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Copyright of Academic Emergency Medicine is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Objective This paper examines how negative experiences with the health-care system create a lack of confidence in receiving medical care in seven countries: Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States. Methods The empirical analysis is based on data from the Commonwealth Fund International Health Policy Survey 2007, with nationally representative samples of adults aged 18 and over. For the analysis of the experience of cost barriers and confidence in receiving medical care, we conducted pairwise comparisons of group percentages as well as country-wise multivariate logistic regression models. Results Individuals who have experienced cost barriers show a significantly lower level of confidence in receiving safe and quality medical care than those who have not. This effect is most pronounced in the United States, where people who have foregone necessary treatment because of costs are four times as likely to lack confidence as individuals without the experience of cost barriers (adjusted odds ratio 4.00). In New Zealand, Germany, and Canada, individuals with the experience of cost barriers are twice as likely to report low confidence compared with those without this experience (adjusted odds ratios of 1.95, 2.19 and 2.24, respectively). In the Netherlands and UK, cost barriers are only a marginal phenomenon. Conclusions The fact that the experience of financial barriers considerably lowers confidence indicates that financial incentives, such as private co-payments, have a negative effect on overall public support and therefore on the legitimacy of health-care systems. [ABSTRACT FROM AUTHOR]

Aim: The American Academy of Pediatrics and the European Centre for Pediatric and Adolescent Medicine guideline define fever as a temperature >38.0°C for all ages and recommend use of rectal thermometers in children <3 years. Based on new literature, this definition of fever using a fixed threshold of 38.0°C needs to be re‐examined. Design: A multi‐site diagnostic accuracy study was conducted to compare an "age‐based" threshold model with a "fixed" threshold over 38.0°C on a total of 894 patients of which 373 were ill. Methods: The "age‐based" and "fixed" threshold fever determinations were then compared to a clinical categorization ("well" or "ill") conducted by a clinician through a comprehensive examination. Results: The sensitivity and accuracy for the age‐based thresholds were found to be superior to the fixed thresholds in all ages and current ear thermometers were found equivalent to rectal thermometers in infants <6 months. [ABSTRACT FROM AUTHOR]

Objective: The objective was to describe and validate construction of a population‐based, longitudinal cohort of injured older adults from 9‐1‐1 call to 1‐year follow‐up using existing data sources, probabilistic linkage, and multiple imputation. Methods: This was a descriptive cohort study conducted in seven counties in Oregon and Washington from January 1, 2011, through December 31, 2011, with follow‐up through December 31, 2012. The primary cohort included all injured adults ≥ 65 years served by 44 emergency medical services (EMS) agencies. We used nine existing databases to assemble the cohort, including EMS data, two state trauma registries, two state discharge databases, two state vital statistics databases, the Oregon Physician Order for Life‐Sustaining Treatment registry, and Medicare claims data. We matched data files using probabilistic linkage and handled missing values with multiple imputation. We independently validated data processes using 1,350 randomly sampled records for probabilistic linkage and 3,140 randomly sampled records for variables created from existing data sources. Results: There were 15,649 injured older adults in the primary cohort, with 13,661 (87.3%) total matched records and 9,337 (59.7%) matches to the index ED/hospital visit. The sensitivity of linkage was 99.9% (95% confidence interval [CI] = 99.3%–100%) for any match and 98.3% (95% CI = 96.2%–99.4%) for index event matches. The specificity of linkage was 95.7% (95% CI = 93.7%–97.2%) for any match and 100% (95% CI = 99.2%–100%) for index event matches. Name, date of birth, home zip code, age, and hospital had the highest yield for linkage. Patients with matched records tended to be higher acuity than unmatched patients, suggesting selection bias if unmatched patients were excluded. Compared to hand‐abstracted values, the sensitivity of electronically derived variables ranged from 18.2% (abdominal‐pelvic Abbreviated Injury Scale score ≥ 3) to 97.4% (in‐hospital mortality), with specificity of 88.0% to 99.8%. Conclusions: A population‐based emergency care cohort with long‐term outcomes can be constructed from existing data sources with high accuracy and reasonable validity of resulting variables. [ABSTRACT FROM AUTHOR]

