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Background: Influenza causes significant morbidity and mortality in the United States. Among patients infected with influenza, the presence of bacterial co-infection is associated with worse clinical outcomes; less is known regarding the clinical importance of viral co-infections. The objective of this study was to determine rates of viral co-infections in emergency department (ED) patients with confirmed influenza and association of co-infection with disease severity., Methods: Secondary analysis of a biorepository and clinical database from a parent study where rapid influenza testing was implemented in four U.S. academic EDs, during the 2014-2015 influenza season. Patients were systematically tested for influenza virus using a validated clinical decision guideline. Demographic and clinical data were extracted from medical records; nasopharyngeal specimens from influenza-positive patients were tested for viral co-infections (ePlex, Genmark Diagnostics). Patterns of viral co-infections were evaluated using chi-square analysis. The association of viral co-infection with hospital admission was assessed using univariate and multivariate regression., Results: The overall influenza A/B positivity rate was 18.1% (1071/5919). Of the 999 samples with ePlex results, the prevalence of viral co-infections was 7.9% (79/999). The most common viral co-infection was rhinovirus/enterovirus (RhV/EV), at 3.9% (39/999). The odds of hospital admission (OR 2.33, 95% CI: 1.01-5.34) increased significantly for those with viral co-infections (other than RhV/EV) versus those with influenza A infection only., Conclusion: Presence of viral co-infection (other than RhV/EV) in ED influenza A/B positive patients was independently associated with increased risk of hospital admission. Further research is needed to determine clinical utility of ED multiplex testing., (© 2022 The Authors. Influenza and Other Respiratory Viruses published by John Wiley & Sons Ltd.)

Background: Influenza B accounts for approximately one fourth of the seasonal influenza burden. However, research on the importance of influenza B has received less attention compared to influenza A. We sought to describe the association of both coinfections and comorbidities with disease severity among adults presenting to emergency departments (ED) with influenza B., Methods: Nasopharyngeal samples from patients found to be influenza B positive in four US and three Taiwanese ED over four consecutive influenza seasons (2014-2018) were tested for coinfections with the ePlex RP RUO panel. Multivariable logistic regressions were fitted to model adjusted odds ratios (aOR) for two severity outcomes separately: hospitalization and pneumonia diagnosis. Adjusting for demographic factors, underlying health conditions, and the National Early Warning Score (NEWS), we estimated the association of upper respiratory coinfections and comorbidity with disease severity (including hospitalization or pneumonia)., Results: Amongst all influenza B positive individuals (n = 446), presence of another upper respiratory pathogen was associated with an increased likelihood of hospitalization (aOR = 2.99 [95% confidence interval (95% CI): 1.14-7.85, p = 0.026]) and pneumonia (aOR = 2.27 [95% CI: 1.25-4.09, p = 0.007]). Chronic lung diseases (CLD) were the strongest predictor for hospitalization (aOR = 3.43 [95% CI: 2.98-3.95, p < 0.001]), but not for pneumonia (aOR = 1.73 [95% CI: 0.80-3.78, p = 0.166])., Conclusion: Amongst ED patients infected with influenza B, the presence of other upper respiratory pathogens was independently associated with both hospitalization and pneumonia; presence of CLD was also associated with hospitalization. These findings may be informative for ED clinician's in managing patients infected with influenza B., (© 2021 The Authors. Influenza and Other Respiratory Viruses published by John Wiley & Sons Ltd.)

All academic medical specialties have the obligation to continuously create new knowledge that will improve patient care and outcomes. Emergency medicine (EM) is no exception. Since its origins over 50 years ago, EM has struggled to fulfill its research mission. EM ranks last among clinical specialties in the percentage of medical school faculty who are National Institutes of Health (NIH)-funded principal investigators (PIs; 1.7%) and the percentage of medical school departments with NIH-funded PIs (33%). Although there has been a steady increase in the number of NIH-funded projects and total NIH dollars, the slowing growth in the number of NIH-funded PIs and lack of growth in the number of EM departments with NIH-funded PIs is cause for concern. In response, the Association of Academic Chairs of Emergency Medicine (AACEM) Research Task Force proposes a set of 2030 strategic goals for the EM research enterprise that are based on sustaining historic growth rates in NIH funding. These goals have been endorsed by the AACEM Executive Committee and the boards of Society for Academic Emergency Medicine (SAEM), American College of Emergency Physicians (ACEP), and American Academy of Emergency Medicine (AAEM). The 2030 strategic goals include 200 NIH-funded projects led by 150 EM PIs in at least 50 EM departments with over $100M in annual funding resulting in over 3% of EM faculty being NIH-funded PIs. Achieving these goals will require a targeted series of focused strategies to increase the number of EM faculty who are competitive for NIH funding. This requires a coordinated, intentional effort with investments at the national, departmental, and individual levels. These efforts are ideally led by medical school department chairs, who can create the culture and provide the resources needed to be successful. The specialty of EM has the obligation to improve the health of the public and to fulfill its research mission., (wileyonlinelibrary.com/journal/acem.)

