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Tony Zitek,1 Mani Hashemi,2 Sara Zagroba,2 Valori H Slane2 1Department of Emergency Medicine, Mount Sinai Medical Center, Miami Beach, FL, USA; 2Department of Emergency Medicine, Kendall Regional Medical Center, Miami, FL, USACorrespondence: Tony Zitek, Department of Emergency Medicine, Mount Sinai Medical Center, 4300 Alton Road, Miami Beach, FL, 33140, USA, Tel +1-305-674-2121 Ext 56632, Email Zitek10@gmail.comPurpose: Acute aortic dissection (AAD) is a highly fatal disorder if not promptly diagnosed. Some international studies have suggested that serum d-dimer levels may be used to exclude AAD, but data are limited. We sought to confirm that d-dimer levels are elevated in American patients with AAD. Additionally, we sought to estimate the test characteristics of the d-dimer for AAD.Patients and Methods: We performed a retrospective analysis of patients in the Hospital Corporation of America database who arrived at the hospital between 2015 and 2019. We queried the database to find patients who had a diagnosis of AAD or (nonspecific) chest pain, and who also had a d-dimer performed within 24 hours of arrival at the hospital. The median d-dimer was compared in those diagnosed with AAD versus chest pain. We estimated the test characteristics of d-dimer for AAD at the standard cutoff value of 500 ng/mL.Results: In total, 48,902 patients met the criteria for analysis, including 572 with AAD and 48,330 with chest pain. The median d-dimers were 2455 ng/mL and 385 ng/mL for the AAD and chest pain groups, respectively (p < 0.0001). Using a cutoff of 500 ng/mL, the sensitivity of the d-dimer was 91.1% and the specificity was 71.4%.Conclusion: Serum d-dimer values are higher in patients with AAD than in those with nonspecific chest pain. At the standard cutoff of 500 ng/mL, the serum d-dimer has a high sensitivity for AAD, but not high enough that d-dimer levels alone can be used in isolation to exclude AAD.Keywords: aorta, dissection, d-dimer, diagnosis

Tony Zitek,1,2 Luke Weber,1 Dominique Pinzon,1 Nicole Warren1– 3 1Department of Emergency Medicine, Mount Sinai Medical Center, Miami Beach, FL, USA; 2Department of Emergency Medicine, Herbert Wertheim College of Medicine at Florida International University, Miami, FL, USA; 3Department of Medical Education, University of Miami School of Medicine, Miami, FL, USACorrespondence: Tony ZitekMount Sinai Medical Center, Department of Emergency Medicine, 4300 Alton Road, Miami Beach, FL, 33140, USA, Tel +1 305-674-2121 x56632, Email Zitek10@gmail.comAbstract: Immune thrombocytopenia (ITP) is characterized by a platelet count less than 100 × 10^9/L without anemia or leukopenia. Patients with ITP may be asymptomatic, or they may have mild bleeding like petechiae, purpura, or epistaxis. In rare cases, they may present to the emergency department (ED) with life-threatening bleeding as a result of their thrombocytopenia. The emergency physician should thus be prepared to diagnose ITP and treat the bleeding that can result from it. The diagnosis of ITP requires excluding secondary causes of thrombocytopenia, and in the ED, the bare minimum workup for ITP includes a complete blood count and a peripheral blood smear. The peripheral blood smear should show a small number of large platelets with normal morphology, and there should not be an increased number of schistocytes. Many patients with ITP require no emergent treatment. However, if a patient with suspected ITP presents to the ED with critical hemorrhage, the emergency physician should initiate treatment with a platelet transfusion, corticosteroids, and intravenous immune globulin (IVIG) as soon as possible. For less severe bleeding, platelet transfusions are not recommended, and the treatment consists of corticosteroids by themselves or in conjunction with IVIG.Keywords: ITP, symptoms, diagnosis, treatment

