Faculty Bibliography

BACKGROUND:There have been few investigations examining the benefits, consequences, and patterns of use for prophylactic antibiotics for nasal packing in the emergency department setting. Given the frequency of epistaxis in the emergency department, it is an ideal setting to study the efficacy and utilization patterns of prophylactic antibiotics in nasal packing. OBJECTIVE:Our aim was to assess both rates of utilization and evidence of benefit for prophylactic antibiotics in patients with nasal packing for epistaxis. METHODS:A single-institution retrospective review of 275 cases of anterior nasal packing in an urban emergency department between September 2013 and April 2017 was performed. Chi-square statistical analysis was used to evaluate results. RESULTS:Among 275 cases studied, there were no instances of toxic shock syndrome. Roughly 73% of patients with nonabsorbable packing received prophylactic antibiotics. Only one (1.1%) case of sinusitis was noted among the nonabsorbable packing with prophylaxis group, with no such complication in the nonprophylaxis group. In contrast, 95% of patients with absorbable nasal packing were not given prophylactic antibiotics. Analysis of all cases given prophylactic antibiotics vs. no prophylaxis, regardless of packing type, revealed no statistically significant difference in the development of acute sinusitis (1% vs. 0.56%; p = 0.6793). CONCLUSIONS:There was no observed advantage or disadvantage to using prophylactic antibiotics in anterior nasal packing in the emergency department, regardless of whether patients received absorbable or nonabsorbable packing. However, patients who receive nonabsorbable nasal packing were more likely to receive antibiotic prophylaxis.

BACKGROUND AND PURPOSE/OBJECTIVE:The coronavirus disease-2019 (COVID-19) pandemic caused unprecedented demand and burden on emergency health care services in New York City. We aim to describe our experience providing acute stroke care at a comprehensive stroke center (CSC) and the impact of the pandemic on the quality of care for patients presenting with acute ischemic stroke (AIS). METHODS:We retrospectively analyzed data from a quality improvement registry of consecutive AIS patients at New York University Langone Health's CSC between 06/01/2019-05/15/2020. During the early stages of the pandemic, the acute stroke process was modified to incorporate COVID-19 screening, testing, and other precautionary measures. We compared stroke quality metrics including treatment times and discharge outcomes of AIS patients during the pandemic (03/012020-05/152020) compared with a historical pre-pandemic group (6/1/2019-2/29/2020). RESULTS:A total of 754 patients (pandemic-120; pre-pandemic-634) were admitted with a principal diagnosis of AIS; 198 (26.3%) received alteplase and/or mechanical thrombectomy. Despite longer median door to head CT times (16 vs 12 minutes; p = 0.05) and a trend towards longer door to groin puncture times (79.5 vs. 71 min, p = 0.06), the time to alteplase administration (36 vs 35 min; p = 0.83), door to reperfusion times (103 vs 97 min, p = 0.18) and defect-free care (95.2% vs 94.7%; p = 0.84) were similar in the pandemic and pre-pandemic groups. Successful recanalization rates (TICI≥2b) were also similar (82.6% vs. 86.7%, p = 0.48). After adjusting for stroke severity, age and a prior history of transient ischemic attack/stroke, pandemic patients had increased discharge mortality (adjusted OR 2.90 95% CI 1.77 - 7.17, p = 0.021) CONCLUSION: Despite unprecedented demands on emergency healthcare services, early multidisciplinary efforts to adapt the acute stroke treatment process resulted in keeping the stroke quality time metrics close to pre-pandemic levels. Future studies will be needed with a larger cohort comparing discharge and long-term outcomes between pre-pandemic and pandemic AIS patients.

Background and Objectives: The 2018-2019 measles outbreak saw 1123 cases in the United States, the most since measles was declared eradicated in 2000, with 654 of those cases identified in New York City. Because measles is extremely contagious, it can lead to dangerous complications in immunodeficient populations. As a result, it is important to determine which presenting factors are high risk in order to isolate these patients early, and prevent further exposure Methods: This study examines factors including demographics, signs and symptoms, vital signs, and labs in 112 patients who were tested for measles throughout the NYU Langone Health system. Primary outcomes included positive measles diagnosis by either confirmatory test, while secondary outcomes included admission to hospital or ICU. Chart review data was collected in REDCap. All statistical analysis was done in SPSS Statistics. Independent predictors were measured through a binary logistic regression model Results: Throughout the study time period, 112 patients were tested for measles. Three of these patients were excluded due to a lack of confirmatory test results. In the 84 pediatric patients, either not being immunized to measles or having a fever at the time of presentation were independent predictors of having measles in those who were tested (p<0.05). Of the 31 pediatric patients who had confirmed measles, the presence of conjunctivitis or tachypnea were independent predictors of being admitted to the hospital from the emergency department (p<0.05). Additionally, it was found that physicians ordered only one of two available confirmatory tests for measles detection in 37 patients. There were 11 instances of patients testing positive for one test and negative for the other, leaving the possibility that measles could have been missed in some patients who only received one of these diagnostic studies
Conclusion(s): In pediatric patients, vaccination status and the presence of fever can be used to indicate if a patient is at risk for measles, while the presence of conjunctivitis or tachypnea suggests that the patient may require hospitalization. Additionally, both confirmatory tests should be run in order to prevent underdiagnoses. These findings have the potential to change hospital protocols for suspected measles patients to better detect and isolate potentially infectious emergency department patients

