Hops extracts are used to alleviate menopausal symptoms and as an alternative to hormone replacement therapy, but they can produce potentially harmful drug-drug interactions. The nuclear xenobiotic ...receptor pregnane X receptor (PXR) is promiscuously activated by a range of structurally distinct chemicals. It has a key role in the transcriptional regulation of genes that encode xenobiotic metabolism enzymes. In this study, hops extracts are shown to induce the expression of numerous drug metabolism and excretion proteins. The beta-bitter acid colupulone is demonstrated to be a bioactive component and direct activator of human PXR. The 2.8-A resolution crystal structure of the ligand binding domain of human PXR in complex with colupulone was elucidated, and colupulone was observed to bind in a single orientation stabilized by both van der Waals and hydrogen bonding contacts. The crystal structure also indicates that related alpha- and beta-bitter acids have the capacity to serve as PXR agonists as well. Taken together, these results reveal the structural basis for drug-drug interactions mediated by colupulone and related constituents of hops extracts.
The use of computed tomography (CT) has been scrutinized in emergency medicine, particularly in patients with cancer. Previous studies have characterized the rate of CT use in this population; ...however, limited data are available about the yield of this modality compared with radiography and its clinical decision-making effect.
To determine whether CT imaging of the chest increases identification of clinically significant results compared with chest radiography (CXR) in patients with cancer.
This was a retrospective chart review of patients with a history of solid tumors presenting to an emergency department in 2017. Patients who received both CXR and CT (or CT angiography) of the chest during their assessment were identified and the rate of clinically significant findings on imaging was compared. Clinical findings were further categorized as requiring nonurgent, urgent, or emergent attention. Descriptive statistics and chi-squared testing were performed between the 2 imaging modalities.
From 839 patients meeting inclusion criteria, 287 were randomly sampled. The predominant malignancies were lung (32.4%), breast (13.9%), and head and neck cancer (13.6%). A greater number of patients had clinically significant findings identified on CT imaging (n = 222) compared with CXR (n = 108). Stratification upon urgency of these findings (nonurgent, urgent, or emergent) reveals a significant difference in all strata (p < 0.05).
Compared with CXR, CT imaging of the chest identified significantly more clinically relevant findings requiring attention and consequently affecting clinical decision making.
Study objective
Earlier intervention for opioid use disorder (OUD) may reduce long‐term health implications. Emergency departments (EDs) in the United States treat millions with OUD annually who may ...not seek care elsewhere. Our objectives were (1) to compare two screening measures for OUD characterization in the ED and (2) to determine the proportion of ED patients screening positive for OUD and those who endorse other substance use to guide future screening programs.
Methods
A cross‐sectional study of randomly selected adult patients presenting to three Midwestern US EDs were enrolled, with duplicate patients excluded. Surveys were administered via research assistant and documented on tablet devices. Demographics were self‐reported, and OUD positivity was assessed by the DSM 5 checklist and the WHO ASSIST 3.1. The primary outcome was the concordance between two screening measures for OUD. Our secondary outcome was the proportion of ED patients meeting OUD criteria and endorsed co‐occurring substance use disorder (SUD) criteria.
Results
We enrolled 1305 participants; median age of participants was 46 years (range 18–84), with 639 (49.0%) Non‐Hispanic, White, and 693 (53.1%) female. Current OUD positivity was identified in 17% (222 out of 1305) of the participants via either DSM‐5 (two or more criteria) or ASSIST (score of 4 or greater). We found moderate agreement between the measures (kappa = 0.56; Phi coefficient = 0.57). Of individuals screening positive for OUD, 182 (82%) endorsed criteria for co‐occurring SUD.
Conclusions
OUD is remarkably prevalent in ED populations, with one in six ED patients screening positive. We found a high prevalence of persons identified with OUD and co‐occurring SUD, with moderate agreement between measures. Developing and implementing clinically feasible OUD screening in the ED is essential to enable intervention.
Patients with active cancer account for a growing percentage of all emergency department (ED) visits and have a unique set of risks related to their disease and its treatments. Effective triage for ...this population is fundamental to facilitating their emergency care.
We evaluated the validity of the Emergency Severity Index (ESI; version 4) triage tool to predict ED-relevant outcomes among adult patients with active cancer.