Tony Zitek,1– 3 Omar Ahmed,3 Chee Lim,4 Rianda Carodine,1,5 Kent Martin2 1Department of Emergency Medicine, University Medical Center of Southern Nevada, Las Vegas, NV, USA; 2Department of Emergency Medicine, Kendall Regional Medical Center, Miami, FL, USA; 3Department of Emergency Medicine, University of Nevada, Las Vegas School of Medicine, Las Vegas, NV, USA; 4Touro University Nevada College of Osteopathic Medicine, Henderson, NV, USA; 5University of Nevada, Las Vegas, NV, USACorrespondence: Tony ZitekDepartment of Emergency Medicine, Kendall Regional Medical Center, 11750 SW 40 th St, Miami, FL 33175, USAEmail Zitek10@gmail.comPurpose: Many experts recommend ordering an ultrasound and a urinalysis on all patients with scrotal pain. While the ultrasound may help diagnose a number of potential causes of scrotal pain, the urinalysis primarily has value in assessing for epididymo-orchitis. This study sought to evaluate the utility of these diagnostic tests for patients who presented to the emergency department (ED) with acute scrotal pain and possible epididymo-orchitis.Patients and Methods: This was a single-center chart review of patients presenting to the ED with scrotal pain. Trained research assistants reviewed charts to obtain urinalysis and ultrasound results as well as diagnoses and treatments provided. Using the final diagnosis as a gold standard, the sensitivity and specificity of ultrasound and urinalysis were calculated for the diagnosis of epididymo-orchitis. Also, through a prespecified definition of “changed management,” we estimated the percentage of cases in which a urinalysis changed management of patients with acute scrotal pain.Results: We identified 663 adult and pediatric patients who presented with scrotal pain during 2016. All patients had an ultrasound performed, and 458 (69.1%) had a urinalysis done. The sensitivity of urinalysis for epididymo-orchitis was 58.2% (95% CI 48.9% to 67.1%), and the specificity was 85.1% (95% CI 80.8% to 88.7%). For ultrasound, the sensitivity was 78.8% (95% CI 71.4% to 85.0%) and the specificity was 98.1% (95% CI 96.4% to 99.1%). In 24 of 458 cases (5.2% [95% CI 3.4% to 7.7%]) where a urinalysis was obtained, its results may have changed management of the patient.Conclusion: The diagnosis of patients who present to the ED with scrotal pain is primarily driven by the ultrasound results. While the urinalysis may occasionally provide some benefit in the evaluation of patients with suspected epididymo-orchitis, the reflexive ordering of a urinalysis in patients with scrotal pain may be unnecessary.Keywords: epididymitis, urinalysis, antibiotics, ultrasound

Introduction: Standard emergency medicine practice includes tetanus vaccine administration as part of wound care management for patients who are not fully immunized. Since there have been no available studies in the United States reaffirming the prevalence of Clostridium tetani (C tetani) since 1926, we sought to identify its prevalence in a major urban county in the US.Methods: We sampled soil, rusted metal, concrete, and dog feces to determine the prevalence of C tetani in a single metropolitan county in the United States. Soil samples and swabs were collected from four locations: the soil of a public park and an elementary school; dog feces from a single public dog park; and rusted surfaces (metal and concrete) in common student areas of a university campus. The presence of C tetani in each sample was determined using a quantitative polymerase chain reaction.Results: In total, 200 samples were collected, of which 37 (18.5%) tested positive for C tetani DNA. Among the 140 samples taken from the soil, just one (0.7%) tested positive for C tetani DNA. Of the 40 samples of rusted metal and concrete surfaces, 30 (75%) tested positive for C tetani, and six (30%) of the 20 samples from dog feces tested positive for C tetani.Conclusion: We found that C tetani is frequently present on rusted metal and concrete surfaces but rarely in soil samples. Minor wounds contaminated with soil may be considered low risk for tetanus. However, future studies should assess the burden of C tetani in other similar urban, suburban, and rural environments to help determine the threat of C tetani more exactly.

Background: Increasingly, patient satisfaction scores are being used to assess emergency physicians. We sought to determine whether the patient satisfaction scores collected by our hospital system are lower for patients who are treated in the emergency department (ED) on night shifts as compared to those treated on day shifts.Methods: We performed a cross-sectional analysis of patient satisfaction scores from three EDs in Florida. We obtained satisfaction data from NRC Health (the company that provides our surveys) using a random sample of 1,000 completed surveys from patients treated in 2022; we also performed manual chart review to obtain clinical data. The satisfaction surveys asked patients how likely they would be to recommend the facility (from 0–10). Patients who provided a score of 9 or 10 were considered “promoters.” For our primary analysis, we compared the percentage of promoters for the day shift encounters (7 AM to 7 PM) to the night shift encounters (7 PM to 7 AM). We also performed a multivariable logistic regression analysis using several demographic and clinical variables to further assess the association between night shift arrival and satisfaction scores.Results: Of the 1,000 surveys analyzed, 66.3% of patients arrived during the day shift, and 33.7%arrived during the night shift. Of those who arrived during the day shift, 525 (79.2%) were promoters compared to 228 (67.7%) of those who arrived during the night shift, a difference of 11.5% (95%confidence interval [CI] 5.7–17.4%), P < 0.001. On multivariable analysis, night shift arrival was associated with a lower chance of a patient being a promoter, with adjusted odds ratio 0.60 (95% CI 0.43–0.84), P = 0.003.Conclusion: Patients who presented to the ED during the night shift were less likely to be promoters than patients who arrived during the day shift. Assessments of patient satisfaction data should account for time of visit and other facility-related and operational characteristics.

