CT). We defined high risk for LVOTO as a post-transcatheter mitral valve replacement (TMVR) predicted neo-LVOT \u3c 150 mm(2).
RESULTS: A total of 157 patients with a median Neo-LVOT of 0 (IQR 0-80.4) were included. Median age was 79 (72-83), and most were females (89.2%). A total of 59 patients (37.6%) had severe mitral stenosis, 48 (30.6%) had severe mitral regurgitation, and 98 (58%) had both. The median STS score was 22.6 (17-29.6). Most patients were in NYHA class III or IV (77.1%), and the median KCCQ-12 was 48.9 (IQR: 29-68.7). Overall, the majority of patients were assigned to medical therapy (54.1%). There were a total of 41 deaths (26.1%) at a median follow-up time of 247 days (IQR: 70-568). When separated into non-severe MAC and severe MAC, patients with severe MAC had higher rates of all-cause mortality at 1 year (unadjusted HR: 2.44; 95% CI: 1.13-5.24; p = 0.02). Severe MAC patients were more likely to be assigned to medical therapy. Treatment allocation was not independently associated with a higher or lower risk of death.
CONCLUSIONS: Patients with severe MV disease at high-risk for LVOTO (LVOT \u3c 150 mm(2)) after TMVR were overwhelmingly female and were most frequently assigned to medical therapy. Patients with severe MAC had higher rates of death. Treatment allocation was not independently associated with mortality. Novel transcatheter therapies are needed to definitively treat this high-risk population
Risks for adverse events by sex and age after prescription opioid dose reduction
No full textINTRODUCTION: Prescription opioid dose reductions can raise the risk of adverse events for patients on long-term opioid therapy for non-cancer pain. Evidence on whether risks differ by age or sex is needed to support tailored clinical decision-making.
METHODS: In 2024, a secondary analysis of an observational cohort study was conducted across 8 U.S. healthcare systems analyzing electronic health record and claims data from a prescription opioid registry (excluding buprenorphine prescriptions) between 1/1/2012 and 12/31/2018, including adults with stable prescription opioid use and a subsequent ≥ 2-month dose reduction period (n=60,040), yielding 600,234 dose reduction periods as the analytic sample. Differences in the association between dose reduction level (1-\u3c 15%, 15-\u3c 30%, 30-\u3c 100%, 100% from baseline) and potential adverse events (emergency department visits, opioid overdose, all-cause mortality, benzodiazepine prescription fills) in the month after dose reduction by sex and age group were examined by including interaction terms in logistic regression models.
RESULTS: Of the 600,234 dose reduction periods, 346,733 were among women, with a mean age of 57.5 [SD=13.2] years for women and 56.7 [SD=12.1] years for men. Associations between dose reduction levels and potential adverse events did not differ significantly by sex, but differed by age for emergency department visits: patients 40-64 and ≥ 65 years with dose reductions of 30-\u3c 100% had lower odds compared to those aged 19-39 (adjusted ratio of odds ratios [aROR]=0.87, CI 0.80, 0.96; aROR=0.82, CI 0.74, 0.91; respectively).
CONCLUSIONS: Patients under 40 may benefit from closer monitoring in the month after dose reduction, given their higher odds of an emergency department visit
Correlates of Deliberate Self-Harm in Youth With Autism and/or Intellectual Disability
No full textOBJECTIVE: To identify correlates of deliberate self-harm (DSH) in youth with autism and/or intellectual disability (ID).
METHOD: This retrospective longitudinal cohort analysis used claims data for youth ages 5 to 24 years continuously enrolled in Medicaid in a midwestern state for 6 months and diagnosed with autism and/or ID between 2010 and 2020 (N = 41,230). Cox proportional hazards regression examined associations between demographic and clinical variables and time to DSH for study cohorts with autism and/or ID.
RESULTS: Autism was diagnosed in 34.3% of the sample, ID was diagnosed in 30.6%, and both autism and ID were diagnosed in 35.1%. Sample youth were predominantly male (73.4%) and had an internalizing (74.8%) or externalizing (62.1%) mental health condition. At least 1 DSH event was identified for 734 youths (2.6%) with autism and 686 youths (2.7%) with ID during follow-up. Increased risk of DSH was associated with older age; female sex; history of abuse or neglect; and co-occurring externalizing problems, internalizing problems, substance use, and thought problems for the autism cohort and ID cohort and with the presence of a chronic complex medical condition in the autism cohort. Risk of DSH was significantly lower for youth with moderate ID and youth eligible for Medicaid via disability and foster care.