Objectives The opioid abuse and overdose epidemic in the United States has led to the need for new practice policies to guide clinicians. We describe implementation of opioid-related policies in emergency departments ( EDs) in New England to gauge progress and determine where further work is needed. Methods This study analyzed data from the 2015 National Emergency Department Inventory-New England survey. The survey queried directors of every ED ( n = 195) in the six New England states to determine the implementation of five specific policies related to opioid management. ED characteristics (e.g., annual visits, location, and admission rates) were also obtained and a multivariable analysis was conducted to identify ED characteristics independently associated with the number of opioid-related policies implemented. Results Overall, 169 EDs (87%) responded, with a >80% response rate in each state. Implementation of opioid-related policies varied as follows: 1) use of a screening tool for patients with suspected prescription opioid abuse potential ( n = 30, 18%), 2) access state prescription drug monitoring program ( PDMP) before prescribing opioids ( n = 132, 78%), 3) notify the primary opioid prescriber when prescribing opioids for ED patients with chronic pain ( n = 69, 41%), 4) refer patients with opioid abuse to recovery resources ( n = 117, 70%), and 5) prescribe naloxone to patients at risk of opioid overdose after ED discharge ( n = 19, 12%). EDs located in metropolitan areas and with at least one attending physician on duty 24/7 were less likely to implement opioid policies (incident rate ratio [ IRR] = 0.65, 95% confidence interval [ CI] = 0.48-0.89; and IRR = 0.78, 95% CI = 0.6-1.0, respectively) while EDs with ≥15% hospitalization rate that used electronic computerized medication ordering and those in Rhode Island were more likely to implement opioid policies ( IRR = 1.23, 95% CI = 1.03-1.48; IRR = 1.95, 95% CI = 1.19-3.22; and IRR = 1.30, 95% CI = 1.08-1.56, respectively). Conclusions The implementation of opioid-related policies varies among New England EDs. The presence of policies recommending use of screening tools and prescribing naloxone for at-risk patients was low, whereas those regarding utilization of the PDMP and referral of patients with opioid abuse to recovery resources were more common. These data provide important benchmarks for future evaluations and recommendations. [ABSTRACT FROM AUTHOR]

Objective Delayed diagnosis of Kawasaki disease ( KD) may lead to serious cardiac complications. We sought to create and test the performance of a natural language processing ( NLP) tool, the KD- NLP, in the identification of emergency department ( ED) patients for whom the diagnosis of KD should be considered. Methods We developed an NLP tool that recognizes the KD diagnostic criteria based on standard clinical terms and medical word usage using 22 pediatric ED notes augmented by Unified Medical Language System vocabulary. With high suspicion for KD defined as fever and three or more KD clinical signs, KD- NLP was applied to 253 ED notes from children ultimately diagnosed with either KD or another febrile illness. We evaluated KD- NLP performance against ED notes manually reviewed by clinicians and compared the results to a simple keyword search. Results KD- NLP identified high-suspicion patients with a sensitivity of 93.6% and specificity of 77.5% compared to notes manually reviewed by clinicians. The tool outperformed a simple keyword search (sensitivity = 41.0%; specificity = 76.3%). Conclusions KD- NLP showed comparable performance to clinician manual chart review for identification of pediatric ED patients with a high suspicion for KD. This tool could be incorporated into the ED electronic health record system to alert providers to consider the diagnosis of KD. KD- NLP could serve as a model for decision support for other conditions in the ED. [ABSTRACT FROM AUTHOR]

