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The study aimed to assess the diagnostic accuracy of point-of-care ultrasound (POCUS) in identifying small bowel obstruction (SBO) and to investigate the impact of clinician experience level and body mass index (BMI) on POCUS performance for diagnosing SBO in the Emergency Department. We systematically searched PubMed and Cochrane databases from January 2011–2022. We performed a meta-analysis using individual patient-level data from prospective diagnostic accuracy studies from which we obtained data from the corresponding authors. Overall test characteristics and subgroup analysis across clinician experience levels and a range of BMI were calculated. The primary outcome was SBO as the final diagnosis during hospitalization. We included Individual patient data from 433 patients from 5 prospective studies. Overall, 33% of patients had a final diagnosis of SBO. POCUS had 83.0% (95%CI 71.7%–90.4%) sensitivity and 93.0% (95%CI 55.3%–99.3%) specificity; LR+ was 11.9 (95%CI 1.2–114.9) and LR- was 0.2 (95%CI 0.1–0.3). Residents had exhibited a sensitivity of 73.0% (95%CI 56.6%–84.9%) and specificity of 88.2% (95%CI 58.8%–97.5%), whereas attendings had demonstrated a sensitivity of 87.7% (95%CI 71.1%–95.4%) and specificity of 91.4% (95%CI 57.4%–98.8%). Among those patients with BMI<30 kg/m2, POCUS showed a sensitivity of 88.6% (95%CI 79.5%–94.7%) and a specificity of 84.0% (95%CI 75.3%–90.6%), while patients with BMI ≥ 30 kg/m2 exhibited a sensitivity of 72.0% (95%CI 50.6%–87.9%) and specificity of 89.5% (95%CI 75.2%–97.1%). POCUS correctly identified those patients with SBO with high sensitivity and specificity. Diagnostic accuracy was slightly reduced when performed by resident physicians and among patients with a BMI ≥ 30 kg/m2. Registration: PROSPERO registration number: CRD42022303598.

The importance of this study is to devise an efficient tool for assessing frailty in the ED. The goals of this study are 1) to correlate ultrasonographic (US) measurements of muscle thickness in older ED patients with frailty and 2) to correlate US-measured sarcopenia with falls, subsequent hospitalizations and ED revisits. Participants were conveniently sampled from a single ED in this prospective cohort pilot study of patients aged 65 or older. Participants completed a Fatigue, Resistance, Ambulation, Illness and Loss of Weight (FRAIL) scale assessment and US measurements of their upper arm muscles, quadricep muscles, and abdominal wall muscles thickness. We conducted one-month follow-up phone calls to assess for falls, ED revisits, and subsequent hospital visits. We enrolled 43 patients (mean age of 78.5). Ultrasound measurements of the three muscle groups were not significantly different between frail and non-frail groups. Frail participants had greater bicep asymmetry (a difference of 0.47 cm vs 0.24 cm, p < .01). A predictive logistic regression model using average quadriceps thickness and biceps asymmetry was found to identify frail patients (AUC of 0.816). Participants with subsequent falls had smaller quadriceps (1.18 cm smaller, p < .01). Subsequently hospitalized patients were found to have smaller quadriceps muscles (0.54 cm smaller, p = .03) and abdominal wall muscles (0.25 cm smaller, p = .01). US measurements of sarcopenia in older patients had mild to moderate associations with frailty, falls and subsequent hospitalizations. Further investigation is needed to confirm these findings.

Cutaneous leishmaniasis is a disease characterized by ulcerating skin lesions, the resolution of which requires an effective, but regulated, immune response that limits parasite growth without causing permanent tissue damage. While mechanisms that control the parasites have been well studied, the factors regulating immunopathologic responses are less well understood. IL-22, a member of the IL-10 family of cytokines, can contribute to wound healing, but in other instances promotes pathology. Here we investigated the role of IL-22 during leishmania infection, and found that IL-22 limits leishmania-induced pathology when a certain threshold of damage is induced by a high dose of parasites. Il22-/- mice developed more severe disease than wild-type mice, with significantly more pathology at the site of infection, and in some cases permanent loss of tissue. The increased inflammation was not due to an increased parasite burden, but rather was associated with the loss of a wound healing phenotype in keratinocytes. Taken together, these studies demonstrate that during cutaneous leishmaniasis, IL-22 can play a previously unappreciated role in controlling leishmania-induced immunopathology.

Risk factors for difficult IV access (DIVA) include provider experience, patient medical history, female gender, vein characteristics, and history of difficult access [5,6]. Delays in medical care are a source of concern in the ED given the undifferentiated nature of most patients and the potential for time sensitive conditions including myocardial infarctions, strokes, sepsis and infections, and surgical emergencies. Future directions for research also include interventions to decrease possible bias and reduce these delays, as well as further characterization of the specific downstream impact of DIVA-related delays in medical care and disposition on outcomes in time-sensitive conditions.Presentations None.Financial support This is a non-funded study, with no compensation or honoraria for participation, consulting or conducting the study.Author contributions MRS: methodology, writing-original draft, review & editing, MAL: data curation, formal analysis, WMK: writing: review & editing, HS: conceptualization, methodology, writing- review & editingConflict of interest disclosure MRS reports no conflict of interest.

