The American journal of emergency medicine
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Urinary tract infections (UTIs) seen in the emergency department are commonly treated as an outpatient with oral antibiotics. Given that antibiotics are available for over-the-counter purchase in Mexico, there is speculation that potential misuse and overuse of antibiotics in United States-Mexico border areas could lead to antibiotic resistance patterns that would render some empiric treatments for UTIs less effective. The purpose of this study was to examine the effectiveness of Infectious Disease Society of America (IDSA) guideline-recommended antibiotics for treatment of outpatient UTI diagnosed in the emergency department. Data were collected from a county hospital on the U.S.-Mexico border with a metropolitan area of over 2 million people. Secondary analysis included frequency of urine culture isolated, resistance rates of urine pathogens, and prescriber habits. ⋯ Our findings suggest that, while part of standard IDSA guidelines, fluoroquinolones and TMP-SMX are not ideal empiric antibiotics for treatment of outpatient UTI in the U.S.-Mexico border region studied due to high resistance rates. Although not listed as first line agents per current IDSA recommendations, 2nd and 3rd generation cephalosporins, and amoxicillin/clavulanate would be acceptable options given resistance patterns demonstrated in accordance with IDSA allowance for tailoring selection to local resistance. Nitrofurantoin appears to be consistent with recommendations and demonstrates a favorable resistance profile for treatment of outpatient UTI within this region.
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'Surprise billing', or the phenomenon of unexpected coverage gaps in which patients receiving out-of-network medical bills after what they thought was in-network care, has been a major focus of policymakers and advocacy groups recently, particularly in the Emergency Department (ED) setting, where patients' ability to choose a provider is exceedingly limited. The No Surprises Act is the legislative culmination to address "surprise bills," with the aim of promoting price transparency as a solution for billing irregularities. However, the knowledge and perceptions of patients regarding emergency care price transparency, particularly the degree to which ED patients are cost conscious is unknown. Accordingly, we sought to quantify that perception by measuring patients' direct predictions for the cost of their care. ⋯ This study is the first to our knowledge that sought to quantify how patients perceive the cost of acute, unscheduled care in the ED. We found that ED patients generally do not consider the price before going to the ED, and subsequently overestimate the negotiated total costs of acute, unscheduled emergency care as well as their out-of-pocket responsibility for care. Certain demographics are less predictive of this association. Notably, patients with Medicare/Medicaid and those with high school education or below were of the furthest off in predicting the actual cost of care. This lends credence to the established trend of patients' limited knowledge of the total cost of healthcare; moreover, that they overestimate the cost of their care could serve as a barrier to accessing that care particularly in more vulnerable groups. We hope that this finding adds useful information to policymakers in sculpting future legislation around surprise billing.
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Observational Study
Transient synovitis of the hip: Current practice and risk of misdiagnosis.
Transient synovitis (TS) is a common and benign cause of hip pain in children, but must be distinguished from more serious entities such as septic arthritis, osteomyelitis, and pyomyositis. Our objectives were to determine the risk of missed bacterial musculoskeletal infection and rates of diagnostic testing in children diagnosed with TS. ⋯ In this large observational study, missed bacterial musculoskeletal infection in children diagnosed with TS was rare but more common in younger children. The optimal combination of bloodwork and radiographic testing, especially ultrasound, to distinguish TS from more serious disease remains unclear.
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Case Reports
Case report of a phencyclidine false positive due to lamotrigine use with confirmatory testing.
Urine toxicology screens are useful in diagnosing patients who present with acute psychosis with a history of substance abuse. Being aware of potential false positive reactants is paramount in diagnostic accuracy. Currently, lamotrigine is not listed among common cross-reactants with phencyclidine (PCP). ⋯ There is little in the medical literature describing cross-reactivity of lamotrigine and PCP on urine drug screens. This can be especially difficult to deduce in a known drug abuser who presents psychotic and non-contributory in their work up.
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Multicenter Study
High sensitivity troponin - Six hours is the magic number.
High sensitivity troponin assays have become widespread for emergency department evaluation of acute chest pain. We assessed if a high sensitivity troponin under the 99th percentile upper reference limit drawn at 6 h or greater from symptom onset could safely rule out acute coronary syndrome in patients who did not meet the rapid rule-out strategy. ⋯ This study assessed patients with chest pain with high sensitivity troponin values between 3 ng/L and the 99th percentile upper reference limit after 6 h of chest pain and found that they have a low rate of clinically relevant adverse cardiac events and NSTEMI.