Table of Content

15 June 2016, Volume 7 Issue 2

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Review Article

Circulating microRNAs as potential biomarkers for diagnosis of congenital heart defects

Wan-qin Xie, Lin Zhou, Yong Chen, Bin Ni

2016, 7(2):  85-89.  doi:10.5847/wjem.j.1920-8642.2016.02.001

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BACKGROUND: MicroRNAs are small non-coding RNAs of approximately 22 nucleotides in length, and play important regulatory roles in normal heart development and the pathogenesis of heart diseases. Recently, a few prospective studies have implicated the diagnostic role of microRNAs in congenital heart defects (CHD).
DATA RESOURCES: This review retrieved the research articles in PubMed focusing on the altered microRNAs in cardiac tissue or serum of patients with CHD versus healthy normal controls, as well as the studies exploring circulating microRNAs as potential biomarkers for (fetal) CHD.
RESULTS: Most of the studies of interest were conducted in recent years, implicating that the topic in this review is a newly emerging field and is drawing much attention. Moreover, a number of differentially expressed microRNAs between CHD specimens and normal controls have been reported.
CONCLUSION: Circulating microRNAs may serve as potential biomarkers for diagnosis of CHD in the future, with more efforts paving the road to the aim.

Original Articles

German critical incident reporting system database of prehospital emergency medicine: Analysis of reported communication and medication errors between 2005-2015

Christian Hohenstein, Thomas Fleischmann, Peter Rupp, Dorothea Hempel, Sophia Wilk, Johannes Winning

2016, 7(2):  90-96.  doi:10.5847/wjem.j.1920-8642.2016.02.002

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BACKGROUND: Communication failure in prehospital emergency medicine can affect patient safety as it does in other areas of medicine as well. We analyzed the database of the critical incident reporting system for prehospital emergency medicine in Germany retrospectively regarding communication errors.
METHODS: Experts of prehospital emergency medicine and risk management screened the database for verbal communication failure, non-verbal communication failure and missing communication at all.
RESULTS: Between 2005 and 2015, 845 reports were analyzed, of which 247 reports were considered to be related to communication failure. An arbitrary classification resulted in six different kinds: 1) no acknowledgement of a suggestion; 2) medication error; 3) miscommunication with dispatcher; 4) utterance heard/understood improperly; 5) missing information transfer between two persons; and 6) other communication failure.
CONCLUSION: Communication deficits can lead to critical incidents in prehospital emergency medicine and are a very important aspect in patient safety.

Risk assessment of the emergency processes: Healthcare failure mode and effect analysis

Yasamin Molavi Taleghani, Fatemeh Rezaei, Hojat Sheikhbardsiri

2016, 7(2):  97-105.  doi:10.5847/wjem.j.1920-8642.2016.02.003

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BACKGROUND: Ensuring about the patient's safety is the first vital step in improving the quality of care and the emergency ward is known as a high-risk area in treatment health care. The present study was conducted to evaluate the selected risk processes of emergency surgery department of a treatment-educational Qaem center in Mashhad by using analysis method of the conditions and failure effects in health care.
METHODS: In this study, in combination (qualitative action research and quantitative cross-sectional), failure modes and effects of 5 high-risk procedures of the emergency surgery department were identified and analyzed according to Healthcare Failure Mode and Effects Analysis (HFMEA). To classify the failure modes from the "nursing errors in clinical management model (NECM)", the classification of the effective causes of error from "Eindhoven model" and determination of the strategies to improve from the "theory of solving problem by an inventive method" were used. To analyze the quantitative data of descriptive statistics (total points) and to analyze the qualitative data, content analysis and agreement of comments of the members were used.
RESULTS: In 5 selected processes by "voting method using rating", 23 steps, 61 sub-processes and 217 potential failure modes were identified by HFMEA. 25 (11.5%) failure modes as the high risk errors were detected and transferred to the decision tree. The most and the least failure modes were placed in the categories of care errors (54.7%) and knowledge and skill (9.5%), respectively. Also, 29.4% of preventive measures were in the category of human resource management strategy.
CONCLUSION: "Revision and re-engineering of processes", "continuous monitoring of the works", "preparation and revision of operating procedures and policies", "developing the criteria for evaluating the performance of the personnel", "designing a suitable educational content for needs of employee", "training patients", "reducing the workload and power shortage", "improving team communication" and "preventive management of equipment's" were on the agenda as the guidelines.