Objectives: Emergency department (ED) patients with serious skin and soft tissue infections (SSTIs) are often hospitalized to receive intravenous (IV) antibiotics. Appropriate patients may avoid admission following a single-dose, long-acting IV antibiotic., Methods: We conducted a preintervention versus postintervention design trial at 11 U.S. EDs comparing hospitalization rates under usual care to those using a clinical pathway that included a single IV dalbavancin dose. We enrolled adults with cellulitis, abscess, or wound infection with an infected area of ≥75 cm 2 without other indications for hospitalization. Clinical pathway participants discharged from the ED received a 24-hour follow-up telephone call and had a 48- to 72-hour in-person visit. We hypothesized that, compared to usual care, the clinical pathway would result in a significant reduction in the initial hospitalization rate., Results: Of 156 and 153 participants in usual care and clinical pathway periods, median infection areas were 255.0 (interquartile range [IQR] = 150.0 to 500.0) cm 2 and 289.0 (IQR = 161.3 to 555.0) cm 2 , respectively. During their initial care, 60 (38.5%) usual care participants were hospitalized and 27 (17.6%) pathway participants were hospitalized (difference = 20.8 percentage points [PP], 95% confidence interval [CI] = 10.4 to 31.2 PP). Over 44 days, 70 (44.9%) usual care and 44 (28.8%) pathway participants were hospitalized (difference = 16.1 PP, 95% CI = 4.9 to 27.4 PP)., Conclusions: Implementation of an ED SSTI clinical pathway for patient selection and follow-up that included use of a single-dose, long-acting IV antibiotic was associated with a significant reduction in hospitalization rate for stable patients with moderately severe infections. Registration: NCT02961764., (© 2021 The Authors. Academic Emergency Medicine published by Wiley Periodicals LLC on behalf of Society for Academic Emergency Medicine.)

Background: Peramivir offers a single-dose intravenous (IV) treatment option for influenza (vs 5-day oral dosing for oseltamivir). We sought to compare outcomes of emergency department (ED) patients at high risk for influenza complications treated with IV peramivir vs oral oseltamivir., Methods: During the 2015-16 and 2016-17 influenza seasons, adult patients in two US EDs were randomized to either oral oseltamivir or IV peramivir treatment group. Eligibility included positive molecular influenza test; met CDC criteria for antiviral treatment; able to provide informed consent and agree to follow-up assessment. Outcomes were measured by clinical end-point indicators, including FLU-PRO Score, Ordinal Scale, Patient Global Impression on Severity Score, and Karnofsky Performance Scale for 14 days. Non-inferior t test was performed to assess comparative outcomes between the two groups., Results: Five hundred and seventy-five (68%) of 847 influenza-positive patients were approached. Two hundred and eighty-four met enrollment criteria and 179 were enrolled; of these 95 (53%) were randomized to peramivir, and 84 to oseltamivir. Average FLU-PRO score at baseline was similar (peramivir: 2.67 vs oseltamivir: 2.52); the score decreased over time for both groups (day 5: peramivir: 1.71 vs oseltamivir: 1.62; day 10: peramivir: 1.48 vs oseltamivir: 1.37; day 14: peramivir: 1.40 vs oseltamivir: 1.33; all P < .05 for significantly non-inferior). Influenza-related complications were similar between two groups (All: peramivir: 31% vs oseltamivir: 21%, P > .05; pneumonia: peramivir: 11% vs oseltamivir: 14%, P > .05)., Conclusions: Clinical outcomes of influenza-infected patients treated with single-dose IV peramivir were comparable to those treated with oral oseltamivir, suggesting potential utility of peramivir for influenza-infected patients in the ED., (© 2020 The Authors. Influenza and Other Respiratory Viruses Published by John Wiley & Sons Ltd.)

