Academic Emergency Medicine最新文献

{"title":"Using natural language processing to identify emergency department patients with incidental lung nodules requiring follow-up.","authors":"Christopher L Moore, Vimig Socrates, Mina Hesami, Ryan P Denkewicz, Joe J Cavallo, Arjun K Venkatesh, R Andrew Taylor","doi":"10.1111/acem.15080","DOIUrl":"10.1111/acem.15080","url":null,"abstract":"<p><strong>Objectives: </strong>For emergency department (ED) patients, lung cancer may be detected early through incidental lung nodules (ILNs) discovered on chest CTs. However, there are significant errors in the communication and follow-up of incidental findings on ED imaging, particularly due to unstructured radiology reports. Natural language processing (NLP) can aid in identifying ILNs requiring follow-up, potentially reducing errors from missed follow-up. We sought to develop an open-access, three-step NLP pipeline specifically for this purpose.</p><p><strong>Methods: </strong>This retrospective used a cohort of 26,545 chest CTs performed in three EDs from 2014 to 2021. Randomly selected chest CT reports were annotated by MD raters using Prodigy software to develop a stepwise NLP \"pipeline\" that first excluded prior or known malignancy, determined the presence of a lung nodule, and then categorized any recommended follow-up. NLP was developed using a RoBERTa large language model on the SpaCy platform and deployed as open-access software using Docker. After NLP development it was applied to 1000 CT reports that were manually reviewed to determine accuracy using accepted NLP metrics of precision (positive predictive value), recall (sensitivity), and F1 score (which balances precision and recall).</p><p><strong>Results: </strong>Precision, recall, and F1 score were 0.85, 0.71, and 0.77, respectively, for malignancy; 0.87, 0.83, and 0.85 for nodule; and 0.82, 0.90, and 0.85 for follow-up. Overall accuracy for follow-up in the absence of malignancy with a nodule present was 93.3%. The overall recommended follow-up rate was 12.4%, with 10.1% of patients having evidence of known or prior malignancy.</p><p><strong>Conclusions: </strong>We developed an accurate, open-access pipeline to identify ILNs with recommended follow-up on ED chest CTs. While the prevalence of recommended follow-up is lower than some prior studies, it more accurately reflects the prevalence of truly incidental findings without prior or known malignancy. Incorporating this tool could reduce errors by improving the identification, communication, and tracking of ILNs.</p>","PeriodicalId":7105,"journal":{"name":"Academic Emergency Medicine","volume":" ","pages":"274-283"},"PeriodicalIF":3.4,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142997976","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Diagnostic reasoning and cognitive error in emergency medicine: Implications for teaching and learning.","authors":"Thierry Pelaccia, Jonathan Sherbino, Peter Wyer, Geoff Norman","doi":"10.1111/acem.14968","DOIUrl":"10.1111/acem.14968","url":null,"abstract":"<p><strong>Background: </strong>Accurate diagnosis in emergency medicine (EM) is high stakes and challenging. Research into physicians' clinical reasoning has been ongoing since the late 1970s. The dual-process theory has established itself as a valid model, including in EM. It is based on the distinction between two information-processing systems. System 1 rapidly generates one or more diagnostic hypotheses almost instantaneously, driven by experiential knowledge, while System 2 proceeds more slowly and analytically, applying formal rules to arrive at a final diagnosis.</p><p><strong>Methods: </strong>We reviewed the literature on dual-process theory in the fields of cognitive science, medical education and emergency medicine.</p><p><strong>Results and conclusion: </strong>The literature reflects two prominent interpretations regarding the relationship between the fast and slow phases and these interpretations carry very different implications for the training of clinical learners. One interpretation, prominent in the EM community, presents it as a \"check-and-balance\" framework in which most diagnostic error is caused by cognitive biases originating within System 1. As a result, EM residents are frequently advised to deploy analytical (System 2) strategies to correct such biases. However, such teaching approaches are not supported by research into the nature of diagnostic reasoning. An alternative interpretation assumes a harmonious relationship between Systems 1 and 2 in which both fast and slow processes are driven by underlying knowledge that conditions performance and the occurrence of errors. Educational strategies corresponding to this alternative have not been explored in the EM literature. In this paper, we offer proposals for improving the teaching and learning of diagnostic reasoning by EM residents.</p>","PeriodicalId":7105,"journal":{"name":"Academic Emergency Medicine","volume":" ","pages":"320-326"},"PeriodicalIF":3.4,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11921069/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142455477","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Factors and outcomes associated with under- and overdiagnosis of sepsis in the first hour of emergency department care.","authors":"Shivansh R Pandey, Sarah K S Knack, Brian E Driver, Matthew E Prekker, Nathaniel Scott, Sarah J Ringstrom, Ellen Maruggi, Olivia Kaus, Walker Tordsen, Michael A Puskarich","doi":"10.1111/acem.15074","DOIUrl":"10.1111/acem.15074","url":null,"abstract":"<p><strong>Background: </strong>Sepsis remains the leading cause of in-hospital death and one of the costliest inpatient conditions in the United States, while treatment delays worsen outcomes. We sought to determine factors and outcomes associated with a missed emergency physician (EP) diagnosis of sepsis.