St. Barnabas Hospital

Introduction: Failure to recognize and act on clinical deterioration remains a key contributor to morbidity and mortality in hospitalized patients. We hypothesized that a structured, institution-wide review of Rapid Response (RR) and Cardiac Arrest (CA) activations would identify actionable gaps in escalation practices and inform system-level interventions. Methods: We performed a retrospective review of all RR (n=119) and CA (n=93) activations at a community hospital in the Bronx from July 2024 to July 2025. Standardized RR/CA documentation and EMR chart review were used to extract clinical variables. Descriptive statistics and trend analyses were used to identify patterns and escalation gaps. Results: Over a 12-month period, 119 RRs and 93 CAs were analyzed. 59.6% of RRs occurred during the day shift, without evidence of unit clustering or a direct association between RR activation and shift change. Only 31% of RRs were initiated by nurses. A separate nursing survey revealed that 100% of nurses felt confident and knew the criteria for activating a RR; however, 45% of nurses worried about calling a rapid response unnecessarily. The most common triggers for RRs were altered mental status (33%) and respiratory failure (25%). Among the 93 CAs, only 6 cases (6.45%) had a preceding RR called. The initial rhythm was pulseless electrical activity in 58% of cases, 29% asystole and 0.097% had a shockable rhythm. Of the CAs, 9 had shockable rhythms with a 44.4% ROSC rate. The remaining 84 non-shockable rhythms had a 58.3% ROSC rate. ROSC was achieved in 48% of CAs. Overall survival to discharge was 2.1%. Conclusions: This 12-month review of RRs and CAs underscores the need for targeted interventions to identify patients at risk for decompensation. Early recognition of clinical decline can be augmented using the Modified Early Warning Score (MEWS) scoring system within the EMR to support real-time risk stratification and earlier escalation. Furthermore, our nursing survey results suggests a need to encourage nursing staff to activate a RR. Implementing an electronic scoring system to send an alert when higher level of care is warranted along with encouraging all staff to call a rapid response may help prevent future cardiac arrests.

Emergency departments (EDs) serve patients at high risk for overdose. There is increasing interest in peer-delivered ED interventions for substance use but little rigorous research on their effectiveness. To examine the effectiveness of an initiative (Relay) operated by the New York City Health Department that dispatches trained peer wellness advocates (WAs) to support ED patients after a nonfatal opioid overdose. This randomized clinical trial compared Relay and site-directed care (SDC) at 4 EDs in New York, New York. Adult patients presenting after opioid-involved overdose were enrolled from October 6, 2020, to June 30, 2022, with 12 months of outcome follow-up. Statistical analysis was performed from November 4, 2024, to May 6, 2025. ED workers (generally physicians) called the Relay hotline for patients presenting after a suspected opioid-involved overdose. WAs met patients in the ED to provide peer support and brief overdose risk reduction education. WAs attempted to contact patients for 90 days to provide ongoing support, education, and referrals using a harm reduction framework. Opioid-related adverse events (any opioid-involved overdose [fatal or nonfatal] or any other substance use-related ED visit) in the 12 months after enrollment were identified using health care administrative data plus self-report. Among a total of 253 participants randomized, 127 were randomized to the Relay arm and 126 to the SDC arm. A total of 247 participants, 125 in the Relay arm and 122 in the SDC arm (190 [76.9%] men; 80 [32.4%] Black, 126 [51.0%] Hispanic or Latinx, 76 [30.8%] White, and 91 other race [36.8%]), were included in the intention-to-treat analyses. No statistically significant differences between arms were observed for the primary outcome (mean [SD] opioid-related adverse events, 3.29 [4.52] in the Relay arm and 4.10 [9.36] in the SDC arm; rate ratio, 1.02; 95% CI, 0.72-1.45; P = .90). By 12 months after enrollment, 24 participants (9.7%) had died (17 [70.8%] due to overdose). Relay participants reported high satisfaction with the ED intervention. This randomized clinical trial examining the impact of an ED peer navigator intervention on subsequent opioid-related adverse events did not find significant outcome differences for Relay vs SDC participants. These findings highlight the importance of intervening to save lives in this high-risk population and suggest potential refinements to future ED peer intervention research. ClinicalTrials.gov Identifier: NCT04317053.

