Articles related to Emergency Medicine

Early Initiation of DOACs in Atrial Fibrillation Patients Post-Stroke In the quest to optimize stroke management, the timing of direct oral anticoagulants (DOACs) initiation in atrial fibrillation patients who have experienced an acute ischemic stroke has been a subject of debate. This article presents the findings of an open-label trial conducted across 103 sites in 15 countries, investigating the effects of early initiation of DOACs compared to later initiation. The study randomly assigned participants to either early anticoagulation (within 48 hours post minor or moderate stroke, or on day 6 or 7 post major stroke) or later anticoagulation (day 3 or 4 post minor stroke, day 6 or 7 post moderate stroke, or day 12, 13, or 14 post major stroke). The primary outcome was a composite of recurrent ischemic stroke, systemic embolism, major extracranial bleeding, symptomatic intracranial hemorrhage, or vascular death within 30 days post randomization. Out of 2013 participants, 1,006 were assigned to early anticoagulation and 1,007 to later anticoagulation. The primary outcome event occurred in 2.9% of the early-treatment group and 4.1% of the later-treatment group by 30 days. The incidence of recurrent ischemic stroke was lower in the early-treatment group at both 30 and 90 days. […]

Dive into how the FDA-approved Farxiga is changing the heart failure treatment landscape. Colleagues, let’s dive into a remarkable milestone. Farxiga, known as dapagliflozin, now has FDA approval. This is groundbreaking for heart failure treatment. It applies to all patients, regardless of their left ventricular ejection fraction (LVEF) status. The approval didn’t happen overnight. Let’s talk about the DELIVER trial, a vital part of the process. It involved over 6,000 patients, all over 40. Each had heart failure, LVEF above 40%, and may or may not have had type 2 diabetes. They took either dapagliflozin or a placebo daily, plus their usual therapy. The trial had a clear goal: time to the first composite event. This included CV death, heart failure hospitalization, or an urgent heart failure visit. The goal applied to everyone, including patients with LVEF less than 60%. Fast forward about 2.3 years, the results were significant. Dapagliflozin cut the composite outcome by 18% versus the placebo. Both worsening heart failure and CV death rates dropped in the dapagliflozin group. The best part? These findings were consistent, even in patients with lower LVEF or diabetes. Expanding the picture, let’s consider two trials together: DELIVER and DAPA-HF. Over 22 […]

Navigate the complex world of diagnosing Chiari malformation in this insightful review of a clinical case. To understand Chiari malformation, let’s explore a clinical case. A mid-30s patient with a migraine history came to the ED with a sudden posterior headache. Accompanied by transient total body numbness, loss of coordination, and an inability to swallow with drooling, these symptoms started abruptly after violent sneezing. Although neurological symptoms faded after 20 seconds, the headache persisted. Regarding vital signs and physical examination, everything was normal. The patient had a head CT ordered. Interpreting the clinical picture and CT images with care is crucial in these cases. Even though a sudden onset headache could signify a ruptured berry aneurysm, no blood was detected on the CT cuts, minimizing that concern. Remember, an LP is seldom recommended if the CT is performed within 6 hours and hemoglobin exceeds 10 g/dL. However, the clinical presentation in this case, characterized by headache and drooling, didn’t match a typical migraine. Be mindful that many patients might loosely use the term “migraine” for any severe headache. The CT cut revealed a brainstem compressed by the cerebellum, indicative of a Chiari malformation type 1. Chiari malformation, characterized by an […]

This deep-dive into acromioclavicular joint injuries unpacks everything a physician needs to know about these prevalent injuries. Acromioclavicular joint (ACJ) injuries, mostly traumatic, can occur across all ages but are more frequent in males aged 20-40, often related to contact sports. Patients usually present with vague shoulder pain and swelling, but visible deformity is rare. Two mechanisms contribute to ACJ injuries: direct, resulting from a direct blow or fall onto the shoulder, and indirect, arising from a fall onto an outstretched hand or elbow. Imaging is crucial for diagnosis. The Rockwood system, among others, categorizes these injuries into six types. Plain radiographs, including an axillary view, generally suffice for accurate grading. However, in certain scenarios, CT or MRI might be necessary. In case of an injury suspicion with initial normal radiographs or contemplating surgical intervention on a type III injury, additional weight-bearing stress views can be beneficial. Indications of ACJ injury on a plain radiograph may include soft tissue swelling, acromioclavicular joint widening, increased coracoclavicular distance, and superior displacement of the distal clavicle. The treatment choice hinges largely on the patient’s age, lifestyle, and injury type. Conservative management typically applies to types I and II injuries, surgical treatment to types […]

In a cluster-randomized trial conducted across multiple countries, a multicomponent clinical intervention was evaluated for the management of postpartum hemorrhage in patients undergoing vaginal delivery. The intervention involved the use of a calibrated blood-collection drape for early detection of postpartum hemorrhage and a treatment bundle consisting of various interventions. The study found that the intervention group had a lower risk of severe postpartum hemorrhage, laparotomy for bleeding, or death from bleeding compared to the usual-care group. The intervention group also had higher rates of postpartum hemorrhage detection and adherence to the treatment bundle.

A phase 3, multicenter, double-blind, randomized, placebo-controlled trial was conducted to evaluate the efficacy and safety of epicutaneous immunotherapy with a peanut patch in children aged 1 to 3 years with peanut allergy. No approved treatment for peanut allergy exists for children under 4 years old. Participants with confirmed peanut allergy were assigned to either receive the peanut patch or a placebo daily for 12 months. The primary endpoint was the treatment response measured by the eliciting dose of peanut protein at 12 months. The trial showed that 67.0% of children in the intervention group demonstrated a treatment response compared to 33.5% in the placebo group. Adverse events occurred in both groups, with serious adverse events and anaphylaxis observed more frequently in the intervention group. However, serious treatment-related adverse events were rare. In conclusion, this trial demonstrated that epicutaneous immunotherapy with a peanut patch for 12 months was more effective than placebo in desensitizing children aged 1 to 3 years with peanut allergy and increasing their tolerance to peanut protein. Although adverse events were observed in both groups, serious treatment-related adverse events were uncommon. These findings suggest that epicutaneous immunotherapy may be a potential treatment option for young children with […]