</p><p><strong>Methods: </strong>We conducted a secondary analysis of a prospective single-center observational cohort of undifferentiated, critically ill medical patients (September 2020-May 2022). EP gestalt of suspicion for sepsis was measured using a visual analog scale (VAS; 0%-100%) at 15 and 60 min post-patient arrival. The primary outcome was an explicit hospital discharge diagnosis of sepsis that was present on arrival. We calculated test characteristics for clinically relevant subgroups and examined factors associated with initial and persistent missed diagnoses. Associations with process (antibiotics) and clinical (mortality) outcomes were assessed after adjusting for severity.</p><p><strong>Results: </strong>Among 2484 eligible patients, 275 (11%) met the primary outcome. A VAS score of ≥50 (more likely than not of being septic) at 15 min demonstrated sensitivity 0.83 (95% confidence interval [CI] 0.78-0.87) and specificity 0.85 (95% CI 0.83-0.86). Older age, hypoxia, hypotension, renal insufficiency, leukocytosis, and both high and low temperature were significantly associated with lower accuracy due to reduced specificity, but maintained sensitivity. Of 48 (17%) and 23 (8%) missed cases at 15 and 60 min, elevated lactate, leukocytosis, bandemia, and positive urinalysis were more common in the missed sepsis compared to nonsepsis cases. Missed diagnoses were associated with median (interquartile range) delay of 48 (27-64) min in antibiotic administration but were not independently associated with inpatient mortality as risk ratios remained close to 1 across VAS scores.</p><p><strong>Conclusions: </strong>This prospective single-academic center study identified patient subgroups at risk of impaired diagnostic accuracy of sepsis, with clinicians often overdiagnosing rather than underdiagnosing these groups. Prompt abnormal laboratory test results can \"rescue\" initial missed diagnoses, serving as potential clinician- and systems-level intervention points to reduce missed diagnoses. Missed diagnoses delayed antibiotics, but not mortality after controlling for severity of illness.</p>","PeriodicalId":7105,"journal":{"name":"Academic Emergency Medicine","volume":" ","pages":"204-215"},"PeriodicalIF":3.4,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11921079/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142891271","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Language barriers and pain disparities in pediatric emergency settings: A call for action.","authors":"Paulina S Lim, Michelle A Fortier, Miriam Bender, Belinda Campos, Theodore Heyming, Zeev N Kain","doi":"10.1111/acem.14894","DOIUrl":"10.1111/acem.14894","url":null,"abstract":"","PeriodicalId":7105,"journal":{"name":"Academic Emergency Medicine","volume":" ","pages":"371-373"},"PeriodicalIF":3.4,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11408702/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140142565","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Documentation of incidentally noted hepatic steatosis to emergency department patients: A retrospective study.","authors":"Amy V Kontrick, Joshua B Alinger, Emily C Goins, Alessia F Mollo, Daniel S Cruz, Danielle M McCarthy","doi":"10.1111/acem.15044","DOIUrl":"10.1111/acem.15044","url":null,"abstract":"<p><strong>Background: </strong>Hepatic steatosis is a common incidental finding on emergency department (ED) imaging studies, occurring in up to 10% of studies, and carries significant long-term morbidity. Frequently considered an unimportant finding, it is unknown how often ED patients are informed of hepatic steatosis. Our objective was to examine hepatic steatosis inclusion in ED discharge materials.</p><p><strong>Methods: </strong>Data from discharged patients at an urban academic ED (>90,000 visits) with abdominal imaging (computed tomography or ultrasound) from 2019 to 2022 were screened. Patients with radiology reports documenting hepatic steatosis were included. Two trained data abstractors analyzed discharge materials and coded disclosure of steatosis (present/absent). Data abstraction also noted how the finding was included (e.g., follow-up instructions, provision of radiology report). Factors associated with patient disclosure were examined through regression models including age, race, ethnicity, insurance, number of imaging studies during encounter, type of imaging study, and inclusion of hepatic steatosis in the impression section of radiology report.</p><p><strong>Results: </strong>Of 10,677 radiology reports, 1209 (11.3%) had documented hepatic steatosis. The mean (±SD) age was 47.1 (±14.1) years; 56.4% were female, 53.5% were White, and 30.7% Hispanic. Only 173 of 1209 patients (14.3%) received any discharge documentation of hepatic steatosis. In 65% of cases where disclosure occurred, the imaging report was pasted verbatim into discharge material. There were no significant differences in discharge documentation by demographic groups. Mention within the radiology report impression (rather than the report body alone) occurred in 73.8% of records and was the strongest predictor of disclosure to patients (adjusted odds ratio 2.18, 95% confidence interval 1.39-3.54).