Kyle Bernard

Objective: Urinary tract infections are a common consideration when assessing pediatric patients with fever. With rising resistance rates and increased focus on antibiotic stewardship, current management needs to be better understood. This study reports the incidence and antibiotic distribution in a nationwide cohort of pediatric emergency department (ED) patients with cystitis and pyelonephritis during an 8-year period.Methods: We performed a cohort study from January 1, 2016, to December 31, 2023, using Epic Cosmos data. Pediatric ED patients (≤18 years) with an ICD-10 code corresponding to cystitis or pyelonephritis were included. The outcomes were the total number of ED presentations, outpatient antibiotic prescriptions, and antibiotics administered in the ED for patients admitted with cystitis or pyelonephritis. Binary logistic regression models were used to measure the relationship between the year and the dependent variables.Results: Among 46,774,814 total pediatric ED visits, 730,863 (1.5%) were for cystitis, and 82,717 (0.2%) were for pyelonephritis. Among those admitted, the most common antibiotics were third-generation cephalosporins (cystitis, 55.6%; pyelonephritis, 62.3%), first-generation cephalosporins (cystitis, 13.8%; pyelonephritis, 13.7%), and ampicillin (cystitis, 10.8%; pyelonephritis, 6.6%). First-generation cephalosporin use rose over time, while ampicillin and ciprofloxacin use declined. Among discharged patients, the most common antibiotics were first-generation cephalosporins (cystitis, 43.1%; pyelonephritis, 33.7%), third-generation cephalosporins (cystitis, 20.8%; pyelonephritis, 25.8%), and trimethoprim-sulfamethoxazole (cystitis, 13.5%; pyelonephritis, 11.8%). First-generation cephalosporin use rose over time, while trimethoprim-sulfamethoxazole and ciprofloxacin use declined. Among those with cystitis specifically, the use of third-generation cephalosporins declined over time.Conclusion: Cystitis and pyelonephritis remain common ED presentations, representing nearly 2% of all pediatric ED visits, and antibiotic selection has shifted notably over time. Understanding the current epidemiology can inform public health planning and antibiotic stewardship in the ED.

Hyperkalemia is a potentially life-threatening condition among patients presenting to the Emergency Department (ED). However, most epidemiological studies have focused on those with end-stage renal disease (ESRD) and there is limited recent, large-scale, and robust data available on the incidence and management of hyperkalemia for non-ESRD patients in the ED. This was a retrospective cohort study of adults (age ≥ 18 years) without ESRD presenting to the ED with hyperkalemia from 1/1/2016 to 12/31/2024. ICD-10 codes were used to identify patients in the Epic Cosmos database. The primary outcome was the incidence of hyperkalemia from all ED visits. Secondary outcomes included rates of admission, cardiac arrest, hemodialysis, and medications administered to treat hyperkalemia. Data were analyzed using summary statistics and odds ratios (OR) with 95% confidence intervals (CI). Among 246,235,769 ED visits, 803,186 (0.33%) had an ICD-10 code for hyperkalemia and 539,033 of those (67.11%) were admitted to the hospital. Cardiac arrest occurred in 18,044 (2.25%) patients with hyperkalemia. Sodium bicarbonate was given in 38.75%, calcium gluconate or chloride in 32.64%, sodium zirconium cyclosilicate in 24.68%, sodium polystyrene sulfonate in 23.12%, and patiromer in 3.04%. Only 2.99% received hemodialysis. Among adult patients without ESRD, hyperkalemia is an uncommon but important condition, with twothirds requiring admission and two percent experiencing cardiac arrest. Sodium bicarbonate and calcium administration is common, while hemodialysis is rare.

Real-world data from vendor-aggregated health information exchanges represent a powerful resource for retrospective clinical research. Epic's Cosmos platform, a large-scale centralized data warehouse, enables querying deidentified electronic health record data. We describe the iterative development of a generalizable clinical informatics workflow for retrospective studies using Cosmos. We applied the Plan-Do-Study-Act cycle to iteratively refine a collaborative research process using Cosmo's SlicerDicer interface, focusing on setting, team, technical preparation, and workflow. We identified multiple areas of improvement to facilitate streamlined collaborative studies. Our institutional review board confirmed Cosmos studies as nonhumans subject research. We expanded collaborations across institutions. We identified key insights for team definition across clinical, research, and skill domains. We expanded our team based on technical skills, domain expertise, and educational aims. We optimized query building and cohort construction, data analysis and validation, and communication processes. We clarified and optimized a collaborative workflow across clinical and informatics expertise. Our collaborative approach to secondary data analysis in Cosmos supports the development of meaningful clinical evidence to support high-quality, well-evidenced patient care. This study demonstrates the application of the Plan-Do-Study-Act cycle to a collaborative workflow for clinically focused secondary data analysis. Our approach allows rapid, reproducible cohort construction and analysis, is adaptable across clinical domains, and scales to multiorganizational collaboration. This approach offers a model for others seeking to develop key clinical insights via retrospective studies within the Cosmos data aggregation tool.

