Objectives: Emergency department (ED) overcrowding is a growing problem, and pediatric patients are contributing. In this study, we aimed to determine which factors influence parents or guardians to choose the ED over their primary care physician (PCP).Methods: A cross-sectional, online survey was administered in an academic hospital pediatric ED from September to October 2017. The 21-question survey was offered to the parents or guardians of pediatric patients triaged as low acuity. The survey assessed establishment and availability of their PCP, perception of illness or injury severity, reasons for choosing the ED, and demographic information.Results: A total of 101 surveys were collected, with a 95% completion rate. Most patients had an established PCP. More than two-thirds did not attempt to contact their PCP prior to their ED visit. Nearly half stated their PCP did not offer after-hours or weekend availability. Most did not feel their child's condition was serious. Almost half would have waited to see their PCP if they could be seen within 24 hours.Conclusions: There appears to be a common misperception that PCPs do not offer extended hours. In addition, the parent or guardian's perception of severity was oftentimes more serious than perceived by medical staff. These results suggest that improving health literacy among our patient population by educating them on PCP availability and capability, ancillary services offered by PCP, and appropriate usage of the ED could potentially reduce nonurgent ED visits.

Synthetic dysfunction observed in cirrhosis results in altered production of procoagulants and anticoagulants that can lead to both bleeding and thrombotic events, respectively. In patients with decompensated cirrhosis, frequent hospital visits often require bedside procedures such as diagnostic paracenteses, thoracenteses and endoscopy. It can be difficult to determine at what coagulation threshold procedures can safely be performed. Currently, the most common therapies given pre-procedurally include fresh frozen plasma (FFP) and vitamin K. The effectiveness of these treatments is estimated by international normalized ratio (INR), an imprecise measure of coagulation in the setting of cirrhosis. Transfusion with FFP may lead to detrimental side effects, including worsening volume overload and increased portal hypertension. We present a case of a 60-year-old patient intubated for acute hypoxic respiratory failure secondary to volume overload who subsequently developed bilateral pneumothoraces, requiring immediate chest tube placement. In this case, the patient had ongoing hepatic decompensation with volume overload and acute worsening of coagulopathy with an INR of 4.2. In this setting, 4-Factor Prothrombin Complex Concentrate (4F-PCC) was chosen to correct coagulation parameters with a low infusion volume. One hour following administration, INR was 1.5. Chest tubes were placed bilaterally and oxygenation improved without bleeding complications. While the data is still lacking, 4F-PCC may be considered for urgent and emergency situations in cirrhotic patients.

No abstract

No abstract

Introduction: Left ventricular non-compaction (LVNC) is a rare genetic condition affecting 1 in 5000 people in which the myocardium of the left ventricle fails to adequately compact, forming deep recesses within the muscle wall. These recesses have been theorized to contribute to thrombus formation and embolic stroke, though the association has never been firmly established in the limited literature over the last 20 years. Hypothesis: We assessed the hypothesis that patients with LVNC, as well as those with hypertrabeculation not meeting LVNC criteria, would have increased rates of lifetime incidence of CVA, LV thrombus diagnosis, and distal arterial embolic events. Methods: We performed a retrospective control-matched cohort study assessing patients at Loyola University Medical Center diagnosed with LVNC, as well as those with hypertrabeculated left ventricles not meeting LVNC criteria, assembling the largest cohort of adult patients in the literature to date. We matched our study patients to controls based on age, HTN, DM, smoking status, history of atrial fibrillation, and history of DVT/PE. Results: Compared to matched controls, neither the LVNC group (n=98) nor the hypertrabeculation group (n=119) showed an increased risk of CVA, but both were associated with an increase in diagnosis of LV thrombus by TTE, TEE, or cMRI (p=0.045, p=0.003, respectively). Furthermore, in the LVNC group, each 10% increase in EF was found to reduce the risk of a composite endpoint of arterial thromboembolism (CVA, LV thrombus, distal arterial embolus) by 50%, while in the hypertrabeculation group, each 10% increase in EF reduced total arterial thromboembolism by 37%. Conclusions: These findings suggest that patients with hypertrabeculated left ventricles are either more likely to have LV thrombi that do not result in CVA events, or that due to the ventricle morphology, LV thrombi are being diagnosed when none are actually present. Furthermore, our study supports the existing literature that more severe systolic dysfunction increases risk for CVA and thromboembolic events, though that association seems largely multifactorial. Based on these results we cannot advocate for or against a particular anticoagulation strategy in patients with LVNC.