</p><p><strong>Conclusions: </strong>Despite the high prevalence of hepatic steatosis in radiology reports, rates of documentation in patient-facing discharge materials are notably low, exposing a possible communication failure with consequences for diagnosis.</p>","PeriodicalId":7105,"journal":{"name":"Academic Emergency Medicine","volume":" ","pages":"284-291"},"PeriodicalIF":3.4,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11921084/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142611978","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Low sexually transmitted infection (STI) screening and presumptive treatment and high STI positivity among United States females visiting the emergency department after sexual assault.","authors":"Guoyu Tao, Chirag G Patel, Kimberly A Stanford","doi":"10.1111/acem.15058","DOIUrl":"10.1111/acem.15058","url":null,"abstract":"<p><strong>Objective: </strong>The Centers for Disease Control and Prevention sexually transmitted infection (STI) treatment guidelines state that the decision to provide STI/human immunodeficiency virus (HIV) testing and presumptive treatment after sexual assault (SA) should be made on an individual basis to minimize retraumatization of the patient. However, little is known about STI screening, presumptive treatment, and positivity in the emergency department (ED) setting. The objective of this study was to evaluate STI testing rates and positivity, presumptive gonorrhea and chlamydia treatment, pregnancy testing, and emergency contraception offered to SA survivors in the ED in the United States.</p><p><strong>Methods: </strong>The Premier Healthcare Database, a national administrative data set containing health care information from inpatient and hospital-based outpatient encounters, was used. Approximately 30% of encounters have available laboratory test results. ED visits for SA (identified by ICD-10-CM codes) among female patients aged 15-44 years between 2019 and 2023 were included. For patients presenting multiple times to the ED, only the first ED visit after SA was included.</p><p><strong>Results: </strong>Of 49,047 total visits where females ages 15-44 years presented to the ED for SA, chlamydia, gonorrhea, syphilis, and HIV tests were conducted in 18.6%, 18.6%, 13.4%, and 16.9%, respectively, and pregnancy tests in 33.1% of visits. Presumptive gonorrhea and chlamydia treatment was provided in 53.7% and 52.2%, respectively, and emergency contraception in 27.2% of visits. Approximately 40% of patients were neither tested nor treated for either chlamydia or gonorrhea. Of patients with available laboratory test results, chlamydia, gonorrhea, and syphilis positivity rates were 10.0%, 3.8%, and 1.0%, respectively.</p><p><strong>Conclusions: </strong>Low STI testing and treatment rates and high STI positivity identified in this study suggest that an important opportunity exists for improving STI screening and presumptive treatment for female patients presenting to the ED after SA.</p>","PeriodicalId":7105,"journal":{"name":"Academic Emergency Medicine","volume":" ","pages":"292-299"},"PeriodicalIF":3.4,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142765336","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Balancing risks and priorities: Achieving right care in diagnosing pulmonary embolism during pregnancy.","authors":"Pierre-Marie Roy, Thomas Moumneh","doi":"10.1111/acem.15082","DOIUrl":"10.1111/acem.15082","url":null,"abstract":"","PeriodicalId":7105,"journal":{"name":"Academic Emergency Medicine","volume":" ","pages":"363-365"},"PeriodicalIF":3.4,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142969156","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Implications of inadequate communication: Emergency care for deaf and hard-of-hearing patients.","authors":"Jason Rotoli, Christopher Moreland, Carl Mirus","doi":"10.1111/acem.15040","DOIUrl":"10.1111/acem.15040","url":null,"abstract":"","PeriodicalId":7105,"journal":{"name":"Academic Emergency Medicine","volume":" ","pages":"374-376"},"PeriodicalIF":3.4,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142567188","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Can first impressions predict patient outcomes?","authors":"Ellie C Treloar, Ann Abraham, Eden Smith, Matheesha Herath, Matthew Watson, Nikki Pennifold, Katarina Foley, Guy Maddern, Matthias Wichmann","doi":"10.1111/acem.15053","DOIUrl":"10.1111/acem.15053","url":null,"abstract":"","PeriodicalId":7105,"journal":{"name":"Academic Emergency Medicine","volume":" ","pages":"351-354"},"PeriodicalIF":3.4,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142738012","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Introduction to the AEM special issue on the science of errors in emergency care, 2025.","authors":"Richard T Griffey, Jeffrey A Kline, Brandon C Maughan, Margaret E Samuels-Kalow","doi":"10.1111/acem.15122","DOIUrl":"10.1111/acem.15122","url":null,"abstract":"","PeriodicalId":7105,"journal":{"name":"Academic Emergency Medicine","volume":" ","pages":"198-199"},"PeriodicalIF":3.4,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143187906","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}