Elisa Sarmiento

Background: Histoplasmosis, caused by Histoplasma capsulatum, presents with a broad clinical spectrum from asymptomatic infection to disseminated disease (DH). Diagnostic modalities, culture, histopathology, antigen detection, and serologic testing, vary in performance. We evaluated their sensitivity and specificity across clinical presentations and immune statuses. Methods: We conducted a retrospective diagnostic study of adults evaluated at Indiana University Health Medical Center who had serum and/or urine submitted for Histoplasma antigen testing to Miravista Diagnostics. Clinical classification (proven, probable) was based on laboratory, imaging, and clinical data according to EORTC/MSG criteria. Controls were patients tested for histoplasmosis but found to have an alternative diagnosis. Diagnostic methods included antigen enzyme immunoassay (EIA), antibody EIA (IgG/IgM), immunodiffusion (ID), complement fixation (CF), and fungal cultures. Results: Among 205 patients, 125 were classified as histoplasmosis (54 proven, 71 probable) and 80 as controls. Antigen EIA in serum and/or urine had sensitivity 121/124 (97.6%) and specificity 75/80 (93.7%). IgG/IgM antibody EIA detected 89/111 (80.2%) cases with specificity 73/79 (92.4%) at a 20 EU/mL cutoff. Combining antigen and antibody testing increased sensitivity to 109/110 (99.1%). Among 75 patients with both serum and urine antigen tested, combined testing added 3/75 (4%) cases beyond urine alone. Antibody sensitivity declined in immunocompromised patients (75.0% vs 93.3% in immunocompetent, P = .0134), while antigen sensitivity remained high across groups. Conclusions: Histoplasma antigen testing is the most sensitive diagnostic method. Antibody testing complements antigen in selected populations, particularly immunocompetent patients with pulmonary disease. Culture remains a complementary but less sensitive tool.

Background: Men are at higher risk for metabolic dysfunction-associated steatotic liver disease (MASLD) with clinically significant fibrosis (CSF) than premenopausal women, but data are lacking in persons with HIV (PWH). The aim of this study was to discover prevalence and severity of MASLD in PWH by sex assigned at birth and menopausal status. Methods: We examined participants from the prospective, cross-sectional HIV NASH CRN who had suppressed HIV-1 RNA, self-reported sex assigned at birth and menopause status, and underwent transient elastography (TE). The primary outcome was MASLD (controlled attenuation parameter [CAP] ≥ 263 dB/m, ≥1 cardiometabolic risk factor, Alcohol Use Disorders Identification Test score <8) with CSF (MASLD-CSF, TE Liver Stiffness Measurement ≥ 8 kPa). Results: Nine hundred and sixty-four PWH were included: 709 men (73.5%) and 255 women (26.5%) with similar median ages (55.1 and 56.6 years, P-value = .08). The most common race was Black (52%). Women had lower prevalence of MASLD-CSF than men (5.5% vs 10.6%, P = .02). In a multivariable logistic regression model for MASLD-CSF, diabetes (OR 3.26 [95% confidence interval 2.01–5.30], P < .0001), hyperlipidemia (1.97 [1.14–3.39], P = .02), and waist circumference (WC) above sex-specific cutoff (women: 80 cm, men: 94 cm) (4.59 [2.12–9.93], P < .0001) were associated with higher odds of MASLD-CSF, while female sex was associated with lower odds (0.43 [0.23–0.81], P = .01). Variables and effect sizes associated with MASLD-CSF differed among sex/menopause subgroups. Conclusions: Female sex was protective against MASLD-CSF in PWH. Men with diabetes, hyperlipidemia, and high WC would be candidates for MASLD screening. Further studies of PWH with women, especially more young women, are needed.

Purpose: It is important for emergency physicians to be able to evaluate and manage pediatric respiratory distress, which is rare in general emergency departments. Despite this importance, the emergency departments show inconsistency in pediatric readiness, while emergency medicine (EM) residents express discomfort in caring for critically ill children due to limited exposure during their residency training. The purpose of this study was to meet this educational need by developing and implementing a curriculum to prepare EM residents to provide safe care for pediatric respiratory distress.Methods: We prospectively assessed 20 senior EM residents after undergoing a 3-hour simulation-based curriculum at Indiana University School of Medicine. The curriculum was developed using the Kern’s methodology by content experts. Pre- and post-curriculum confidence, knowledge, competency, and situational awareness were assessed using the 5-point Likert scale, multiple-choice questions, checklists of a pediatric acute respiratory distress scenario, and a novel modified video version of the situational awareness global assessment technique, respectively.Results: From the pre- to post-intervention phases, the confidence improved from 3.2 ± 0.4 to 3.9 ± 0.2 on the Likert scale (P < 0.001). The knowledge improved from 50.3% ± 12.9% to 75.3% ± 10.6% on the multiple-choice questions (P < 0.001). The competency improved from 46.8% ± 16.0% to 73.6% ± 10.6% (P < 0.001) with significant improvements in 7 of the 14 checklist items. The situational awareness raised both data perception (P < 0.001) and comprehension (P = 0.004) with no significant improvements in data extrapolation (P = 0.120).Conclusion: Preliminary findings suggest that a 3-hour simulation-based curriculum for EM residents, including implementation of a novel situational awareness assessment tool, can improve learner’s confidence, knowledge, competency, and situational awareness of pediatric respiratory distress.