Emergency medicine providers' opioid prescribing practices stratified by gender, age, and years in practice

Shawn M. Varney, Vikhyat S. Bebarta, Lisa M. Mannina, Rosemarie G. Ramos, Victoria J. Ganem, Katherine R. Carey

2016, 7(2):  106-110.  doi:10.5847/wjem.j.1920-8642.2016.02.004

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BACKGROUND: Emergency medicine providers (EMPs) prescribe about 25% of opioids, but the effect of EMP risk perception on decisions to prescribe opioids is unknown. This study was undertaken to identify factors that influence EMP risk and opioid prescribing practices.
METHODS: We distributed an anonymous questionnaire to EMPs at a military trauma and referral center. Response frequencies and distributions were assessed for independence using the Chi-square test.
RESULTS: Eighty-nine EMPs completed the questionnaire (100% response). Respondents were primarily younger male physicians (80%) in practice under five years (55%). Male EMPs were more likely to prescribe more opioid tablets than female ones both when and when not concerned for opioid misuse (P<0.001, P<0.007, respectively). Of the providers, 70% stated that patient age would influence their prescribing decisions. Hydrocodone and oxycodone were the opioids prescribed most frequently. About 60% of the providers reported changing their prescribing behavior would not prevent opioid misuse. Additionally, 40% of the providers believed at least 10% of patients seen at this military ED misused opioids.
CONCLUSION: Female EM providers reported prescribing fewer opioid tablets. Patient age influenced prescribing behavior, but the effect is unknown. Finally, EM providers reported that altering their prescribing behavior would not prevent prescription opioid misuse.

Identifying disparity in emergency department length of stay and admission likelihood

Sean Wilson, Sharmistha Dev, Meredith Mahan, Manu Malhotra, Joseph Miller

2016, 7(2):  111-116.  doi:10.5847/wjem.j.1920-8642.2016.02.005

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BACKGROUND: To assess whether insurance status has an effect on emergency department (ED) length of stay (LOS) and likelihood for admission or transfer to an operating room.
METHODS: This was a retrospective cross-sectional study of all encounters from January 2011 through October 2013 at an urban, academic trauma center. Analysis included multi-variable linear regression for ED LOS and logistic regression for the likelihood of admission.
RESULTS: Overall, 201 535 patients met the inclusion criteria, for which the mean age was 43.8 years, 55.9% were female, 23.4% were uninsured and 8% were of non-black race. Admission rate was 24.5% and operative rate was 1.4%. After adjusting for age, sex, triage acuity and race, the presence of insurance coverage was associated with an increased ED LOS of 575 (95%CI 552-598) vs. 567 (95%CI 543-591) minutes (P<0.01) among admitted patients and a decreased ED LOS of 456 (95%CI 381-531) vs. 499 (95%CI 423-575) minutes (P<0.01) among those transferred to an operating room. Adjusting for these same predictors, insured status remained a predictor for admission (odds ratio 1.24, 95%CI 1.20-1.28, P<0.01) and a negative predictor for transfer to the operating room (odds ratio 0.84, 95%CI 0.77-0.92, P<0.01).
CONCLUSION: The insured experienced a clinically insignificant increase in ED LOS when admitted and a 43-minute decrease in ED LOS when being transferred to the operating room. The insured were more likely to be admitted and less likely to be transferred to an operating room.

Pre-hospital assessment with ultrasound in emergencies: implementation in the field

Kevin P. Rooney, Sari Lahham, Shadi Lahham, Craig L. Anderson, Bryan Bledsoe, Bryan Sloane, Linda Joseph, Megan B. Osborn, John C. Fox

2016, 7(2):  117-123.  doi:10.5847/wjem.j.1920-8642.2016.02.006

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BACKGROUND: Point-of-care ultrasound (US) is a proven diagnostic imaging tool in the emergency department (ED). Modern US devices are now more compact, affordable and portable, which has led to increased usage in austere environments. However, studies supporting the use of US in the prehospital setting are limited. The primary outcome of this pilot study was to determine if paramedics could perform cardiac ultrasound in the field and obtain images that were adequate for interpretation. A secondary outcome was whether paramedics could correctly identify cardiac activity or the lack thereof in cardiac arrest patients.
METHODS: We performed a prospective educational study using a convenience sample of professional paramedics without ultrasound experience. Eligible paramedics participated in a 3-hour session on point-of-care US. The paramedics then used US during emergency calls and saved the scans for possible cardiac complaints including: chest pain, dyspnea, loss of consciousness, trauma, or cardiac arrest.
RESULTS: Four paramedics from two distinct fire stations enrolled a total of 19 unique patients, of whom 17 were deemed adequate for clinical decision making (89%, 95%CI 67%-99%). Paramedics accurately recorded 17 cases of cardiac activity (100%, 95%CI 84%-100%) and 2 cases of cardiac standstill (100%, 95%CI 22%-100%).
CONCLUSION: Our pilot study suggests that with minimal training, paramedics can use US to obtain cardiac images that are adequate for interpretation and diagnose cardiac standstill. Further large-scale clinical trials are needed to determine if prehospital US can be used to guide care for patients with cardiac complaints.