Objectives Clinicians often need to rapidly reverse vitamin K antagonists ( VKAs) in the setting of major hemorrhage or urgent need for surgery. Little is known about the safety profile of the traditional reversal agent, plasma, or the newly approved agent, four-factor prothrombin complex concentrate (4F- PCC), in a randomized setting. This is an integrated analysis of safety data from two clinical trials that evaluated 4F- PCC versus plasma for the treatment of patients requiring rapid VKA reversal for acute major bleeding or prior to an urgent surgical/invasive procedure. Methods This descriptive analysis comprised adverse event ( AE) data from two phase IIIb, randomized, controlled trials. The bleeding and surgical studies were performed across 36 and 33 sites, respectively, in nine countries, with the integrated analysis comprising 388 patients (4F- PCC, n = 191; plasma, n = 197) aged ≥ 18 years, who required VKA reversal due to major bleeding or prior to an urgent surgical/invasive procedure. Patients received either 4F- PCC, containing nonactivated factors II, VII, IX, and X and proteins C and S (Beriplex/Kcentra, CSL Behring) or plasma, both dosed according to baseline international normalized ratio and body weight. Patients were also to receive vitamin K1. AEs and serious AEs ( SAEs) were assessed up to days 10 and 45, respectively. Results The proportion of patients with AEs (4F- PCC, 115/191 [60.2%]; plasma, 124/197 [62.9%]) and SAEs (4F- PCC, 54/191 [28.3%]; plasma, 49/197 [24.9%]) was similar between groups. The proportion of patients with thromboembolic events was also similar between groups (4F- PCC, 14/191 [7.3%]; plasma, 14/197 [7.1%]). There were 13 (6.8%) deaths in the 4F- PCC group and 13 (6.6%) in the plasma group. Fluid overload events occurred in more patients in the plasma group than the 4F- PCC group (25 [12.7%] and 9 [4.7%], respectively). Conclusions These safety data represent the largest controlled assessment of a 4F- PCC to date. For patients requiring urgent VKA reversal, 4F- PCC had a safety profile similar to that of plasma ( AEs, SAEs, thromboembolic events, and deaths), but was associated with fewer fluid overload events. [ABSTRACT FROM AUTHOR]

Objectives The Review Committee for Emergency Medicine (RC-EM) requirement for scholarly activity, which programs may define as an original research project or some other form of scholarly activity, applies to all EM residents. The objectives of this study were to: 1) describe the percentage of residency programs that require an original research project to meet the RC-EM requirement for scholarly activity, 2) describe specific challenges and resources for residents completing the RC-EM scholarly activity requirement, and 3) identify associations between the interpretation of the requirement and early career outcomes. Methods This was a cross-sectional online survey of program or research directors from all U.S. allopathic EM residency programs. Respondents were queried about key demographics and domains relating to research curriculum, resources, expectations, outcomes, challenges, and future opportunities. Data were analyzed using descriptive statistics. Results The overall response rate was 113 of 156 (72%) EM residency programs. Respondents were more likely to represent university-based programs, but otherwise did not differ from nonrespondents across key demographic criteria. An original research project was required by 39% of responding programs, with a minimum deliverable in 93% of these programs. Program directors listed data collection and study design as the principle challenges residents face while completing their scholarly activities. Faculty mentorship, biostatistical support, and travel support were common resources reportedly available to residents. Comparison of programs with an original research requirement to those without revealed many differences in outcomes. Programs with a research requirement were more likely to have residents with oral or poster presentations (46% vs. 25%, mean difference = 21%, 95% confidence interval [CI] = 16% to 28%), published manuscripts (25% vs. 18%, mean difference = 7%, 95% CI = 2% to 10%), entering fellowship training after residency (27% vs. 20%, mean difference = 7%, 95% CI = 4% to 10%), and using a biostatistician (64% vs. 28%, median difference = 26%, 95% CI = 24% to 28%). There were no statistically significant differences in other evaluations of resources or outcome measures, including resident choice of academic career after leaving residency. Conclusions There is no consistent interpretation and implementation of the RC-EM requirement for scholarly activity among EM residency programs. Residency programs requiring an original research project were more likely to have residents with accepted oral or poster presentations, published manuscripts, and entering fellowships after residency training. [ABSTRACT FROM AUTHOR]

Copyright of Academic Emergency Medicine is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Objectives The study hypothesis was that a target-specific anticoagulant would allow successful home treatment of selected patients with deep vein thrombosis ( DVT) and pulmonary embolism ( PE) diagnosed in two urban emergency departments ( EDs). Methods A protocol was established for treating low-risk DVT or PE patients with rivaroxaban and clinic, follow-up at both 2 to 5 weeks, and 3 to 6 months. Patients were determined to be low-risk by using a modified version of the Hestia criteria, supplemented by additional criteria for patients with active cancer. Acceptable outcome rates were defined as venous thromboembolism ( VTE) recurrence ≤ 2.1% or bleeding ≤ 9.4% during treatment. VTE recurrence required positive imaging of any VTE. The International Society of Thrombosis and Hemostasis definition of major or clinically relevant nonmajor bleeding was used. Results From March 2013 through April 2014, a total of 106 patients were treated. Seventy-one (68%) had DVT, 30 (28%) had PE, and five (3%) had both, representing 51% of all DVTs and 27% of all PEs diagnosed in both EDs during the period of study. The 106 patients have been followed for a mean (± SD) of 389 (±111) days (range = 213 to 594 days). No patient had VTE recurrence, and no patient had a major or clinically relevant bleeding event while on therapy (none of the 106, 0%, 95% confidence interval [ CI] = 0% to 3.4%). However, three patients 2.8% (95% CI = 1% to 8%) had recurrent DVT after cessation of therapy. Conclusions Patients diagnosed with VTE and immediately discharged from the ED while treated with rivaroxaban had a low rate of VTE recurrence and bleeding. [ABSTRACT FROM AUTHOR]