The impact of alcohol or opioid use disorders on medication dosing for procedural sedation in the emergency department (ED) is unclear, as most of the literature is from gastrointestinal endoscopy. Exploring how these patient factors affect sedative and analgesic medications may inform more nuanced sedation strategies in the emergency department. This was a retrospective chart-review cohort study across five EDs from 2015 to 2020. Included were adult patients who underwent procedural sedation in the ED, categorized into three a priori groups: alcohol use disorder (AUD), opioid use disorder (OUD), and individuals with neither (non-SUD). Wilcoxon test was used to compare the time-averaged dose of agents between groups. Logistic regression was used to model multi-agent sedations. The propofol time-averaged dose was the primary outcome. Secondary outcomes included other agents, sedation duration, and switching to other agents. 2725 sedations were included in the analysis. 59 patients had a history of AUD, and 40 had a history of OUD. Time-averaged doses of medications did not differ significantly between AUD and non-SUD patients. Likewise, patients with OUD did not receive different doses of medications compared to non-SUD. The propofol doses for non-SUD, AUD, and OUD were 0.033 IQR 0.04; 0.042 IQR 0.05; and 0.058 IQR 0.04 mg/kg*min, respectively. Sedation duration was not different across groups. Having AUD or OUD is not associated with increased odds of requiring multiple sedative agents. Although sedation in patients with AUD or OUD may be associated with significant case bias, these patient factors did not significantly alter outcomes compared to the general population. This study suggests there is no evidence to proactively adjust medication strategy in ED patients with AUD or OUD. •Alcohol and opioid use disorder may not affect med dosing in ED procedural sedation.•Substance use patient factors may not result in longer sedation duration.•Significant case bias should be considered when planning sedation strategy.•SNOMED CT and social history can be used to cohort patients with great accuracy.

Early diagnostic prediction in patients with small bowel obstruction (SBO) can improve time to definitive management and disposition in the emergency department. We sought to develop a nomogram to leverage point-of-care ultrasound (POCUS) and maximize accuracy of prediction of SBO diagnosis. Using data from a prospective cohort of 125 patients with suspected SBO who were evaluated with POCUS in the ED, we developed a nomogram integrating age, gender, comorbidities, prior abdominal surgery, physician's pre-test probability, and POCUS findings to determine post-test risk of SBO. The primary outcome was to develop a nomogram to allow calculating output probabilities for predictive models using POCUS findings. The discriminative ability of the nomogram was tested using a C-statistics, calibration plots, and receiver operating characteristic curves. The derivation cohort included 125 patients with a median age of 54 years who underwent POCUS for a suspected SBO. One-fourth of the patients (25.6% [32/125]) had SBO. Using a retrospective stepwise selection of clinically important variables with the POCUS results, the final nomogram incorporated four relevant factors for the prediction of SBO: small bowel diameter (odds ratio [OR] per 1 mm increase, 1.10; 95% CI, 1.03–1.17; P = 0.001), positive free intraperitoneal fluid between bowel loops (OR, 8.19; 95% CI, 2.62–25.62; P < 0.001), clinician's moderate (OR, 5.94; 95% CI, 0.83–42.57; P = 0.08) or high pretest probability (OR, 11.26; 95% CI, 1.44–88.25; P = 0.02), and patient age (OR per 1 year increase, 1.03; 95% CI, 1.00 to1.07; P = 0.08).The discriminative ability and calibration of the nomogram revealed good predictive ability as indicated by the C-statistic of 0.89 for the SBO diagnosis. A unique nomogram incorporating patient age, physician pretest probability of SBO, and POCUS measurements of small bowel diameter and the presence of free intraperitoneal fluid between bowel loops was developed to accurately predict the diagnosis of SBO in the emergency department. The nomogram should be externally validated in a novel cohort of patients at risk for SBO to better assess predictability and generalizability.