Background: An increasing number of U.S. emergency departments (EDs) have implemented ED-based HIV testing programs since the Centers for Disease Control and Prevention issued revised HIV testing recommendations for clinical settings in 2006. In 2010, the National HIV/AIDS Strategy (NHAS) set an linkage-to-care (LTC) rate goal of 85% within 90 days of HIV diagnosis. LTC rates for newly diagnosed HIV-infected patients vary markedly by site, and many are suboptimal. The optimal approach for LTC in the ED setting remains unknown., Objective: The objective was to perform a brief descriptive analysis of the LTC methods practiced in EDs across the United States to determine the overall linkage rate of ED-based HIV testing programs., Methods: We conducted a systematic review of literature related to U.S. ED HIV testing in the adult population using PubMed, Embase, Web of Science, Scopus, and Cochrane. There were 333 articles were identified; 31 articles were selected after a multiphasic screening process. We analyzed data from the 31 articles to assess LTC methods and rates. LTC methods that involved physical escort of the newly diagnosed patient to an HIV/infectious disease (ID) clinic or interaction with a specialist health care provider at the ED were operationally defined as "intensive" LTC protocol. "Mixed" LTC protocol was defined as a program that employed intensive linkage only part of the coverage hours. All other forms of linkage was defined as "nonintensive" LTC protocol. An LTC rate of ≥85% was used to identify characteristics of ED-based HIV testing program associated with a higher LTC rate., Results: There were 37 ED-based HIV testing programs in the 31 articles. The overall LTC rate was 74.4%. Regarding type of protocol, nine (24.3%) employed intensive LTC protocols, 25 (67.6%) nonintensive, two (5.4%) mixed, and one (2.7%) with unclear protocols. LTC rates for programs with intensive and nonintensive LTC protocols were 80.0 and 72.7%, respectively. Four (44.4%) with intensive protocols and nine (36.0%) with the nonintensive protocols had LTC rates > 85%. The linkage staff employed was different between ED programs. Among them, 25 (67.6%) programs used exogenous staff, 10 (27.0%) used the ED staff, and two had no information. All the programs in the nonintensive group utilized drop-in HIV/ID clinic or medical appointments while seven of nine of the programs in the intensive group physically escorted the patients to the initial medical intake appointment. There were no significant differences in characteristics of ED-based HIV testing programs between those with ≥85% LTC rate versus those with <85% within the intensive or nonintensive group., Conclusion: Intensive LTC protocols had a higher LTC rate and a higher proportion of programs that surpassed the >85% NHAS goal compared to nonintensive methods, suggesting that, when possible, ED-based HIV testing programs should adopt intensive LTC strategies to improve LTC outcomes. However, intensive LTC protocols most often required involvement of multidisciplinary non-ED professionals and external research funding. Our findings provide a foundation for developing best practices for ED-based HIV LTC programs., (© 2016 by the Society for Academic Emergency Medicine.)

Objectives: A significant proportion of geriatric patients experience suboptimal outcomes following episodes of emergency department (ED) care. Risk stratification screening instruments exist to distinguish vulnerable subsets, but their prognostic accuracy varies. This systematic review quantifies the prognostic accuracy of individual risk factors and ED-validated screening instruments to distinguish patients more or less likely to experience short-term adverse outcomes like unanticipated ED returns, hospital readmissions, functional decline, or death., Methods: A medical librarian and two emergency physicians conducted a medical literature search of PubMed, EMBASE, SCOPUS, CENTRAL, and ClinicalTrials.gov using numerous combinations of search terms, including emergency medical services, risk stratification, geriatric, and multiple related MeSH terms in hundreds of combinations. Two authors hand-searched relevant specialty society research abstracts. Two physicians independently reviewed all abstracts and used the revised Quality Assessment of Diagnostic Accuracy Studies instrument to assess individual study quality. When two or more qualitatively similar studies were identified, meta-analysis was conducted using Meta-DiSc software. Primary outcomes were sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) for predictors of adverse outcomes at 1 to 12 months after the ED encounters. A hypothetical test-treatment threshold analysis was constructed based on the meta-analytic summary estimate of prognostic accuracy for one outcome., Results: A total of 7,940 unique citations were identified yielding 34 studies for inclusion in this systematic review. Studies were significantly heterogeneous in terms of country, outcomes assessed, and the timing of post-ED outcome assessments. All studies occurred in ED settings and none used published clinical decision rule derivation methodology. Individual risk factors assessed included dementia, delirium, age, dependency, malnutrition, pressure sore risk, and self-rated health. None of these risk factors significantly increased the risk of adverse outcome (LR+ range = 0.78 to 2.84). The absence of dependency reduces the risk of 1-year mortality (LR- = 0.27) and nursing home placement (LR- = 0.27). Five constructs of frailty were evaluated, but none increased or decreased the risk of adverse outcome. Three instruments were evaluated in the meta-analysis: Identification of Seniors at Risk, Triage Risk Screening Tool, and Variables Indicative of Placement Risk. None of these instruments significantly increased (LR+ range for various outcomes = 0.98 to 1.40) or decreased (LR- range = 0.53 to 1.11) the risk of adverse outcomes. The test threshold for 3-month functional decline based on the most accurate instrument was 42%, and the treatment threshold was 61%., Conclusions: Risk stratification of geriatric adults following ED care is limited by the lack of pragmatic, accurate, and reliable instruments. Although absence of dependency reduces the risk of 1-year mortality, no individual risk factor, frailty construct, or risk assessment instrument accurately predicts risk of adverse outcomes in older ED patients. Existing instruments designed to risk stratify older ED patients do not accurately distinguish high- or low-risk subsets. Clinicians, educators, and policy-makers should not use these instruments as valid predictors of post-ED adverse outcomes. Future research to derive and validate feasible ED instruments to distinguish vulnerable elders should employ published decision instrument methods and examine the contributions of alternative variables, such as health literacy and dementia, which often remain clinically occult., (© 2014 by the Society for Academic Emergency Medicine.)