Application of scoring systems with point-of-care ultrasonography for bedside diagnosis of appendicitis

Erden Erol Ünlüer, Rıfat Urnal, Utku Eser, Serkan Bilgin, Mehmet Hacıyanlı, Orhan Oyar, Haldun Akoğlu, Arif Karagöz

2016, 7(2):  124-129.  doi:10.5847/wjem.j.1920-8642.2016.02.007

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BACKGROUND: Appendicitis is a common disease requiring surgery. Bedside ultrasound (BUS) is a core technique for emergency medicine (EM). The Alvarado score is a well-studied diagnostic tool for appendicitis. This study aimed to investigate the relationship between patients' symptoms, Alvarado score and ultrasound (US) findings, as performed by emergency physicians (EPs) and radiologists, of patients with suspected appendicitis.
METHODS: Three EM specialists underwent the BUS course and core course for appendicitis assessment. Patients suspected of having appendicitis were selected and their Alvarado and modified (m) Alvarado scores calculated. The specialists performed the BUS. Then, patients were given a formal US and surgery consultation if necessary. Preliminary diagnoses, admission or discharge from the emergency department (ED) and final diagnosis were documented. The patients were also followed up after discharge from the hospital.
RESULTS: The determined cut-off value was 2 for Alvarado and 3 for mAlvarado scores. The sensitivities of the two scores were 100%. Each score was used to rule out appendicitis. The results of EP-performed BUS were as follows: accuracy 70%, sensitivity 0.733, specificity 0.673, + LR 2.24, and - LR 0.40 (95%CI). Radiologists were better than EPs at diagnosing appendicitis and radiologists and EPs were equally strong at ruling out appendicitis by US. When US was combined with Alvarado and mAlvarado scores, EP US+Alvarado/mAlvarado scores ≤3 and radiology US+Alvarado/mAlvarado scores ≤4 perfectly ruled out appendicitis.
CONCLUSION: BUS performed by EPs is moderately useful in detecting appendicitis. Combined with scoring systems, BUS may be a perfect tool for ruling out decisions in EDs.

A scoring system for assessing the severity of acute diarrhea of adult patients

Hong-li Xiao, Su-xia Ma, Hai-yu Qi, Xiaoli Li, Yan Wang, Cheng-hong Yin

2016, 7(2):  130-134.  doi:10.5847/wjem.j.1920-8642.2016.02.008

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BACKGROUND: Diarrhea is frequently seen in developed and developing countries, and severe diarrhea is characterized by the high risk of death. Thus, it is very important to assess the severity of diarrhea early. We conducted a multi-center study to identify risk factors for the severity of diarrhea in adult patients and formulate an adult diarrhea state score (ADSS) for out-patient clinicians.
METHODS: A total of 219 adult patients with acute diarrhea were divided into two groups: 132 patients with mild diarrhea and 87 with severe diarrhea. Logistic regression was used to determine risk factors for the severity of diarrhea. The risk factors were assessed and an ADSS was formulated. Receiver operating characteristic (ROC) analysis was made to evaluate the diagnostic accuracy of ADSS, and the Kappa test was used to confirm the diagnostic reliability.
RESULTS: Five risk factors for evaluating the severity of diarrhea in adults included age (P<0.05), axillary temperature (P<0.01), mean arterial pressure (P<0.01), white blood cell count (WBC; P<0.01), and WBC in stool (P<0.01). The area under the ROC curve for ADSS was 0.958 when the cut off value was 4 (a sensitivity of 0.909; a specificity of 0.874), and the Kappa value was 0.781 (P<0.05).
CONCLUSION: The risk factors associated with the pathogenic condition of diarrhea were identified, quantified and formulated into an ADSS, which has high diagnostic accuracy and reliability for the early identification of patients with severe acute diarrhea.

Evaluation of preventable trauma death in emergency department of Imam Reza hospital

Changiz Gholipour, Bahram Samadi Rad, Samad Shams Vahdati, Amir Ghaffarzad, Armita Masoud