Objectives Studies have documented increased advanced radiography use in U.S. emergency departments ( EDs) for injured patients over the past decade. The authors explored trends in recent years (2007 through 2010) in advanced radiography use, specifically head computed tomography ( CT) and nonhead CT scans. Methods This was a retrospective analysis of ED visits conducted using data from the National Hospital Ambulatory Medical Care Survey ( NHAMCS), a representative sample of the U.S. ED visits from 2007 through 2010. All patients designated by the NHAMCS as 'related to injury' were included in analyses. CT use was examined by head and nonhead use. Trends, predictors of utilization, and diagnostic yield for head and nonhead CT scans in injured ED patients were analyzed using survey-weighted logistic regression. Diagnostic yield was defined as the proportion of injury-related visits where patients imaged with CT received International Classification of Diseases, 9th Revision ( ICD-9), code diagnoses of a severe head or nonhead injury. Results Among injured ED patients, head CT use increased from 9.6% in 2007 to 11.6%, a relative increase of 20.8% (p < 0.001), and nonhead CT from 5.5% to 7.3%, a relative increase of 47.3% (p < 0.001). Diagnostic yield for head CT was unchanged (4.9% in 2007 vs. 3.4% in 2010, p = 0.093), but fell for nonhead CT from 6.4% in 2007 to 3.3% in 2010 (p = 0.04. Conclusions Advanced radiography use has continued to increase since 2007 in injured patients, and diagnostic yield for nonhead CT has continued to fall. Head CT is more common than CTs of other body areas and may represent an opportunity for reduction given validated clinical decision rules. [ABSTRACT FROM AUTHOR]

Objectives The use of opioid analgesics in the United States has significantly increased in recent years. However, there is minimal consensus on what discharge counseling should accompany these high-risk prescriptions and large variations in what is done in practice. The objective of this study was to evaluate the effect of a dual-modality (written and spoken) literacy-appropriate educational strategy on patients' knowledge of and safe use of opioid analgesics. Methods This was a prospective, randomized controlled trial. Consecutive discharged patients at an urban academic ED (>88,000 visits) with new prescriptions for hydrocodone-acetaminophen were enrolled. Patients were randomized to receive either usual care or the educational intervention. The educational intervention was a one-page information sheet about hydrocodone-acetaminophen, which was both given to the patients and read aloud by the research assistant (nonblinded). Follow-up phone calls were conducted 4 to 7 days after the visit to assess patient knowledge about the medication and self-report of activities associated with safety of use (e.g., double-dipping with acetaminophen, storage, use with alcohol or while driving). Results A total of 274 patients were enrolled; 210 completed follow-up (110 usual care and 100 intervention). No significant differences in baseline characteristics emerged between the study arms; 42% were male, and 51% were white, with a median age of 43 years. Half of patients had non-back pain orthopedic injuries (49.5%). On follow-up, overall knowledge was poor, with only 28% able to name both active ingredients in the medication. The intervention group had better knowledge of precautions related to taking additional acetaminophen (usual care 18.2%, 95% confidence interval [ CI] = 10.9% to 25.5% vs. intervention 38%, 95% CI = 28.3% to 47.7%; difference = 27.6, 95% CI of difference = 21.5 to 33.7) and knowledge of side effects (usual care median = 1, interquartile range [ IQR] 0 to 2 vs. intervention median = 2, IQR = 1 to 2; p < 0.0001). Additionally, those who received the intervention were less likely to have reported driving within 6 hours after taking hydrocodone (usual care 13.6%, 95% CI = 7.2% to 20% vs. intervention 3%, 95% CI = -0.3% to 6.3%; difference = 10.6, 95% CI of difference = 3.4 to 17.9). There was no difference between groups related to knowledge about drinking alcohol while taking hydrocodone (overall 18.1%) or knowledge that the opioid could be addictive (overall 72.4%). Conclusions This simple strategy improved several, but not all, aspects of patient knowledge and resulted in fewer patients in the intervention arm driving while taking hydrocodone. Integration of a patient education document into conversations about opioids holds promise for improving patient knowledge about these high-risk medications. [ABSTRACT FROM AUTHOR]