The experimental air turbine VT400 is located in hall laboratories of the Department of Power System Engineering. It is a single-stage air turbine located in the suction of the compressor. It is able to solve various problems concerning the construction solution of turbine stages. The content of the article will deal mainly with the description of measurements on this turbine. The up-to-now research on this test rig will be briefly mentioned, too, as well as the description of the ongoing reconstruction.

This paper summarizes the basis for the solution of heat removal by natural convection from both conventional nuclear reactors and reactors with fuel flowing coolant (such as reactors with molten fluoride salts MSR).The possibility of intensification of heat removal through gas lift is focused on. It might be used in an MSR (Molten Salt Reactor) for cleaning the salt mixture of degassed fission products and therefore eliminating problems with iodine pitting. Heat removal by natural convection and its intensification increases significantly the safety of nuclear reactors. Simultaneously the heat removal also solves problems with lifetime of pumps in the primary circuit of high-temperature reactors.

This paper gives a brief overview of types of two-phase flow. Subsequently, it deals with their mutual division and problems with accuracy boundaries among particular types. It also shows the case of water flow through a pipe with external heating and the gradual origination of all kinds of flow. We have met it in solution of safety condition of various stages in pressurized and boiling water reactors. In the MSR there is a problem in the solution of gas-lift using helium as a gas and its secondary usage for clearing of the fuel mixture from gaseous fission products. Theory of gas-lift is described.

Recent design of steam turbine stages is based on the use of 3D blades. This paper presents a comparison of experimental results from testing of three variants of this modern bladings with moderate hub reaction. The influence of row density of nozzles was investigated. Comparisons of overall stage efficiency as well as measured flow fields data are presented in the paper.

Two variants of a stage with modern 3D bladings were tested on a single-stage air turbine to determine the influence of relative width of stator blades (nozzles). The first case means a high-density nozzle row with t/Bax = 0.61; the second one represents a low-density row with t/Bax = 1.12. The 3D shaping of both nozzle cases is based on the same design features. Rotor blades (buckets) are kept the same (also 3D shaped). Comparisons of overall stage efficiency as well as measured flow fields data are presented in the paper.

Some experts have promoted the use of rapid testing for COVID-19. However, with the current technologies available, continuing to replace laboratory-based, real-time reverse transcription polymerase chain reaction tests with rapid (point-of-care) tests may lead to an increased number of false negative tests. Moreover, the more rapid dissemination of false negative results that can occur with the use of rapid tests for COVID-19 may lead to increased spread of the novel coronavirus if patients do not understand the concept of false negative tests. One means of combatting this would be to tell patients who have a “negative” rapid COVID-19 test that their test result was “indeterminate.”

Many public officials are calling for increased testing for the 2019 novel coronavirus disease (COVID-19), and some governments have taken extraordinary measures to increase the availability of testing. However, little has been published about the sensitivity and specificity of the reverse transcriptase-polymerase chain reaction (RT-PCR) nasopharyngeal swabs that are commonly used for testing. This narrative review evaluates the literature regarding the accuracy of these tests, and makes recommendations based on this literature. In brief, a negative RT-PCR nasopharyngeal swab test is insufficient to rule out COVID-19. Thus, over-reliance on the results of the test may be dangerous, and the push for widespread testing may be overstated.

Alteplase is the only Food and Drug Administration-approved intravenous (IV) thrombolytic medication for acute ischemic stroke. However, multiple recent studies comparing tenecteplase and alteplase suggest that tenecteplase is at least as efficacious as alteplase with regards to neurologic improvement. When given at 0.25 milligrams per kilogram (mg/kg), tenecteplase may have less bleeding complications than alteplase as well. This narrative review evaluates the literature and addresses the practical issues with regards to the use of tenecteplase versus alteplase for acute ischemic stroke, and it recommends that physicians consider tenecteplase rather than alteplase for thrombolysis of acute ischemic stroke.