CONCLUSION: Risk factors for DSH in youth with autism and ID are similar to those in neurotypical youth and include increasing age, trauma, mental health conditions, substance use, and female sex. Clinician and consumer education regarding suicide risk and its correlates in youth with autism and ID warrants study
Nurse Pediatric Competency, Certification, and Continuing Education: Impact on EDs\u27 Pediatric Readiness
No full textINTRODUCTION: Children present to emergency departments regardless of their readiness to care for pediatric patients. The National Pediatric Readiness Project is an initiative to improve pediatric emergency care. Increased National Pediatric Readiness Project scores have been associated with decreased mortality. The purpose of this study is to examine the association between nurse pediatric competency, certification, and/or continuing education and weighted pediatric readiness scores.
METHODS: A sub-analysis of the 2021 National Pediatric Readiness Project Assessment examining nurse pediatric competencies and overall pediatric readiness scores of emergency department of United States includes descriptive statistics, testing for the association between hospital characteristics and pediatric patient volume using Fisher\u27s tests and Kruskal-Wallis tests, and Wilcoxon rank-sum tests of score and nurse pediatric competencies.
RESULTS: The majority (89%) of emergency departments require some nurse competency evaluations. Only 20.1% of emergency departments require nurse specialty certification. Most emergency departments have a hospital-specific nurse competency evaluation policy (91.7%) and nurse continuing education policies (98.3%). Having policies for competencies is significantly associated with increased median weighted pediatric readiness scores above the national median: nursing continuing education policy weighted pediatric readiness scores 71.3 (P = .030), nurse specialty certification policy weighted pediatric readiness scores 83.5 (P\u3c .001), and nurse hospital-specific competency evaluation policy weighted pediatric readiness scores 72.3 (P\u3c .001).
DISCUSSION: Most emergency departments have a requirement for nurse pediatric-specific competency evaluations, and having nursing competency requirements is associated with higher weighted pediatric readiness scores. This highlights the importance of emergency nurse pediatric competency, certification, and continuing education on pediatric readiness scores, and therefore, the potential reduction in pediatric mortality
Emergency Physician Employer Market Share and Concentration by Ownership Type
No full textSTUDY OBJECTIVE: With rapid consolidation and corporatization of the emergency physician workforce over recent years, little is known about the current state of the emergency physician market. We characterized employer group market share by ownership structure and market concentration by ownership across geographies.
METHODS: We selected hospitals from the Centers for Medicare and Medicaid Services (CMS) Hospital General Information Dataset (2021). Ivy Clinicians (2024) defined ownership category (majority ownership by health system, private equity, or clinician partnerships [single-site, regional, national]). National Emergency Department Inventories 2021, the most recent data set available, served as a proxy for 2024 emergency department (ED) visit volumes. The primary outcome was market share defined as the percentage of national ED annual visits staffed by employers within each ownership category. Secondary outcomes measured market concentration.
RESULTS: Our sample included 3,998 hospital-based EDs, accounting for 109.7 million ED visits in 2021. Per 2024 ownership data, health system groups staffed 33.0% of ED visits followed by private equity 24.7%, regional partnership 20.8%, national partnership 13.4%, and single-site partnership 8.1%. The top 3 private equity groups staffed 93.5% of the private equity visits. In contrast, the top 31 regional partnerships, 51 single-site partnerships, and 63 health system groups comprised 50% market share within their respective categories. Three national partnerships staff all visits in this category. Of the 306 hospital referral regions, 258 (84%) were highly concentrated.
CONCLUSION: Groups with majority physician ownership staffed less than half of ED visits. The emergency medicine market is highly concentrated regionally, as well as within the private equity and national partnership ownership categories
Evaluation and Management of Alcohol-Intoxicated Patients with Suicide Risk in the Emergency Department: A Scoping Review
No full textBACKGROUND: The severity of suicide risk in patients who present to the emergency department (ED) with cooccurring complaints of suicidal ideation and alcohol intoxication is neither well-understood nor well-recognized by ED staff. While suicide screening has become a standard expectation in ED care, there lacks consensus on standard care practices for the evaluation and management of patients with suicidal ideation and/or attempt and alcohol intoxication.
METHODS: This is a scoping review describing the evaluation and management of ED patients with suicidality and alcohol intoxication. PubMed, Ovid MEDLINE, APA PsycInfo, and CINAHL were searched using relevant terms to describe this ED population. 110 total articles were found and underwent full-text review. Twenty-nine articles met criteria for inclusion.