Objectives As the U.S. economy began its downward trend in 2008, many citizens lost their jobs and, ultimately, their employer-sponsored health care insurance. The expectation was that many of the newly uninsured would turn to emergency departments ( EDs) for their health care. This study was undertaken to determine, first, if changes in the insurance status of the general population were reflected in the ED insurance payer mix and, second, whether there was evidence of an increased reliance on the ED as a continuing source of health care for any payer group(s). Methods This was a retrospective observational study using public data files from the National Hospital Ambulatory Medical Care Survey for Emergency Departments for years 2006 through 2010 (2008 ± 2 years). Changes in the relative proportions of ED visits funded annually by private insurance, Medicaid, Medicare, and self-pay (uninsured) were analyzed using a logistic model. Poisson regression was used to compare trends in the rates of ED visits for each payer type (i.e., number of ED visits per 100 persons with each insurance type). A linear spline term was used to determine if there was a change in each risk estimate after 2008 compared to the risk estimate before 2008. Results Before 2008, the odds of an ED visit being funded by private insurance increased by 4% per year (odds ratio [ OR] = 1.04, 95% confidence interval [ CI] = 0.98 to 1.10; p = 0.15), but after 2008 the odds reversed, decreasing by nearly 10% per year ( OR = 0.91, 95% CI = 0.85 to 0.97; p = 0.02). Medicaid-funded visits demonstrated opposite trends with a small decreasing trend of 2% per year before 2008 ( OR = 0.98, 95% CI = 0.92 to 1.04; p = 0.52), followed by a significantly increasing trend of 20% per year after 2008 ( OR = 1.20, 95% CI = 1.12 to 1.27; p = 0.001). The growth in Medicaid-funded ED visits was attributable to increased numbers of visits by both pediatric (<18 years old) and non-elderly adult (19 to 64 years old) patients. For both Medicaid and private insurance visits, the change in trend in 2008 was statistically significant (p < 0.001 and p = 0.004, respectively). Self-pay visits were fairly steady before 2008 and then increased by about 5% per year after 2008, but this was not statistically significant ( OR = 1.05, 95% CI = 0.96 to 1.14; p = 0.46), nor was the change in trend (p = 0.29). The results for Medicare-funded visits were also small and not statistically significant. There was also evidence of increased reliance on the ED by Medicaid-funded patients based on the comparison of ED visit rates. After 2008, the incidence rate ratio ( IRR) for Medicaid-funded visits increased by 10% per year ( IRR = 1.10, 95% CI = 1.10 to 1.10; p < 0.001) while the IRR for the other three payer groups changed about 1% per year ( IRR = 0.99, 95% CI = 0.99 to 0.099; p < 0.001), indicating an increasing utilization of the ED by patients with Medicaid-funded care. Conclusions After 2008, Medicaid patients were more dependent on ED services than uninsured, Medicare, or privately insured patients. Medicaid patients made up an increasing proportion of ED patients, and the rate of usage of ED services by all ages of Medicaid patients was significantly greater than that of the other three payer groups. [ABSTRACT FROM AUTHOR]