Anywhere from 11.6% to 20% of pediatric and adolescent patients treated for chronic pain are prescribed opioids, but little is known about these patients. The purpose of this study was to determine the characteristics of patients on chronic opioid therapy (COT) and what therapies had been utilized prior to or in conjunction with COT. The study was a retrospective chart review of all chronic pain patients seen during 2020 with those patients on COT separated for analysis. A total of 346 unique patients were seen of which 257 were female (74.3%). The average age was 15.5 years. A total of 48 patients (13.9%) were identified as being on COT with an average age of 18.1 years. Of these, 23 (47.9%) were male which was significantly more than expected. The most common reason for patients to be receiving COT was palliative (13/48), and the second most common was sickle cell anemia (10/48). Patients on COT were significantly more likely to be male, be older, and to be concurrently prescribed benzodiazepines. Concurrent opioid and benzodiazepine therapy is a risk factor for respiratory depression and overdose. Further investigation into the increased proportion of males and benzodiazepine usage in patients on COT is warranted.

Objectives: Widespread Haemophilus influenzae and Streptococcus pneumoniae immunization has decreased occult bacteremia and bacterial meningitis rates. Practice has evolved in pediatric emergency departments (PEDs) to favor fewer diagnostic tests for and empiric treatment of invasive bacterial infection. We lack evidence-based guidance on evaluation and treatment of unimmunized (UnI) or underimmunized (UnderI) febrile children. This study aims to determine how parental report of immunization status in febrile PED patients impacts rates of diagnostic testing, interventions, and hospital admissions. Methods: This is a retrospective cohort study with chart review of encounters of children aged 3 to 36 months presenting to an academic, tertiary care PED in 2019 using International Classification of Diseases-10 code for fever (R50.9). Inclusion criteria were documented fever of 38°C and higher and well appearance. Encounters were excluded if there was a history of chronic illness or documentation of ill appearance or hemodynamic instability. Encounters were grouped by provider-documented immunization status. Fischer exact test and logistic regression compared rates of diagnostic testing (serum, urine or cerebrospinal fluid laboratory studies, and chest radiographs), interventions (intravenous fluid bolus, intravenous antibiotic or steroid administration, respiratory support, or breathing treatment), and hospital admissions between UnderI, UnI, and fully immunized (FI) groups. Results: Of the 1813 encounters reviewed, 1093 (60%) included provider-documented immunization status and 788 (43%) met final inclusion criteria: 23 (2.1%) UnI, 44 (5.8%) UnderI, and 721 (92.1%) FI. The UnderI and UnI children experienced significantly higher rates of laboratory evaluation including complete blood count and blood culture, medical intervention, and antibiotic prescriptions while in the PED. No significant differences were observed for rates of chest radiographs, hospital admissions, or 72-hour PED return visits. Conclusions: Higher rates of laboratory testing and interventions were observed in UnderI and UnI versus FI febrile patients at a PED, likely demonstrating increased clinical suspicion for invasive bacterial infection in this group despite lacking national guidelines. Given continued vaccine hesitancy, further studies are needed for guiding management of febrile UnI and UnderI children presenting for emergency care.

Background: Pediatric emergency department (ED) visits for superficial skin and soft tissue infections (SSTI) have steadily been increasing and point-of-care ultrasound (POCUS) continues to be an effective modality to improve management and shorter ED length of stays (LOS). Objective: We sought to determine the impact of a soft tissue POCUS curriculum on POCUS utilization, ED LOS, and cost-effectiveness. Methods: This was a retrospective pre- and post-interventional study of pediatric patients aged 0 to 17 years. Patients presenting to ED with international classification of disease 9 or 10 code for abscess or cellulitis were included. Data were collected a year before and after curriculum implementation with a 1-year washout training period. Training included continuing medical education, greater than 25 quality assured examinations, and a post-test. We compared diagnostic imaging type, ED LOS, and mean charges in patients with SSTI. Results: We analyzed data on 119 total patients, 38 pre- and 81 post-intervention. We found a significant increase in the total number of POCUS examinations performed pre- to post-curriculum intervention, 26 vs. 59 ( p = 0.0017). Mean total charges were significantly decreased from $3,762 (± 270) to $2,622 (± 158; p = 0.0009). There was a significant trend towards a decrease in average ED LOS 282 (standard error of mean [SEM] ± 19) vs 185 (± 13) minutes ( p = 0.0001). Conclusions: Implementation of a soft tissue POCUS curriculum in a pediatric ED was associated with increased POCUS use, decreased LOS, and lower cost. These findings highlight the importance of POCUS education and implementation in the management of pediatric SSTI.