Background: Stroke code activations are a valuable tool in providing prompt care to stroke patients who may be eligible for treatments such as tPA and endovascular interventions. However, stroke codes involve the immediate attention of many members of the healthcare team and significant hospital resources. The National Institutes of Health Stroke Scale (NIHSS) is commonly used to evaluate stroke severity; however, even patients with an NIHSS score of zero can have ongoing neurologic symptoms and disability. Confusion over the goals of stroke codes and the appropriate situations for their use may contribute to unnecessary activations.
Objective(s): The purpose of this analysis was to evaluate the frequency of stroke code activations in situations where activating a stroke code provides little potential benefit in terms of therapeutic options over a non-emergent neurology consult.
Method(s): We reviewed the records for all emergency department (ED) stroke code activations over the first five months of 2018, looking specifically at cases with an NIHSS score of zero. Within this pool, we identified cases where the patient was documented as being asymptomatic during initial ED evaluation as their symptoms had resolved (transient ischemic attack), as well as those who had been symptomatic for over 24 hours and were outside the therapeutic window. These patients were not eligible for emergent therapeutic intervention. Thus, these were cases in which a stroke code activation was avoidable.
Result(s): Of the 120 stroke codes with an NIHSS of zero, 39 (32.5%) involved patients whose symptoms had completely resolved prior to arrival. Another three cases involved patients who had been symptomatic for over 24 hours and were outside the therapeutic window. Thus, of the stroke code activations with an NIHSS of zero in this time period, 42 (35%) were avoidable as these patients would not have been considered candidates for emergent treatment.
Conclusion(s): Clarification and reinforcement of appropriate criteria for stroke code activation have the potential to reduce overutilization of resources in situations unlikely to affect acute therapeutic management. Addressing this would allow for a reduction in the burden on healthcare professionals and ED resources

Background: The diagnosis of spinal cord compression is often delayed. Classic presentations are frequently variable or absent, leading to a lower clinician index of suspicion. Many patients with compressive lesions do not have the classic signs of rectal or urinary sphincter dysfunction or saddle anesthesia. Signs and symptoms may also evolve over course of an emergency department (ED) encounter. To facilitate rapid diagnosis and treatment of this high morbidity condition, a spinal emergency protocol was developed as part of a quality assurance endeavor.
Method(s): A multi-disciplinary group including emergency medicine, neurology, neurosurgery, and radiology created and implemented a protocol for use in patients presenting to the ED with concern for spinal cord compression. The protocol outlines specific trigger conditions, imaging choices, management strategies, and accountabilities for each involved specialty. All patients presenting to ED who received any spinal MRI from September 2016 to November 2018 were analyzed through chart review to determine whether the spinal emergency protocol was used. Time from MRI order to study start and time from MRI order to MRI read were analyzed for each of these groups. The two sample Wilcoxon test (Mann-Whitney test) was used to evaluate statistical significance.
Result(s): During this time period, 54 patients were evaluated for spinal compressive disease not using the spinal emergency protocol and 24 patients were evaluated using the protocol. The median time from MRI order to initiation of study in patients not on the protocol was 2.75 hours (IQR 1.37-4.37 hours) and for patients on the protocol the median time was 1.58 hours (IQR 1.13-1.97 hours) p value less than 0.01. The median time from MRI order to radiology read for patients not on the protocol was 5.30 hours (IQR 3.59-6.23 hours) and for patients on the protocol was 3.85 hours (IQR 2.72-4.28 hours) p value less than 0.01.
Conclusion(s): The introduction of a spinal emergency protocol led to a significant reduction in the time to the initiation and completion of definitive imaging in this high risk population. While this analysis was conducted at a single site, the implementation of similar protocols in other EDs could lead to reduction in time to diagnosis of spinal cord compression

The clinically atypical nevus (CAN) has long been a contentious entity in the dermatologic community, largely owing to its ability to clinically and histologically resemble melanoma. This has led some to assert that CAN are melanoma precursors. While studies have indicated that CAN mark persons at increased risk for melanoma, the lifetime risk of transformation of an individual nevus into a melanoma has been estimated to be far less than 1 in 1,000, with at least half of melanomas suggested to arise de novo rather than within a preexisting nevus. Despite this evidence, differing attitudes toward the biologic significance and malignant potential of CAN have resulted in substantial variation in management among clinicians. We conducted an IRB-approved survey to assess differences in the attitudes and practices among newly trained dermatologists compared with pigmented lesion specialists regarding the management of CAN. We surveyed 295 specialists from the International Dermoscopy Society (IDS) and 139 U.S. dermatology chief residents, with response rates of 57% (n = 168/295) and 59% (n = 82/139), respectively. Sixty-one percent of chief residents believe dermoscopy helps differentiate melanomas from benign lesions, yet only 39% believe they perform fewer biopsies with dermoscopy. Lacking evidence-based guidelines, most chief residents (68%) use <=1-mm margins in the initial biopsy of CAN, which may be suboptimal, while most IDS members (60%) use >=2-mm margins. There were substantial differences between IDS members and chief residents with respect to management of CAN after biopsy. For biopsies in which the margins came back free, 67% of chief residents would reexcise the site depending on the degree of histologic atypia, in contrast to only 11% of IDS members who would reexcise. The results of our survey noted considerable variability in the clinical management of CAN among specialist and novice dermatologists. The use of educational guidelines may assist in narrowing these practice gaps.
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