Copyright of Academic Emergency Medicine is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Academic Emergency Medicine is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Academic Emergency Medicine is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Objective To examine the degree to which shared risk factors explain the relationship of periodontitis (PD) to rheumatoid arthritis (RA) and to determine the associations of PD and Porphyromonas gingivalis with pathologic and clinical features of RA. Methods Patients with RA (n = 287) and patients with osteoarthritis as disease controls (n = 330) underwent a standardized periodontal examination. The HLA-DRB1 status of all participants was imputed using single-nucleotide polymorphisms from the extended major histocompatibility complex. Circulating anti- P gingivalis antibodies were measured using an enzyme-linked immunosorbent assay, and subgingival plaque was assessed for the presence of P gingivalis using polymerase chain reaction (PCR). Associations of PD with RA were examined using multivariable regression. Results Presence of PD was more common in patients with RA and patients with anti-citrullinated protein antibody (ACPA)-positive RA (n = 240; determined using the anti-cyclic citrullinated peptide 2 [anti-CCP-2] test) than in controls (35% and 37%, respectively, versus 26%; P = 0.022 and P = 0.006, respectively). There were no differences between RA patients and controls in the levels of anti- P gingivalis or the frequency of P gingivalis positivity by PCR. The anti- P gingivalis findings showed a weak, but statistically significant, association with the findings for both anti-CCP-2 (r = 0.14, P = 0.022) and rheumatoid factor (RF) (r = 0.19, P = 0.001). Presence of PD was associated with increased swollen joint counts ( P = 0.004), greater disease activity according to the 28-joint Disease Activity Score using C-reactive protein level ( P = 0.045), and higher total Sharp scores of radiographic damage ( P = 0.015), as well as with the presence and levels of anti-CCP-2 ( P = 0.011) and RF ( P < 0.001). The expression levels of select ACPAs (including antibodies to citrullinated filaggrin) were higher in patients with subgingival P gingivalis and in those with higher levels of anti- P gingivalis antibodies, irrespective of smoking status. Associations of PD with established seropositive RA were independent of all covariates examined, including evidence of P gingivalis infection. Conclusion Both PD and P gingivalis appear to shape the autoreactivity of RA. In addition, these results demonstrate an independent relationship between PD and established seropositive RA. [ABSTRACT FROM AUTHOR]

Copyright of Academic Emergency Medicine is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Academic Emergency Medicine is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

In this study, we examine the relationship between employee perceptions of supervisor abuse, emotional exhaustion, psychological entitlement, and subsequent co-worker abuse. We hypothesize that higher levels of employee psychological entitlement moderate the abusive supervisor - emotional exhaustion relationship - and this interaction mediates the abusive supervision - co-worker abuse relationship. Using multilevel-moderated mediation analysis to analyse day-level survey data from a lagged panel design across five working days from 132 working adults and their co-workers across multiple industries, we found support for our hypothesized model. We discuss implications for theory, future research, and management practice that result from our study. Practitioner points Psychologically entitled employees who perceive more abusive supervision are more emotionally exhausted and more likely to abuse their co-workers; therefore, organizations need to identify patterns indicative of these types of employees., Stressed environments likely exacerbate these relationships, and organizations might consider regular workforce surveys assessing employee emotional exhaustion, which is a trigger for harmful employee work behaviours. [ABSTRACT FROM AUTHOR]

Copyright of Academic Emergency Medicine is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Context The patterns of health care utilization in the United States pose well-established challenges for public policy. Although economic and sociological research has resulted in considerable knowledge about what influences the use of health services, the psychological literature in this area is underdeveloped. Importantly, it is not known whether personality traits are associated with older adults' use of acute and long-term care services. Methods Data were collected from 1,074 community-dwelling seniors participating in a Medicare demonstration. First they completed a self-report questionnaire measuring the 'Big Five' personality traits: Neuroticism, Extraversion, Openness to Experience, Agreeableness, and Conscientiousness. During the next two years, the participants maintained daily journals of their use of health care services. We used regression models based on the Andersen behavioral model of health care utilization to test for associations. Findings Our hypothesis that higher Neuroticism would be associated with greater health care use was confirmed for three services-probability of any emergency department (ED) use, likelihood of any custodial nursing home use, and more skilled nursing facility (SNF) days for SNF users-but was disconfirmed for hospital days for those hospitalized. Higher Openness to Experience was associated with a greater likelihood of custodial home care use, and higher Agreeableness and lower Conscientiousness with a higher probability of custodial nursing home use. For users, lower Openness was associated with more ED visits and SNF days, and lower Conscientiousness with more ED visits. For many traits with significant associations, the predicted use was 16 to 30 percent greater for people high (low) versus low (high) in specific traits. Conclusions Personality traits are associated with Medicare beneficiaries' use of many expensive health care services, findings that have implications for health services research and policy. Accordingly, person-centered interventions, population-based translational effectiveness programs, and other personalized approaches that leverage the profound advances in personality psychology in recent decades should be considered. [ABSTRACT FROM AUTHOR]