2016, 7(2):  135-137.  doi:10.5847/wjem.j.1920-8642.2016.02.009

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BACKGROUND: Trauma is considered as a worldwide problem despite socio-economic development. Motor vehicle accidents (MVAs) are the most important cause of trauma. Trauma related deaths are mostly preventable. This study aimed to investigate the causes and prevention of death in trauma patients.
METHODS: This retrospective, descriptive-analytic study assessed 100 trauma patients referred to our emergency department (ED) from January 2013 to Januanry 2015. The included patients were those with trauma died after arrival at our ED. Age, sex, cause of trauma, clinical causes of death, causes of death defined by autopsy, way of transfer to the ED, time of ambulance arrival at the scene of trauma, and time elapsed to enter the ED from the scene of trauma were studied.
RESULTS: In the 100 patients, 21 (21%) patients were female and 79 (79%) male. Forty-three patients were older than 60 years. Trauma was largely due to pedestrian accidents in 31% of the patients, and 33% had a hypo-volemic shock. About 80% of deaths were due to intra-cranial hemorrhage (ICH) or intra-ventricular hemorrhage (IVH), and spinal injuries were not preventable. Autopsy revealed that 28% of the patients suffered from internal injuries. Autopsy revealed that 19% of the deaths were not preventable and 81% were considered preventable. In our patients, 76 were transferred to the hospital by emergency medicine services (EMS). Analysis of time for ambulance arrival to the scene and frequency of death revealed that 52.2% of the deaths occurred between 11 and 15 minutes. Analysis of time for admission to the ED from the scene of trauma showed that 74.6% deaths occurred between 6 and 10 minutes.
CONCLUSIONS: The rate of hospital preventable deaths is about 80%, a high mortality rate, which denotes a lack of proper diagnosis and treatment. The time for arrival of EMS at the scene of trauma is longer than that in other countries.

Characterization of available automated external defibrillators in the market based on the product manuals in 2014

Chik Leung Ho, Ka Wai Cheng, Tze Hang Ma, Yau Hang Wong, Ka Lok Cheng, Chak Wah Kam

2016, 7(2):  138-146.  doi:10.5847/wjem.j.1920-8642.2016.02.010

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BACKGROUND: To popularize the wide-spread use of automated external defibrillator (AED) to save life in sudden cardiac arrest, we compared the strength and weakness of different types of AEDs to enable a sound selection based on regional requirement.
METHODS: This was a retrospective descriptive study. Different types of AEDs were compared according to the information of AEDs from manuals and brochures provided by the manufacturers. Fifteen types of AEDs were divided into 3 groups, basic, intermediate and advanced.
RESULTS: Lifeline™ AUTO AED had the best performance in price, portability and user-friendly among AEDs of basic level. It required less time for shock charging. Samaritan PAD defibrillator was superior in price, portability, durability and characteristic among AEDs of intermediate level. It had the longest warranty and highest protection against water and dust. Lifeline™ PRO AED had the best performance in most of the criteria among AEDs of advanced level and offered CPR video and manual mode for laypersons and clinicians respectively.
CONCLUSION: Lifeline™ AUTO AED, Samaritan PAD defibrillator, Lifeline™ PRO AED are superior in AEDs of basic, intermediate and advanced levels, respectively. A feasible AED may be chosen by users according to the regional requirement and the current information about the best available products.

Maternal and fetal outcomes in term premature rupture of membrane

Tigist Endale, Netsanet Fentahun, Desta Gemada, Mamusha Aman Hussen

2016, 7(2):  147-152.  doi:10.5847/wjem.j.1920-8642.2016.02.011

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BACKGROUND: Premature rupture of membrane (PROM) is linked to significant maternal prenatal mortalities and morbidity. In Ethiopia, where maternal mortality is still high, the maternal and fetal outcomes in PROM is very important to decrease maternal and child mortality and for better management and prevention of complications. Thus, this study aimed to detect the maternal and fetal outcomes and associated factors in term PROM at Mizan-Aman General Hospital, south-west Ethiopia.
METHODS: A retrospective cross sectional study was conducted using data available at Mizan-Aman General Hospital during a period of 3 years (January 2011 to December 2013). We examined records of 4 525 women who gave birth in the hospital; out of these women, 185 were diagnosed with term PROM and all of them were included in the study. The data of these women were collected using a checklist based on registration books. The data were analyzed using SPSS version 20.0 statistical package. The association between independent and dependent variables was assessed by bivariate and multiple logistic regression analyses. 95%CI and P value less than 0.05 were considered statistically significant.
RESULTS: Of the 4 525 women who gave birth in the hospital, 202 were complicated by term PROM. About 22.2% of the women showed unfavorable maternal outcomes. The most common cause of maternal morbidity and mortality was puerperal sepsis. About 33.5% of neonates experienced unfavorable outcomes. The duration of PROM >12 hours (AOR=5.6, 95%CI 1.3-24.1) latency >24 hours (AOR=2.8, 95%CI 1.7-11.8), residing in rural areas (AOR=4.2, 95%CI 3.96-29.4) and birth weight less than 2 500 g were associated with unfavorable outcomes.
CONCLUSION: Women residing in rural areas, long latency, and neonates with birth weight less 2 500 g may have unfavorable outcomes. Therefore, optimum obstetric and medical care is essential for the reduction of the devastating complications related to disorders.

Clinical Image

An incidental case of Wellens' syndrome in a community emergency department

Deep Jaiswal, Dan Boudreau

2016, 7(2):  153-156.  doi:10.5847/wjem.j.1920-8642.2016.02.012

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