Objectives: Emergency department (ED) computed tomography (CT) use has increased significantly during the past decade. It has been suggested that adherence to clinical decision support (CDS) may result in a safe decrease in CT ordering. In this study, the authors quantified the percentage agreement between routine and CDS-recommended care and the anticipated consequence of strict adherence to CDS on CT use in mild traumatic brain injury (mTBI)., Methods: This was a prospective observational study of patients with mTBI who presented to an urban academic ED of a tertiary care hospital. Patients 18 years or older, presenting within 24 hours of nonpenetrating trauma to the head, from August 2010 to July 2011, were eligible for enrollment. Structured data forms were completed by trained research assistants (RAs). The primary outcome was the percentage agreement between routine head CT use and CDS-recommended head CT use. CDS examined were: the 2008 American College of Emergency Physicians [ACEP] neuroimaging, the New Orleans rule, and the Canadian head CT rule. Differences between outcome groups were assessed using the chi-square test for categorical variables and the Kruskal-Wallis rank test for continuous variables. The percentage agreement between routine practice and CDS-recommended practice was calculated., Results: Of the 169 patients enrolled, 130 (76.9%) received head CT scans, and five of the 130 (3.8%) had acute traumatic intracranial findings. For all subjects, agreement between routine practice and CDS-recommended practice was 77.5, 65.7, and 78.1%, for the ACEP, Canadian, and New Orleans CDS, respectively. Strict adherence to the 2008 ACEP neuroimaging CDS would result in no statistically significant difference in head CT use (routine care, 76.9%; CDS-recommended, 82.8%; p = 0.17). Strict adherence to the New Orleans CDS would result in an increase in head CT use (routine care, 76.9%; CDS-recommended, 94.1%; p < 0.01). Strict adherence to the Canadian CDS would result in a decrease in head CT use (routine care, 76.9%; CDS-recommended, 56.8%; p < 0.01)., Conclusions: There is a 60% to 80% agreement between routine and CDS-recommended head CT use. Of the three CDS systems examined, the only one that may result in a reduction in head CT use if strictly followed was the Canadian head CT CDS. Further studies are needed to examine reasons for the less than optimal agreement between routine care and care recommended by the Canadian head CT CDS., (© 2013 by the Society for Academic Emergency Medicine.)

Objectives: The objective was to describe the proportions of successful linkage to care (LTC) and identify factors associated with LTC among newly diagnosed human immunodeficiency virus (HIV)-positive patients, from two urban emergency department (ED) rapid HIV screening programs., Methods: This was a retrospective analysis of programmatic data from two established urban ED rapid HIV screening programs between November 2005 and October 2009. Trained HIV program assistants interviewed all patients tested to gather risk behavior data using a structured data collection instrument. Reactive results were confirmed by Western blot testing. Patients were provided with scheduled appointments at HIV specialty clinics at the institutions where they tested positive within 30 days of their ED visit. "Successful" LTC was defined as attendance at the HIV outpatient clinic within 30 days after HIV diagnosis, in accordance with the ED National HIV Testing Consortium metric. "Any" LTC was defined as attendance at the outpatient HIV clinic within 1 year of initial HIV diagnosis. Multivariate logistic regression was performed to determine factors associated with any LTC or successful LTC., Results: Of the 15,640 tests administered, 108 (0.7%) were newly identified HIV-positive cases. Nearly half (47.2%) of the patients had been previously tested for HIV. Successful LTC occurred in 54% of cases; any LTC occurred in 83% of cases. In multivariate analysis, having public medical insurance and being self-pay were negatively associated with successful LTC (odds ratio [OR] = 0.33, 95% confidence interval [CI] = 0.12 to 0.96; OR = 0.34, 95% CI = 0.13 to 0.89, respectively); being female and having previously tested for HIV was negatively associated with any LTC (OR = 0.30, 95% CI = 0.10 to 0.93; OR = 0.23, 95% CI = 0.07 to 0.77, respectively)., Conclusions: In spite of dedicated resources for arranging LTC in the ED HIV testing programs, nearly 50% of patients did not have successful LTC (i.e., LTC occurred at >30 days), although >80% of patients were LTC within 1 year of initial diagnosis. Further evaluation of the barriers associated with successful LTC for those with public insurance and self-pay is warranted., (© 2012 by the Society for Academic Emergency Medicine.)