We conducted a prespecified analysis of the observational cohort established by the National Cancer Institute–supported Comprehensive Oncologic Emergencies Research Network’s multicenter (18 sites) study of ED visits by patients with active cancer (N = 1075). We used a series of χ2 tests for independence to relate ESI scores with 1) disposition, 2) ED resource use, 3) hospital length of stay, and 4) 30-day mortality.
Among the 1008 subjects included in this analysis, the ESI distribution skewed heavily toward high acuity (>95% of subjects had an ESI level of 1, 2, or 3). ESI was significantly associated with patient disposition and ED resource use (p values < 0.05). No significant associations were observed between ESI and the non-ED based outcomes of hospital length of stay or 30-day mortality.
ESI scores among ED patients with active cancer indicate higher acuity than the general ED population and are predictive of disposition and ED resource use. These findings show that the ESI is a valid triage tool for use in this population for outcomes directly relevant to ED care.
Objectives
National data reveal that 60% of the 4.5 million annual emergency department (ED) visits by patients with cancer result in admission. Many of these visits are due to a febrile illness. ...Current literature provides limited guidance on how to treat non‐neutropenic febrile ED patients. This study characterizes clinical outcomes of non‐neutropenic febrile patients with cancer presenting to an academic, Comprehensive Cancer Center affiliated ED.
Methods
Retrospective chart review of 101 randomly selected adult patients with active cancer presenting with a chief complaint of fever or a documented fever in the ED and an absolute neutrophil count above 1000 between October 2015 and September 2016. Descriptive statistics were calculated.
Results
The primary malignancies represented were hematologic (24%), gastrointestinal (13%), head and neck (13%), and genitourinary (8%). Sixty‐two percent were on chemotherapy, 15% on radiation therapy, and 12% were on targeted therapy. Severe illness outcomes occurred in 39% and 83% were admitted with a median length of stay of 4 days. Among admitted patients, 24% experienced a length of stay ≤2 days. A return visit to the ED or an in‐system hospitalization within 7 days of the index visit occurred in 10% and death occurred within 7 days of the index visit in 4%.
Conclusion
A majority of patients presenting to the ED with non‐neutropenic fever are admitted (83%), of whom nearly a quarter experience a length of stay of ≤2 days with infrequent serious illness outcomes. Future efforts should focus on the development of risk stratification tools in this population to avoid potentially unnecessary hospitalizations.
Objectives
To describe statewide emergency medical service (EMS) protocols relating to identification, management, and reporting of elder abuse in the prehospital setting.
Design
Cross‐sectional ...analysis.
Setting
Statewide EMS protocols in the United States.
Participants
Publicly available statewide EMS protocols identified from published literature, http://EMSprotocols.org, and each state's public health website.
Measurements
Protocols were reviewed to determine whether elder abuse was mentioned, elder abuse was defined, potential indicators of elder abuse were listed, management of older adults experiencing abuse was described, and instructions regarding reporting were provided. EMS protocols for child abuse were reviewed in the same manner for the purpose of comparison.
Results
Of the 35 publicly available statewide EMS protocols, only 14 (40.0%) mention elder abuse. Of protocols that mention elder abuse, 6 (42.9%) define elder abuse, 10 (71.4%) describe indicators of elder abuse, 8 (57.1%) provide instruction regarding management, and 12 (85.7%) provide instruction regarding reporting. Almost twice as many states met each of these metrics for child abuse.
Conclusion
Statewide EMS protocols for elder abuse vary in regard to identification, management, and reporting, with the majority of states having no content on this subject. Expansion and standardization of protocols may increase the identification of elder abuse.
Objective
The core content of emergency medicine (EM) residency training includes the management of oncologic emergencies; however, documented knowledge gaps continue to exist in this subtopic. This ...study represents a targeted needs assessment as indicated by Step 2 of Kern's curriculum design to determine the specific training gaps to be addressed within the oncologic EM curriculum.
Methods
A multi‐institutional cross‐sectional survey of oncologists (surgical and medical) and emergency physicians (attendings and residents) was conducted during 2023 at five institutions. The voluntary survey consisted of general and specialty‐specific questions exploring gaps in oncologic emergency–specific training/education topics. Descriptive statistics reported responses as frequencies and percentages.