Recent studies have shown a higher incidence of complications from acute appendicitis in Hispanic populations. Hispanic ethnicity alone has been shown to be a risk factor. In contrast, one study found little evidence of racial disparities in complication rates. The objective of this study was to identify physician bias regarding whether ethnicity drives further testing after initial radiologic imaging has been obtained in the evaluation of appendicitis in our pediatric emergency department (PED). The use of computed tomography (CT) scan in the diagnosis of appendicitis was compared between Hispanic versus non-Hispanic populations when ultrasound (US) was indeterminate. This is a retrospective cohort study of Hispanic and non-Hispanic patients aged 2-18 who presented to the PED with right lower quadrant abdominal pain over a one-year period (January 1, 2017 to December 29, 2017). Both groups were subdivided into positive, negative, or indeterminate US findings for appendicitis. Each subgroup was analyzed based on those who had CT imaging done. A total of 471 ultrasounds were performed, 162 Hispanic and 309 non-Hispanic patients. Indeterminate US scans were documented in 90/162 (56%) Hispanic versus 155/309 (50%) non-Hispanic patients. Of those with indeterminate US scans, 30% Hispanic versus 32% non-Hispanic patients received CT scans. Negative US scans were documented in 54/162 (33%) Hispanic versus 102/309 (33%) non-Hispanic patients. Of those with negative US scans, 7% Hispanic versus 5% non-Hispanic patients received CT scans. Chi-square analysis comparing both the proportion of CT scans received for indeterminate US scans (p=0.71) and negative US scans (p=0.52) showed no statistical significance. There was no significant difference in the number of CT scans ordered for indeterminate US scans between Hispanic and non-Hispanic patients. One can infer that there is no inherent bias toward ordering advanced imaging in Hispanic children based on ethnicity alone.

A suspected diagnosis of cancer in the emergency department (ED) may be associated with poor outcomes, related to health disparities, however data are limited. This is a retrospective observational cohort of the Indiana State Department of Health Cancer Registry, and the Indiana Network for Patient Care. First time cancer diagnoses appearing in the registry between January 2013 and December 2017 were included. Cases identified as patients who had an ED visit in the 6 months before their cancer diagnosis; controls had no preceding ED visits. The primary outcome was mortality, comparing ED-associated mortality to non-ED-associated. 134,761 first-time cancer patients were identified, including 15,432 (11.5%) cases. The mean age was same at 65, more of the cases were Black than the controls (12.4% vs 7.4%, P < .0001) and more were low income (36.4%. vs 29.3%). The top 3 ED-associated cancer diagnoses were lung (18.4%), breast (8.9%), and colorectal cancers (8.9%), whereas the controls were breast (17%), lung (14.9%), and prostate cancers (10.1%). Cases observed an over three-fold higher mortality, with cumulative death rate of 32.9% for cases vs 9.0% for controls (P < .0001). Regression analysis predicting mortality, controlling for many confounders produced an odds ratio of 4.12 (95% CI 3.72–4.56 for cases). This study found that an ED visit within 6 months prior to the first time of ICD-coded cancer is associated with Black race, low income and an overall three-fold increased adjusted risk of death. The mortality rates for ED-associated cancers are uniformly worse for all cancer types. These data suggest that additional work is needed to reduce disparities among ED-associated cancer diagnoses.

Background Endotracheal intubation is a high-risk procedure. Optimisation of all aspects of the procedure, including patient positioning, is important to facilitate success and minimise complications. The objective of this systematic review was to determine the association between inclined patient positioning and first-pass success and other clinically important outcomes among patients undergoing endotracheal intubation. Methods A search of PubMed, CINAHL, SCOPUS, EMBASE and Cochrane, from inception through October 2020 was conducted. Studies were assessed independently by two authors to determine eligibility for inclusion. Included studies were any randomised or observational study that compared supine to inclined patient positioning for endotracheal intubation and assessed one of our predefined outcomes. Simulation studies were excluded. Study results were meta-analysed using a random effects model. The quality of the evidence for outcomes of interest was assessed using the Grading of Recommendations, Assessment, Development and Evaluations approach. Results A total of 5113 studies were identified, of which 10 studies representing 18 371 intubations were included for meta-analysis. There was no statistically significant difference in the primary outcome of first-pass success rate (relative risk 1.02, 95% CI 0.98 to 1.05) or secondary outcomes of oesophageal intubation, glottic view, hypotension, hypoxaemia, mortality or peri-intubation arrest. Likewise, there were no statistically significant differences in any of the outcomes in predefined subgroup analyses of randomised controlled trials, intubations in acute settings or intubations performed with >45 degrees of incline. Overall quality of evidence was rated as low or very low for most outcomes. Conclusions This systematic review and meta-analysis found no evidence of benefit or harm with inclined versus supine patient positioning during endotracheal intubation in any setting.