Objectives: Over the past decade, clinicians have become increasingly reliant on computed tomography (CT) for the evaluation of patients with suspected acute appendicitis. To limit the radiation risks and costs of CT, investigators have searched for biomarkers to aid in diagnostic decision-making. We evaluated one such biomarker, calprotectin or S100A8/A9, and determined the diagnostic performance characteristics of a developmental biomarker assay in a multicenter investigation of patients presenting with acute right lower quadrant abdominal pain., Methods: This was a prospective, double-blinded, single-arm, multicenter investigation performed in 13 emergency departments (EDs) from August 2009 to April 2010 of patients presenting with acute right lower quadrant abdominal pain. Plasma samples were tested using the investigational S100A8/A9 assay. The primary outcome of acute appendicitis was determined by histopathology for patients undergoing appendectomy or 2-week telephone follow-up for patients discharged without surgery. The sensitivity, specificity, negative likelihood ratio (LR-), and positive likelihood ratio (LR+) of the biomarker assay were calculated using the prespecified cutoff value of 14 units. A post hoc stability study was performed to investigate the potential effect of time and courier transport on the measured value of the S100A8/A9 assay test results., Results: Of 1,052 enrolled patients, 848 met criteria for analysis. The median age was 24.5 years (interquartile range [IQR] = 16-38 years), 57% were female, and 50% were white. There was a 27.5% prevalence of acute appendicitis. The sensitivity and specificity for the investigational S100A8/A9 assay in diagnosing acute appendicitis were estimated to be 96% (95% confidence interval [CI] = 93% to 98%) and 16% (95% CI = 13% to 19%), respectively. The LR- ratio was 0.24 (95% CI = 0.12 to 0.47), and the LR+ was 1.14 (95% CI = 1.10 to 1.19). The post hoc stability study demonstrated that in the samples that were shipped, the estimated time coefficient was 7.6 × 10(-3) ± 2.0 × 10(-3) log units/hour, representing an average increase of 43% in the measured value over 48 hours; in the samples that were not shipped, the estimated time coefficient was 2.5 × 10(-3) ± 0.4 × 10(-3) log units/hour, representing a 13% increase on average in the measured value over 48 hours, which was the maximum delay allowed by the study protocol. Thus, adjusting the cutoff value of 14 units by the magnitude of systematic inflation observed in the stability study at 48 hours would result in a new cutoff value of 20 units and a "corrected" sensitivity and specificity of 91 and 28%, respectively., Conclusions: In patients presenting with acute right lower quadrant abdominal pain, we found the investigational enzyme-linked immunosorbent assay (ELISA) test for S100A8/A9 to perform with high sensitivity but very limited specificity. We found that shipping effect and delay in analysis resulted in a subsequent rise in test values, thereby increasing the sensitivity and decreasing the specificity of the test. Further investigation with hospital-based laboratory analyzers is the next critical step for determining the ultimate clinical utility of the ELISA test for S100A8/A9 in ED patients presenting with acute right lower quadrant abdominal pain., (© 2012 by the Society for Academic Emergency Medicine.)