Results
Of the 833 surveys sent across the five sites, 302 (36.3%) were accessed by link; of these, 271 (89.7%) surveys were completed. There were no differences in the responses between early and later respondents and no differences in the characteristics of respondents between sites. A vast majority of the oncologist and EM groups (91.2% and 83.0%, respectively) reported a belief that emergency physicians would benefit from additional oncologic emergency training. Our survey identified 16 important topics for inclusion in an oncologic EM curriculum, including five topics not present on the 2022 Model of Clinical Practice of Emergency Medicine.
Conclusions
Based on this needs assessment, an oncologic EM curriculum should include the topics listed under oncologic emergencies in the 2022 Model of the Clinical Practice of Emergency Medicine along with our respondent‐identified topics of radiation therapy adverse effects, stem cell transplant complications, and the management of cancer‐specific postsurgical complications, pain, and common diseases in patients with cancer.
Around one million United States emergency department (ED) visits annually are due to acute decompensated heart failure (ADHF) symptoms. Characterizing ED symptom presentation of ADHF patients may ...improve clinical care, yet sex and age differences in ED chief complaints have not been thoroughly investigated. This paper aims to describe differences in chief complaints and comorbid conditions for ED patients with a ADHF diagnosis, stratified by sex and age.
Retrospective analysis of adults presenting to North Carolina EDs in NC DETECT, a statewide syndromic surveillance system, between 2010 and 2016 with a diagnosis of ADHF. Frequencies of chief complaint categories for ED visits and comorbid conditions, stratified by sex and age, were evaluated and standardized differences computed.
Top chief complaints were dyspnea (19.1%), chest pain (13.5%), and other respiratory complaints (13.4%). In the 18-44 age group, females when compared to males reported more nausea/vomiting (6.7% versus 4.1%) and headache (4.2% versus 2.0%). In those 45-64 and 65+ years old, complaints were similar by sex. When stratified by age group alone, the 18-44 and 45-64 age groups had more complaints of chest pain, whereas balance issues, weakness, and confusion were more common in the 65+ age group.
Sex and age differences in atypical ADHF symptoms were seen in in ED patients with ADHF. Characterizing variation of ADHF symptoms in ED patients can inform the identification of ED patients with ADHF and the management of ADHF-related symptoms.
Patients with simultanagnosia, which is a component of Bálint syndrome, have a restricted spatial window of visual attention and cannot see more than one object at a time. As a result, these patients ...see the world in a piecemeal fashion, seeing the local components of objects or scenes at the expense of the global picture. To directly test the relationship between the restriction of the attentional window in simultanagnosia and patients' difficulty with global-level processing, we used a gaze-contingent display to create a literal restriction of vision for healthy participants while they performed a global/local identification task. Participants in this viewing condition were instructed to identify the global and local aspects of hierarchical letter stimuli of different sizes and densities. They performed well at the local identification task, and their patterns of inaccuracies for the global level task were highly similar to the pattern of inaccuracies typically seen with simultanagnosic patients. This suggests that a restricted spatial area of visual processing, combined with normal limits to visual processing, can lead to difficulties with global-level perception.
Abstract Simultanagnosia is a disorder of visual attention, defined as an inability to see more than one object at once. It has been conceived as being due to a constriction of the visual “window” of ...attention, a metaphor that we examine in the present article. A simultanagnosic patient (SL) and two non-simultanagnosic control patients (KC and ES) described social scenes while their eye movements were monitored. These data were compared to a group of healthy subjects who described the same scenes under the same conditions as the patients, or through an aperture that restricted their vision to a small portion of the scene. Experiment 1 demonstrated that SL showed unusually low proportions of fixations to the eyes in social scenes, which contrasted with all other participants who demonstrated the standard preferential bias toward eyes. Experiments 2 and 3 revealed that when healthy participants viewed scenes through a window that was contingent on where they looked (Experiment 2) or where they moved a computer mouse (Experiment 3), their behavior closely mirrored that of patient SL. These findings suggest that a constricted window of visual processing has important consequences for how simultanagnosic patients explore their world. Our paradigm's capacity to mimic simultanagnosic behaviors while viewing complex scenes implies that it may be a valid way of modeling simultanagnosia in healthy individuals, providing a useful tool for future research. More broadly, our results support the thesis that people fixate the eyes in social scenes because they are informative to the meaning of the scene.
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