Introduction: Alcohol withdrawal syndrome (AWS) is a common condition prompting emergency department (ED) presentation. However, there are limited recent, large‐scale, robust data available on the incidence, admission, and medical treatment of AWS in the ED.Methods: This was a retrospective cohort study of ED presentations for AWS from January 1, 2016, to December 31, 2023, using Epic Cosmos. All ED visits with ICD‐10 codes corresponding to AWS were included. Outcomes included percentage of total ED visits, percentage admitted, length of stay (LOS), and medications administered. Binary logistic regression models were used to measure the relationship between time and dependent variables and reported as odds ratios (ORs) with 95% confidence intervals (CIs).Results: Out of 242,804,798 ED encounters, 670,430 (0.28%) visits were due to AWS with a rise over time (OR 1.074, 95% CI 1.072–1.075). Of these, 386,618 (57.7%) were admitted (46.2% inpatient floor, 11.5% ICU). Median (IQR) hospital LOS was 3 (2–5) days and median (IQR) ICU LOS was 2 (1–4) days. Among all ED patients, benzodiazepine use declined over time (84.9% to 77.1%; OR 0.917, 95% CI 0.914–0.920), while phenobarbital (4.0% to 21.2%; OR 1.255, 95% CI 1.250–1.259) and gabapentin (11.0% to 16.3%; OR 1.054, 95% CI 1.050–1.057) use increased. Oral and intravenous (IV) benzodiazepines were common (63.1% and 66.6%, respectively). Among IV benzodiazepines, lorazepam was most common (59.9%). Among those discharged from the ED, 29.0% were prescribed benzodiazepines (chlordiazepoxide 21.1%, lorazepam 5.5%, diazepam 1.9%). Anticraving medications, such as gabapentin (1.5%), naltrexone (0.4%), and acamprosate (<0.1%) were uncommon, but rising over time.Conclusions: AWS represents a common reason for ED presentation, with most patients being admitted. We identified a rising incidence with a shift in management to include agents such as phenobarbital and gabapentin. These findings provide important evidence on current trends in AWS to inform health policy and knowledge translation efforts as well as emphasizing the need for ongoing research and evaluation of clinical practices to optimize outcomes for patients with AWS.

Objective Deep vein thrombosis (DVT) is a significant cause of morbidity and mortality worldwide, accounting for substantial healthcare utilization. However, management strategies have evolved, and current data on the incidence, admission rates, and medical management of DVT in the emergency department (ED) setting are needed. Methods This cross-sectional study analyzed ED presentations for DVT from 2016 to 2023 using the Cosmos database. Inclusion criteria were patients aged ≥18 years with an ICD-10 code for acute extremity DVT. The outcomes were incidence rates, admission rates, and anticoagulant prescriptions. Data were analyzed using descriptive statistics, and subgroup analyses were performed for upper and lower extremity DVTs. Results Of 190,144,463 total ED encounters, 368,044 (0.2%) were due to DVT. Among the DVT cases, 119,986 patients (32.6%) were admitted, at a stable rate during the study period. Apixaban was the most prescribed anticoagulant (40.3%), followed by rivaroxaban (28.3%), enoxaparin (7.9%), warfarin (3.6%), and dabigatran (0.3%). Use of apixaban increased from 12.4% in 2016 to 56.2% in 2023. Lower extremity DVTs accounted for 88.5% of cases, with a 32.1% admission rate, whereas upper extremity DVTs accounted for 11.7% of cases, with a 37.0% admission rate. Conclusion This study provides a summary of DVT presentation and management in US EDs during an 8-year period. The findings highlight stable incidence rates, reduced admission rates compared with historical data, and a significant shift toward the use of direct oral anticoagulants, particularly apixaban, for outpatient management. These trends underscore the importance of evidence-based practices and ongoing research to optimize DVT management and improve patient outcomes.