RESULTS: Patients with suicide-related complaints while intoxicated are less likely to receive a psychiatric evaluation or to be admitted psychiatrically. This is concerning given that alcohol use is demonstrated to be both a proximal and long-term risk factor for suicide attempt(s). Existing literature includes recommendations to evaluate patients while intoxicated and to re-evaluate when sober. To create safe plans of care for these patients, clinicians need to identify the patterns of alcohol use: alcohol use to facilitate suicide, binge drinking episodes, or alcohol use disorder (AUD). ED interventions can then build from understanding of how the alcohol use and suicidality interact. Though no specific ED-based interventions were found for this patient subpopulation, interventions shown to mitigate suicide risk and/or decrease alcohol use include: brief interventions (e.g. Screening, Brief Intervention, and Referral to Treatment (SBIRT)), peer navigators, crisis safety plans, discussion about restricting access to lethal means, and/or inpatient psychiatric admission.
CONCLUSION: There is a lack of published guidelines, standards of care, and best practices to help consultation-liaison, emergency psychiatrists, and ED providers in the management of this population, despite overwhelming literature linking alcohol intoxication and suicide attempt/death. Further research is needed to (1) elucidate the core elements for standardized assessments and (2) develop evidence-based interventions to improve outcomes/decrease rates of intoxicated suicide completion
Personalizing denosumab therapy in postmenopausal Indian women with osteoporosis: predictive role of bone turnover markers and body mass index in determining dosing interval
No full textUNLABELLED: This prospective study evaluated whether bone turnover markers (BTMs) and body mass index (BMI) can guide individualized denosumab dosing in postmenopausal Indian women with osteoporosis. Lower baseline β-CTX and BMI were independently associated with safe deferral of denosumab beyond 6 months, without increased fracture risk. These findings support a personalized, phenotype-based approach to denosumab therapy in low-turnover populations.
PURPOSE: To evaluate whether baseline bone turnover markers (BTMs) and body mass index (BMI) can predict the safety and feasibility of extending the dosing interval of denosumab beyond six months in postmenopausal Indian women with osteoporosis.
METHODS: In this prospective observational study, 56 postmenopausal women with DXA-confirmed osteoporosis were initiated on denosumab (60 mg subcutaneously).None of the participants had received prior anti-resorptive therapies. Several participants were on vitamin D supplementation, consistent with their high baseline serum 25-hydroxyvitamin D levels. Serum ß-CTX levels were measured at 6 months, guiding the timing of subsequent injections. Participants were classified into two groups: standard (dose at 6 months) and delayed (dose deferred beyond 6 months if ß-CTX \u3c 300 pg/mL). Baseline BTMs, BMI, and fracture outcomes were analysed. Multivariate logistic regression was used to identify predictors of delayed dosing.
RESULTS: Twenty-eight women received delayed injections (median interval: 9.5 months). Compared to the standard group, the delayed group had significantly lower baseline ß-CTX levels (497 vs. 794 pg/mL; p \u3c 0.001) and lower BMI (23.29 ± 2.77 vs. 25.59 ± 3.03 kg/m²; p = 0.005). Multivariate analysis showed both lower baseline ß-CTX (OR: 0.99; 95% CI: 0.98-1.00; p = 0.027) and lower BMI (OR: 0.60; 95% CI: 0.40-0.89; p = 0.012) independently predicted delayed denosumab administration. No new vertebral fractures were observed in either group during follow-up.
CONCLUSIONS: Lower baseline bone turnover and lower BMI may help identify postmenopausal Indian women in whom denosumab dosing can be safely deferred beyond six months. These findings are preliminary and do not establish long-term safety or efficacy; further studies with extended follow-up are needed before adopting extended dosing intervals in clinical practice
A Case of Sickle Cell Beta Thalassemia and Recurrent Septicemia
No full textSickle cell anemia and beta-thalassemia are among the most common hemoglobin disorders. They are characterized by abnormal hemoglobin production, leading to ineffective erythropoiesis and severe anemia. Compound forms, such as sickle cell beta-thalassemia (HbS/β-thalassemia), may experience a wide range of complications, including impaired splenic function and increased susceptibility to infections. In this case report, we describe the case of a 57-year-old female patient with sickle cell/beta0-thalassemia (Sß0) with frequent and prolonged hospital admissions for sepsis complicated by recurrent liver abscess requiring multiple procedures for intrahepatic drainage. This patient was found to have an abscess with cholelithiasis, with a multiseptated hypodense collection within the liver. Recurrent liver abscesses are rare and underreported in this population. This case highlights the need for further research to clarify pathophysiology and ultimately improve management