526 Background: Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality worldwide. Soy contains isoflavones and other bioactive compounds with anti-inflammatory and anti-proliferative effects that may influence liver carcinogenesis. However, epidemiologic studies have reported inconsistent findings. This review aims to investigate the association between soy food consumption and the risk of HCC. Methods: A systematic search was conducted in PubMed, Scopus, and Cochrane for relevant studies published up to 6 September 2025. We included case-control and cohort studies that reported risk estimates for HCC based on varying levels of soy consumption, and assessed heterogeneity using Cochrane’s Q and I² statistics. Random-effects meta-analysis with inverse-variance method was used to pool effect sizes comparing the highest versus lowest categories of soy food consumption. Results: Three studies involving 22,153 participants, all from Asian populations, were included. Based on two case-control studies, in unadjusted analysis, soy food consumption was associated with 10% reduced odds of HCC (odds ratio [OR] 0.90 [95%CI, 0.83-0.98]; I 2 =0.0%, p=0.69). However, after adjusting for key confounders including hepatitis B or C infection and other lifestyle factors such as alcohol use and smoking, this association was no longer significant (adjusted OR 0.46 [0.13-1.60]; I 2 =97%, p<0.001), consistent with findings from a prospective cohort study. Dose-response analysis was not feasible due to inconsistent measurement units. Conclusions: These findings suggest that soy consumption alone is unlikely to play a major role in HCC prevention. Large-scale prospective studies with standardized dietary assessments are needed to clarify whether soy has benefits in high-risk populations, particularly those with chronic liver disease.

Abstract Background Stroke prevention in atrial fibrillation (AF) patients is commonly managed with direct oral anticoagulants (DOACs), which carry an inherent risk of bleeding. We aimed to compare the safety of Factor XI/XIa inhibitors to DOACs, specifically focusing on the risk of major bleeding complications. Purpose We conducted a meta-analysis to assess the safety and efficacy of Factor XI/XIa inhibitors in patients with AF requiring stroke prevention. Methods We conducted a systematic search of different databases for randomized controlled trials (RCTs) comparing Factor XI/XIa to DOACs for stroke prophylaxis in AF Patients. Statistical analysis was performed using R, with Risk Ratios (RR) calculated using a random-effects model. Heterogeneity was assessed using I² and Chi² indices. Results Three RCTs comprising 16,772 patients with AF were included. Of the participants studied, 8,728 (52%) received Factor XI/XIa inhibitors, and 8,044 (48%) received DOACs. Overall, Factor XI/XIa inhibitors were associated with a significantly lower risk of major bleedings (RR 0.39, 95% confidence interval [CI] 0.29–0.53; p < 0.01; I² = 2.8%) compared to Factor Xa inhibitors. There was no significant difference in all-cause mortality between the groups (RR 0.85, 95% CI 0.63–1.15; p = 0.29; I² = 0.0%). Adverse events occurred at similar rates in both treatment arms, with no statistically significant differences observed (RR 1.01, 95% CI 0.97–1.05; p = 0.61; I² = 0.0%). Conclusion This meta-analysis shows that Factor XI/XIa inhibitors significantly reduce the risk of major and clinically relevant non-major bleeding compared to Factor Xa inhibitors, with no significant differences in all-cause mortality or adverse events. These findings highlight Factor XI/XIa inhibitors as promising alternatives for anticoagulation therapy in AF, particularly for patients at high risk of bleeding.