Background: The emergency department (ED) is one of the most frequent sources of medical care for many HIV-infected individuals. However, the characteristics and ED utilization patterns of patients with HIV/AIDS-related illness as the primary ED diagnosis (HRIPD) are unknown., Methods: We identified the ED utilization patterns of HRIPD visits from a weighted sample of US ED visits (1993-2005) using the National Hospital Ambulatory Medical Care Survey, a nationally representative survey. Data on visits by patients≥18 years old were analysed using procedures for multiple-stage survey data. We compared the utilization patterns of HRIPD vs. non-HRIPD visits, and patterns across three periods (1993-1996, 1997-2000 and 2001-2005) to take into account changes in HIV epidemiology., Results: Overall, 492 000 HRIPD visits were estimated to have occurred from 1993 to 2005, corresponding to 5-in-10 000 ED visits. HRIPD visits experienced longer durations of stay (5.2 h vs. 3.4 h; P=0.001), received more diagnostic tests (5.1 vs. 3.3; P<0.001), were prescribed more medications (2.5 vs. 1.8; P<0.001) and were more frequently seen by physicians (99.5%vs. 93.8%; P<0.001) compared with non-HRIPD visits. HRIPD visits were more likely to result in admission [adjusted odds ratio (OR) 7.67; 95% confidence interval (CI) 5.14-11.44]. The proportion of HRIPD visits that required emergent/urgent care or were seen by attending physicians, and the number of diagnostic tests ordered, significantly increased over time (P<0.05), while the wait time (P=0.003) significantly decreased between the second and third study periods (P<0.05)., Conclusions: Although HRIPD visits were infrequent relative to all ED visits, HRIPD visits utilized significantly more resources than non-HRIPD visits and the utilization also increased over time., (© 2010 British HIV Association.)

Abstract Public health research requires sound design and thoughtful consideration of potential biases that may influence the validity of results. It also requires careful implementation of protocols and procedures that are likely to translate from the research environment to actual clinical practice. This article is the product of a breakout session from the 2009 Academic Emergency Medicine consensus conference entitled "Public Health in the ED: Screening, Surveillance, and Intervention" and serves to describe in detail aspects of performing emergency department (ED)-based public health research, while serving as a resource for current and future researchers. In doing so, the authors describe methodologic features of study design, participant selection and retention, and measurements and analyses pertinent to public health research. In addition, a number of recommendations related to research methods and future investigations related to public health work in the ED are provided. Public health investigators are poised to make substantial contributions to this important area of research, but this will only be accomplished by employing sound research methodology in the context of rigorous program evaluation., ((c) 2009 by the Society for Academic Emergency Medicine.)

This article describes the results of the human immunodeficiency virus (HIV) and sexually transmitted infections (STI) prevention in the emergency department (ED) component of the 2009 Academic Emergency Medicine Consensus Conference entitled "Public Health in the ED: Surveillance, Screening, and Intervention." The objectives were to use experts to define knowledge gaps and priority research questions related to the performance of HIV and STI surveillance, screening, and intervention in the ED. A four-step nominal group technique was applied using national and international experts in HIV and STI prevention. Using electronic mail, an in-person meeting, and a Web-based survey, specific knowledge gaps and research questions were identified and prioritized. Through two rounds of nomination and refinement, followed by two rounds of election, consensus was achieved for 11 knowledge gaps and 14 research questions related to HIV and STI prevention in EDs. The overarching themes of the research priority questions were related to effectiveness, sustainability, and integration. While the knowledge gaps appear disparate from one another, they are related to the research priority questions identified. Using a consensus approach, we developed a set of priorities for future research related to HIV and STI prevention in the ED. These priorities have the potential to improve future clinical and health services research and extramural funding in this important public health sector., ((c) 2009 by the Society for Academic Emergency Medicine.)

Objectives: The objectives were to determine attitudes and perceptions (A&P) of emergency medicine (EM) residents toward emergency department (ED) routine provider-driven rapid HIV testing services and the impact of both a focused training program (FTP) and implementation of HIV testing on A&P., Methods: A three-phase, consecutive, anonymous, identity-unlinked survey was conducted pre-FTP, post-FTP, and 6 months postimplementation. The survey was designed to assess residents' A&P using a five-point Likert scale. A preimplementation FTP provided both the rationale for the HIV testing program and the planned operational details of the intervention. The HIV testing program used only indigenous ED staff to deliver HIV testing as part of standard-of-care in an academic ED. The impact of the FTP and implementation on A&P were analyzed by multivariate regression analysis using generalized estimating equations to control for repeated measurements in the same individuals. A "favorable" A&P was operationally defined as a mean score of >3.5, "neutral" as mean score of 2.5 to 3.5, and "unfavorable" as mean score of <2.5., Results: Thirty of 36 residents (83.3%) participated in all three phases. Areas of favorable A&P found in phase I and sustained through phases II and III included "ED serving as a testing venue" (score range = 3.7-4.1) and "emergency medicine physicians offering the test" (score range = 3.9-4.1). Areas of unfavorable and neutral A&P identified in phase I were all operational barriers and included required paperwork (score = 3.2), inadequate staff support (score = 2.2), counseling and referral requirements (score range = 2.2-3.1), and time requirements (score = 2.9). Following the FTP, significant increases in favorable A&P were observed with regard to impact of the intervention on modification of patient risk behaviors, decrease in rates of HIV transmission, availability of support staff, and self-confidence in counseling and referral (p < 0.05). At 6 months postimplementation, all A&P except for time requirements and lack of support staff scored favorably or neutral. During the study period, 388 patients were consented for and received HIV testing; six (1.5%) were newly confirmed HIV positive., Conclusions: Emergency medicine residents conceptually supported HIV testing services. Most A&P were favorably influenced by both the FTP and the implementation. All areas of negative A&P involved operational requirements, which may have influenced the low overall uptake of HIV testing during the study period., ((c) 2009 by the Society for Academic Emergency Medicine.)