Acute cholecystitis can be difficult to diagnose in the emergency department (ED); no single finding can rule in or rule out the disease. A prediction score for the diagnosis of acute cholecystitis for use at the bedside would be of great value to expedite the management of patients presenting with possible acute cholecystitis. The 2013 Tokyo Guidelines is a validated method for the diagnosis of acute cholecystitis but its prognostic capability is limited. The purpose of this study was to prospectively validate the Bedside Sonographic Acute Cholecystitis (SAC) Score utilizing a combination of only historical symptoms, physical exam signs, and point-of-care ultrasound (POCUS) findings for the prediction of the diagnosis of acute cholecystitis in ED patients. This was a prospective observational validation study of the Bedside SAC Score. The study was conducted at two tertiary referral academic centers in Boston, Massachusetts. From April 2016 to March 2019, adult patients (≥18 years old) with suspected acute cholecystitis were enrolled via convenience sampling and underwent a physical exam and a focused biliary POCUS in the ED. Three symptoms and signs (post-prandial symptoms, RUQ tenderness, and Murphy's sign) and two sonographic findings (gallbladder wall thickening and the presence of gallstones) were combined to calculate the Bedside Sonographic Acute Cholecystitis (SAC) Score. The final diagnosis of acute cholecystitis was determined from chart review or patient follow-up up to 30 days after the initial assessment. In patients who underwent operative intervention, surgical pathology was used to confirm the diagnosis of acute cholecystitis. Sensitivity, specificity, PPV and NPV of the Bedside SAC Score were calculated for various cut off points. 153 patients were included in the analysis. Using a previously defined cutoff of ≥ 4, the Bedside SAC Score had a sensitivity of 88.9% (95% CI 73.9%–96.9%), and a specificity of 67.5% (95% CI 58.2%–75.9%). A Bedside SAC Score of < 2 had a sensitivity of 100% (95% CI 90.3%–100%) and specificity of 35% (95% CI 26.5%–44.4%). A Bedside SAC Score of ≥ 7 had a sensitivity of 44.4% (95% CI 27.9%–61.9%) and specificity of 95.7% (95% CI 90.3%–98.6%). A bedside prediction score for the diagnosis of acute cholecystitis would have great utility in the ED. The Bedside SAC Score would be most helpful as a rule out for patients with a low Bedside SAC Score < 2 (sensitivity of 100%) or as a rule in for patients with a high Bedside SAC Score ≥ 7 (specificity of 95.7%). Prospective validation with a larger study is required.

We sought to determine the ability of lung point‐of‐care ultrasound (POCUS) to predict mechanical ventilation and in‐hospital mortality in patients with coronavirus disease 2019 (COVID‐19). This was a prospective observational study of a convenience sample of patients with confirmed COVID‐19 presenting to 2 tertiary hospital emergency departments (EDs) in Iran between March and April 2020. An emergency physician attending sonographer performed a 12‐zone bilateral lung ultrasound in all patients. Research associates followed the patients on their clinical course. We determined the frequency of positive POCUS findings, the geographic distribution of lung involvement, and lung severity scores. We used multivariable logistic regression to associate lung POCUS findings with clinical outcomes. A total of 125 patients with COVID‐like symptoms were included, including 109 with confirmed COVID‐19. Among the included patients, 33 (30.3%) patients were intubated, and in‐hospital mortality was reported in 19 (17.4%). Lung POCUS findings included pleural thickening 95.4%, B‐lines 90.8%, subpleural consolidation 86.2%, consolidation 46.8%, effusions 19.3%, and atelectasis 18.3%. Multivariable logistic regression incorporating binary and scored POCUS findings were able to identify those at highest risk for need of mechanical ventilation (area under the curve 0.80) and in‐hospital mortality (area under the curve 0.87). In the binary model ultrasound (US) findings in the anterior lung fields were significantly associated with a need for intubation and mechanical ventilation (odds ratio [OR] 3.67; 0.62–21.6). There was an inverse relationship between mortality and posterior lung field involvement (OR 0.05; 0.01–0.23; and scored OR of 0.57; 0.40–0.82). Anterior lung field involvement was not associated with mortality. In patients with COVID‐19, the anatomic distribution of findings on lung ultrasound is associated with outcomes. Lung POCUS‐based models may help clinicians to identify those patients with COVID‐19 at risk for clinical deterioration. Key Words: COVID‐19; Lung Ultrasound; Mechanical ventilation; Prediction; ICU admission; Mortality; Clinical outcome; Risk stratification; Diagnostic accuracy

Identifying the potential for SARS-CoV-2 reinfection is crucial for understanding possible long-term epidemic dynamics. We analysed longitudinal PCR and serological testing data from a prospective cohort of 4,411 United States employees in 4 states between April 2020 and February 2021. We conducted a multivariable logistic regression investigating the association between baseline serological status and subsequent PCR test result in order to calculate an odds ratio for reinfection. We estimated an odds ratio for reinfection ranging from 0.14 (95% CI: 0.019 to 0.63) to 0.28 (95% CI: 0.05 to 1.1), implying that the presence of SARS-CoV-2 antibodies at baseline is associated with around 72% to 86% reduced odds of a subsequent PCR positive test based on our point estimates. This suggests that primary infection with SARS-CoV-2 provides protection against reinfection in the majority of individuals, at least over a 6-month time period. We also highlight 2 major sources of bias and uncertainty to be considered when estimating the relative risk of reinfection, confounders and the choice of baseline time point, and show how to account for both in reinfection analysis.