Disclosure: H. Angammana: None. M. Park: None. J. Pesantez: None. A. Sajan: None.Introduction: Myxedema coma is a rare endocrine emergency characterized by profound hypothyroidism with high mortality, often precipitated by infection, medication noncompliance or systemic illness. We present a case of refractory fatal myxedema coma complicated by acute hypoxic respiratory failure, septic shock and multiorgan failure. Case Presentation: A 79-year-old female with a history of hypothyroidism presented with progressively worsening lethargy for few days. She had been noncompliant with levothyroxine for several months. On admission, she was obtunded, hypothermic (90.5 °F), bradycardic (46 beats per minute), and hypotensive (88/50 mmHg). The physical exam revealed facial puffiness, periorbital edema, and generalized non-pitting edema. The laboratory findings were significant for Thyroid Stimulating Hormone (TSH) of 74 IU/mL [0.4-4.0] and free thyroxine (FT4) of 0.27 ng/dL [0.8-1.8]. She also had elevated white blood count (18.2 x10^9/L [4-11 x10^9]), elevated creatinine of 2.1 mg/dL [0.6-1.1], and hyponatremia (127 mmol/L [135-145]). She developed pneumonia with worsening respiratory distress and was intubated for airway protection. Shortly after, she had a lower gastrointestinal bleed requiring multiple blood transfusions. The patient was promptly started on intravenous levothyroxine, liothyronine, hydrocortisone, antibiotics and supportive care. Following initial stabilization, her TSH had improved to 4.76 IU/mL and mental status improved. She was subsequently downgraded to the general medical floor. However, she soon deteriorated in a few days with acute kidney injury requiring renal replacement therapy, newly diagnosed heart failure with a reduced ejection fraction (20%), bilateral pleural effusions and decubitus ulcers with osteomyelitis. She reverted to being lethargic and had a cardiac arrest secondary to aspiration. Given her poor prognosis, care was transitioned to comfort measures, and she passed away under hospice care. Her last drawn TSH was 13.83 IU/ml while on intravenous levothyroxine and liothyronine. Discussion: Myxedema coma continues to have a high mortality rate of about 50%. Predictors of poor prognosis include advanced age, persistent hypothermia, hypotension, bradycardia, sepsis, mechanical ventilation. The prognosis of myxedema coma remains difficult to determine due to its rarity. While early diagnosis and aggressive management have improved survival rates, complications such as sepsis, respiratory failure, and multiorgan dysfunction still result in poor outcomes like in our patient. Further research is needed to refine prognostic models and explore novel therapeutic strategies to improve survival in these patients.Presentation: Monday, July 14, 2025

Acute large bowel obstruction caused by colorectal cancer is a critical surgical emergency, often presenting as a life-threatening condition. This case involves a 71-year-old male who presented to the emergency department with complete large bowel obstruction secondary to a sigmoid mass, raising concern for malignancy. Initial plans were made for decompression and colonoscopy. However, the patient left the hospital against medical advice and subsequently returned two days later with massive abdominal distension and peritonitis. Emergent exploratory celiotomy revealed a septic abdomen with gross contamination due to perforation in the ascending colon near the hepatic flexure, which was not amenable to repair. At a minimum, a subtotal colectomy was required. The patient underwent a single-stage oncologic subtotal colectomy with a hand-sewn ileosigmoid anastomosis and fascial closure. Pathologic evaluation confirmed stage IIb invasive sigmoid adenocarcinoma with negative margins and 0/43 lymph nodes. The patient was discharged on postoperative day nine without complications. For patients presenting with abdominal sepsis from fecal contamination caused by large bowel perforation due to sigmoid malignancy and obstruction, surgical management options vary widely. These range from damage control surgery with multiple subsequent procedures to single-stage resection and anastomosis. This case underscores the importance of individualized, careful decision-making both preoperatively and intraoperatively. It highlights the factors to consider when evaluating the feasibility of single-stage oncologic surgery and the risks associated with performing a primary anastomosis during emergent operations.

Abdominal aortic aneurysms (AAAs) possess significant patient morbidity and mortality, but diagnosis can be missed or delayed given variable presenting symptoms. Renal colic is a potential “red herring” in cases of symptomatic AAA. This case involves an atypical presentation of flank pain likely due to both nephrolithiasis and an AAA. Prompt recognition of AAAs by the emergency department (ED) is critical to prevent misdiagnosis and initiate rapid treatment when indicated.

Isolated hip fractures incur significant mortality within 1year of operative repair. Adequate analgesia is important in maintaining functional status and facilitating recovery. A multi-modal pain management strategy incorporating regional anesthesia may decrease the need for high-dose narcotics and promote faster recovery. The Pericapsular Nerve Group (PENG) block was thus developed as a regional anesthesia option for patients with hip fractures. It involves an ultrasound-guided approach that targets the anterior hip zone to provide a motor-sparing hip block. This write-up provides a sequential, step-by-step guide on how to perform the PENG block in the emergency department.