Early diagnosis of persons infected with human immunodeficiency virus (HIV) through diagnostic testing and screening is a critical priority for individual and public health. Emergency departments (EDs) have an important role in this effort. As EDs gain experience in HIV testing, it is increasingly apparent that implementing testing is conceptually and operationally complex. A wide variety of HIV testing practice and research models have emerged, each reflecting adaptations to site-specific factors and the needs of local populations. The diversity and complexity inherent in nascent ED HIV testing practice and research are associated with the risk that findings will not be described according to a common lexicon. This article presents a comprehensive set of terms and definitions that can be used to describe ED-based HIV testing programs, developed by consensus opinion from the inaugural meeting of the National ED HIV Testing Consortium. These definitions are designed to facilitate discussion, increase comparability of future reports, and potentially accelerate wider implementation of ED HIV testing.

Objectives: To design and evaluate a rapid polymerase chain reaction (PCR)-based assay for detecting Eubacteria and performing early screening for selected Class A biothreat bacterial pathogens., Methods: The authors designed a two-step PCR-based algorithm consisting of an initial broad-based universal detection step, followed by specific pathogen identification targeted for identification of the Class A bacterial biothreat agents. A region in the bacterial 16S rRNA gene containing a highly variable sequence flanked by clusters of conserved sequences was chosen as the target for the PCR assay design. A previously described highly conserved region located within the 16S rRNA amplicon was selected as the universal probe (UniProbe, Integrated DNA Technology, Coralville, IA). Pathogen-specific TaqMan probes were designed for Bacillus anthracis, Yersinia pestis, and Francisella tularensis. Performance of the assay was assessed using genomic DNA extracted from the aforementioned biothreat-related organisms (inactivated or surrogate) and other common bacteria., Results: The UniProbe detected the presence of all tested Eubacteria (31/31) with high analytical sensitivity. The biothreat-specific probes accurately identified organisms down to the closely related species and genus level, but were unable to discriminate between very close surrogates, such as Yersinia philomiragia and Bacillus cereus., Conclusions: A simple, two-step PCR-based assay proved capable of both universal bacterial detection and identification of select Class A bacterial biothreat and biothreat-related pathogens. Although this assay requires confirmatory testing for definitive species identification, the method has great potential for use in ED-based settings for rapid diagnosis in cases of suspected Category A bacterial biothreat agents.

Objectives: To develop and evaluate screening algorithms to predict current chlamydial and gonococcal infections in emergency department (ED) settings and assess their performance., Methods: Between 2002 and 2005, adult patients aged 18 to 35 years attending an urban ED were screened for Chlamydia trachomatis (Ct) and Neisseria gonorrhoeae (GC) and completed a brief demographic and behavioral questionnaire. Using multiple unconditional logistic regressions, the authors developed four separate predictive models and applicable clinical risk scores to screen for infection. They developed models for females and males separately, for Ct and GC infections combined, and for Ct infection alone. The sensitivities and specificities of the clinical risk scores at different cutoffs were used to examine performance of the algorithms., Results: Among 5,537 patients successfully screened for Ct and GC, the overall prevalence of infection was 9.6%. Age was the strongest predictor of infection. Adjusting for other predictors, the prevalence odds ratio (POR) was 2.2 (95% confidence interval [CI] = 1.7 to 2.8) for Ct and GC combined and 2.9 (95% CI = 2.1 to 4.1) for Ct alone comparing females 25 years and younger to females older than 25 years. Among males, the association was stronger with an adjusted POR of 3.3 (95% CI = 2.3 to 4.7) for Ct and GC combined and 3.2 (95% CI = 2.1 to 4.7) for Ct infection alone., Conclusions: If the decision to incorporate Ct and GC screening into routine ED care is made, age alone appears to be a sufficient screening criterion.