Background: Emergency physicians commonly treat patients with atrial fibrillation (AF) or atrial flutter (AFL) with rapid ventricular response, and intravenous (IV) diltiazem is the most commonly used medication for rate control of such patients. We sought to compare rate control success and safety outcomes for emergency department (ED) patients with AF or AFL who, after a diltiazem bolus, received a diltiazem drip compared to those who did not receive a drip. Methods: We performed a retrospective cohort study comparing outcomes of ED patients from a single hospital system with AF and AFL and a heart rate (HR) > 100 beats/min who received a diltiazem drip after an IV diltiazem bolus to those who received no drip. The primary outcome was a HR < 100 beats/min at the time of ED disposition. Secondary outcomes were hospital length of stay and safety (hypotension, electrical cardioversion, vasopressor use, and death). We compared groups using propensity score matching. Results: Between January 1, 2020, and November 8, 2022, there were 746 AF or AFL patients eligible for analysis. Of those, 382 (51.2%) received a diltiazem drip and 364 (48.8%) did not. In the unadjusted analysis, the last recorded ED HR was <100 beats/min in 55.2% of patients in the drip group compared to 65.9% in the no‐drip group (difference 10.7%, 95% confidence interval [CI] 3.7 to 17.7). After propensity matching, diltiazem drip use was associated with lower likelihood of rate control in the ED (OR 0.69, 95% CI 0.48–0.99) and 22.5 h (95% CI 12.2–36.8) longer hospital stay. Conclusions: For patients with AF or AFL, the use of a diltiazem drip after an IV diltiazem bolus was associated with less rate control in the ED. [ABSTRACT FROM AUTHOR]

Introduction: Computed tomography pulmonary angiography (CTPA) is the test of choice for diagnosis of pulmonary embolism (PE) in the emergency department (ED), but this test may be indeterminate for technical reasons such as inadequate contrast filling of the pulmonary arteries.  Many hospitals have requirements for intravenous (IV) catheter size or location for CTPAs to reduce the chances of inadequate filling, but there is a lack of clinical data to support these requirements. The objective of this study was to determine if a certain size or location of IV catheter used for contrast for CTPA is associated with an increased chance of an indeterminate CTPA. Methods: This was a retrospective chart review of patients who underwent CTPA in the emergency department.  A CTPA was considered indeterminate if the radiology report indicated it was inadequate to exclude a pulmonary embolism.  The reason for the study being indeterminate, and the size and location of the IV catheter were abstracted. The rate of inadequate contrast filling of the pulmonary vasculature was calculated and compared for various IV catheter sizes and locations.  In particular, 20-gauge or larger IV catheters in the antecubital fossa or forearm were compared to all other sizes and locations. Results: A total of 19.3% of the 1500 CTPA reports reviewed met our criteria as indeterminate, and 51.6% of those were due to inadequate filling.  Patients with a 20-gauge IV catheter or larger placed in the antecubital fossa or forearm had inadequate filling 9.2% of the time compared to 13.2% for patients who had smaller IVs or IVs in other locations (difference:  4.0% [95% CI -1.7% to 9.7%]).  There were also no statistically significant differences in the rates of inadequate filling when data were further stratified by IV catheter location and size. Conclusion: We did not detect any statistically significant differences in the rate of inadequate contrast filling based on IV catheter locations or sizes.  While small differences not detected in this study may exist, it seems prudent to proceed with CTPA in patients with difficult IV access who need emergent imaging even if they have a small or distally located IV.

Introduction: The peripheral internal jugular (IJ), also called the “easy IJ,” is an alternative to peripheral venous access reserved for patients with difficult intravenous (IV) access. The procedure involves placing a single-lumen catheter in the IJ vein under ultrasound (US) guidance. As this technique is relatively new, the details regarding the ease of the procedure, how exactly it should be performed, and the safety of the procedure are uncertain. Our primary objective was to determine the success rate for peripheral IJ placement. Secondarily, we evaluated the time needed to complete the procedure and assessed for complications.Methods: This was a prospective, single-center study of US-guided peripheral IJ placement using a 2.5-inch, 18-gauge catheter on a convenience sample of patients with at least two unsuccessful attempts at peripheral IV placement by nursing staff. Peripheral IJ lines were placed by emergency medicine (EM) attending physicians and EM residents who had completed at least five IJ central lines. All physicians who placed lines for the study watched a 15-minute lecture about peripheral IJ technique. A research assistant monitored each line to assess for complications until the patient was discharged. Results: We successfully placed a peripheral IJ in 34 of 35 enrolled patients (97.1%). The median number of attempts required for successful cannulation was one (interquartile range (IQR): 1 to 2). The median time to successful line placement was 3 minutes and 6 seconds (IQR: 59 seconds to 4 minutes and 14 seconds). Two lines failed after placement, and one of the 34 successfully placed peripheral IJ lines (2.9%) had a complication – a local hematoma. There were, however, no arterial punctures or pneumothoraces. Although only eight of 34 lines were placed using sterile attire, there were no line infections.  Conclusion: Our research adds to the growing body of evidence supporting US-guided peripheral internal jugular access as a safe and convenient procedure alternative for patients who have difficult IV access.