Changing global demography is resulting in older people presenting to emergency departments (EDs) in greater numbers than ever before. They present with greater urgency and are more likely to be admitted to hospital or re-attend and utilize greater resources. They experience longer waits for care and are less likely to be satisfied with their experiences. Not only that, but older people suffer poorer health outcomes after ED attendance, with higher mortality rates and greater dependence in activities of daily living or rates of admission to nursing homes. Older people’s assessment and management in the ED can be complex, time consuming, and require specialist skills. The interplay of multiple comorbidities and functional decline result in the complex state of frailty that can predispose to poor health outcomes and greater care needs. Older people with frailty may present to services in an atypical fashion requiring detailed, multidimensional, and increasingly multidisciplinary care to provide the correct diagnosis and management as well as appropriate placement for ongoing care or admission avoidance. Specific challenges such as delirium, functional decline, or carer strain need to be screened for and managed appropriately. Identifying patients with specific frailty syndromes can be critical to identifying those at highest risk of poor outcomes and most likely to benefit from further specialist interventions. Models of care are evolving that aim to deliver multidimensional assessment and management by multidisciplinary specialist care teams (comprehensive geriatric assessment). Increasingly, these models are demonstrating improved outcomes, including admission avoidance or reduced death and dependence. Delivering this in the ED is an evolving area of practice that adapts the principles of geriatric medicine for the urgent-care environment.

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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 CTPA studies 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 suboptimal CTPA. Methods This was a retrospective chart review of patients who underwent CTPA in the ED. A CTPA study was considered suboptimal if the radiology report indicated it was technically limited or inadequate to exclude a PE. The reason for the study being suboptimal, and the size and location of the IV catheter, were abstracted. We calculated the rate of inadequate contrast filling of the pulmonary vasculature and compared the rate for various IV catheter sizes and locations. In particular, we compared 20-gauge or larger IV catheters in the antecubital fossa or forearm to all other sizes and locations. Results A total of 19.3% of the 1500 CTPA reports reviewed met our criteria as suboptimal, 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% confidence interval, −1.7%–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.

BackgroundCertain essential and conditionally essential nutrients (CENs) perform functions involved in aerobic exercise performance. However, increased intake of such nutrient combinations has not actually been shown to improve such performance.MethodsFor 1 mo, aerobically fit, young adult women took either a combination of 3 mineral glycinate complexes (daily dose: 36 mg iron, 15 mg zinc, and 2 mg copper) + 2 CENs (daily dose: 2 g carnitine and 400 mg phosphatidylserine), or the same combination with generic mineral complexes, or placebo (n = 14/group). In Trial 1, before and after 1 mo, subjects were tested for 3 mile run time (primary outcome), followed by distance covered in 25 min on a stationary bike (secondary outcome), followed by a 90 s step test (secondary outcome). To test reproducibility of the run results, and to examine a lower dose of carnitine, a second trial was done. New subjects took either mineral glycinates + CENs (1 g carnitine) or placebo (n = 17/group); subjects were tested for pre- and post-treatment 3 mile run time (primary outcome).ResultsIn Trial 1, the mineral glycinates + CENs decreased 3 mile run time (25.6 ± 2.4 vs 26.5 ± 2.3 min, p < 0.05, paired t-test) increased stationary bike distance after 25 min (6.5 ± 0.6 vs 6.0 ± 0.8 miles, p < 0.05, paired t-test), and increased steps in the step test (43.8 ± 4.8 vs 40.3 ± 6.4 steps, p < 0.05, paired t-test). The placebo significantly affected only the biking distance, but it was less than for the glycinates-CENs treatment (0.2 ± 0.4. vs 0.5 ± 0.1 miles, p < 0.05, ANOVA + Tukey). The generic minerals + CENs only significantly affected the step test (44.1 ± 5.2 vs 41.0 ± 5.9 steps, p < 0.05, paired t-test) In Trial 2, 3 mile run time was decreased for the mineral glycinates + CENs (23.9 ± 3.1 vs 24.7 ± 2.5, p < 0.005, paired t-test), but not by the placebo. All changes for Test Formula II or III were high compared to placebo (1.9 to 4.9, Cohen’s D), and high for Test Formula II vs I for running and biking (3.2 & 3.5, Cohen’s D).ConclusionIn summary, a combination of certain mineral complexes plus two CENs improved aerobic exercise performance in fit young adult women.