The 2006 Academic Emergency Medicine Consensus Conference discussed key concepts within the field of surge capacity. Within the breakout session on research priorities, experts in disaster medicine and other related fields used a structured nominal-group process to delineate five critical areas of research. Of the 14 potential areas of discovery identified by the group, the top five were the following: 1) defining criteria and methods for decision making regarding allocation of scarce resources, 2) determining effective triage protocols, 3) determining key decision makers for surge-capacity planning and means to evaluate response efficacy (e.g., incident command), 4) developing effective communication and information-sharing strategies (situational awareness) for public-health decision support, and 5) developing methods and evaluations for meeting workforce needs. Five working groups were formed to consider the above areas and to devise sample research questions that were refined further by the entire group of participants.

Objective: To perform a systematic review of the emergency medicine literature to assess the appropriateness of offering routine HIV screening to patients in the emergency department (ED)., Methods: The systematic review was conducted with the aid of a structured template, a companion explanatory guide, and a grading and methodological scoring system based on published criteria for critical appraisal. Two reviewers conducted independent searches using OvidR, PubMed, MD Consult, and Grateful Med. Relevant abstracts were reviewed; those most pertinent to the stated objective were selected for complete evaluation using the structured template., Results: Fifty-two relevant abstracts were reviewed; of these, nine were selected for detailed evaluation. Seven ED-based prospective cross-sectional seroprevalence studies found HIV rates of 2-17%. Highest rates of infection were seen among patients with behavioral risks such as male homosexual activity and intravenous drug use. Two studies demonstrated feasibility of both standard and rapid HIV testing in the ED, with more than half of the patients approached consenting to testing by either method, consistent with voluntary testing acceptance rates described in other settings. Several cost-benefit analyses lend indirect support for HIV screening in the ED., Conclusions: Multiple ED-based studies meeting the Centers for Disease Control and Prevention Guideline threshold to recommend routine screening, in conjunction with limited feasibility trials and extrapolation from cost-benefit studies, provide evidence to recommend that EDs offer HIV screening to high-risk patients (i.e., those with identifiable risk factors) or high-risk populations (i.e., those where HIV seroprevelance is at least 1%).

Objective: To determine which neurologic signs or symptoms are predictive of new focal lesions on head CT in HIV-infected patients., Methods: Prospective study with convenience sample enrollment of HIV-infected patients who presented to a large inner-city university-based ED over an 11-month period. Patients were assessed using a standardized neurologic evaluation to ascertain whether they had developed new or changed neurologic signs or symptoms. Patients with any new or changed neurologic findings had a head CT scan in the ED. The association between individual complaints or findings and new focal lesions on head CT was assessed by univariate analysis, and sensitivity, specificity, and positive predictive values were calculated. Stepwise logistic regression analysis was then carried out to estimate the relative risk for those variables independently associated with new focal lesions on CT scans. A decision guideline was developed incorporating those variables., Results: One hundred ten patients were identified as having new or changed neurologic signs or symptoms and had a head CT done in the ED. Twenty-seven patients (24%) had focal lesions on head CT, of which 19 (18%) were identified as new focal lesions; eight of these (7%) demonstrated a mass effect. Clinical findings most strongly associated with new focal findings on head CT were: 1) new seizure, relative risk (RR) = 73.5, 95% CI = 6.2 to 873.0; 2) depressed or altered orientation, RR = 39.1, 95% CI = 4.6 to 330.0; and 3) headache, different in quality, RR = 27.0, 95% CI = 3.2 to 230.1. Use of these three findings as a screen for ordering head CT in the ED would have identified 95% (18/19) of the patients with new focal intracranial lesions, and resulted in a 53% reduction in the number of head CTs ordered in the ED. Inclusion of one additional parameter (prolonged headache, > or =3 days), would have resulted in identification of 100% of all new focal lesions, with a 37% reduction in the number of head CTs ordered. Among those patients with new focal findings, 74% required emergent management (i.e., seizure control, IV antibiotics, IV steroids or surgery). The most common intracranial lesion among patients with CD4 counts less than 200 cells/microL was toxoplasmosis, while cerebrovascular accidents (ischemic or hemorrhagic) were most common in those with CD4 counts greater than 200 cells/microL., Conclusion: Specific clinical signs and symptoms were associated with the presence of new intracranial lesions in a group of HIV-infected patients who presented to the ED with neurologic complaints. These clinical findings can be incorporated into guidelines for determining the need for emergent head CT. Validation and widespread application of these guidelines could result in limiting the use of emergent neuroimaging to a more well-defined HIV-infected patient population.