Context: Colorectal cancer is a major cause of mortality in the United States, with 52,857 deaths estimated in 2012. To explore further the social inequalities in colorectal cancer mortality, we used fundamental cause theory to consider the role of societal diffusion of information and socioeconomic status. Methods: We used the number of deaths from colorectal cancer in U.S. counties between 1968 and 2008. Through geographical mapping, we examined disparities in colorectal cancer mortality as a function of socioeconomic status and the rate of diffusion of information. In addition to providing year-specific trends in colorectal cancer mortality rates, we analyzed these data using negative binomial regression. Findings: The impact of socioeconomic status (SES) on colorectal cancer mortality is substantial, and its protective impact increases over time. Equally important is the impact of informational diffusion on colorectal cancer mortality over time. However, while the impact of SES remains significant when concurrently considering the role of diffusion of information, the propensity for faster diffusion moderates its effect on colorectal cancer mortality. Conclusions: The faster diffusion of information reduces both colorectal cancer mortality and inequalities in colorectal cancer mortality, although it was not sufficient to eliminate SES inequalities. These findings have important long-term implications for policymakers looking to reduce social inequalities in colorectal cancer mortality and other, related, preventable diseases. [ABSTRACT FROM AUTHOR]

ACADEMIC EMERGENCY MEDICINE 2012; 19:843-849 © 2012 by the Society for Academic Emergency Medicine Abstract Objectives: Drug overdose is a leading cause of cardiac arrest and is currently the second leading cause of overall injury-related fatality in the United States. Despite these statistics, the incidence of adverse cardiovascular events (ACVEs) in emergency department (ED) patients following acute drug overdose is unknown. With this study, we address the 2010 American Heart Association Emergency Cardiovascular Care update calling for research to characterize the incidence of in-hospital ACVE following drug overdose. Methods: This was a prospective cohort study at two tertiary care hospitals over 12 months. Consecutive adult ED patients with acute drug overdose were prospectively followed to hospital discharge. The main outcome was occurrence of in-hospital ACVE, defined as the occurrence of one or more of the following: myocardial injury, shock, ventricular dysrhythmia, and cardiac arrest. Results: There were 459 ED patients with suspected drug overdose, of whom 274 acute drug overdose qualified and were included for analysis (mean [±SE] age = 40.3 [±1.0] years; 63% male). Hospital course was complicated by ACVE in 16 patients (some had more than one): 12 myocardial injury, three shock, two dysrhythmia, and three cardiac arrest. The incidence of ACVE was 5.8% overall (95% confidence interval [CI] = 3.6% to 9.3%) and 10.7% (95% CI = 6.6% to 16.9%) among inpatient admissions, with all-cause mortality at 0.7% (95% CI = 0.2% to 2.6%). Conclusions: Based on this study of adult patients with acute drug overdose, ACVE may occur in up to 9.3% overall and up to 16.9% of hospital admissions. Implications for the evaluation and triage of ED patients with acute drug overdose require further study with regard to optimizing interventions to prevent adverse events. [ABSTRACT FROM AUTHOR]

ACADEMIC EMERGENCY MEDICINE 2012; 19: 562-568 © 2012 by the Society for Academic Emergency Medicine Abstract Objectives: The Infectious Disease Society of America (IDSA) and American Thoracic Society (ATS) developed guidelines for the management of community-acquired pneumonia (CAP); however, there are sparse data on actual rates of antibiotic use in the emergency department (ED) setting. Methods: Data were obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS) for ED visits during 1993 through 2008 for adults with a diagnosis of pneumonia. Results: During the study period there were an estimated 23,252,000 pneumonia visits, representing 1.8% of all ED visits. The visit rate for pneumonia during this 16-year period may have increased (p trend = 0.055). Overall, 66% of adult patients with a primary diagnosis of pneumonia had documentation of an antibiotic administered while in the ED. There was an increase in antibiotic administration for adults with pneumonia from 1993 through 2008 (49% to 80%; p trend < 0.001). Specifically, there was an increase in use of macrolides from 1993 to 2006 (20% to 30%, p trend < 0.001) and a marked increase in use of quinolones from 0% to 39% from 1993 through 2008 (p trend < 0.001). Penicillin and cephalosporin use remained stable. Use of an antibiotic consistent with 2007 IDSA/ATS guidelines increased from 22% (95% confidence interval [CI] = 16% to 27%) of cases in 1993-1994 to 68% (95% CI = 63% to 73%) of cases in 2007-2008 (p trend < 0.001). Conclusions: ED visit rates for pneumonia increased slightly from 1993 through 2008. Although antibiotic administration in the ED has increased for adults with CAP, guideline-concordant antibiotics may not be consistently administered. [ABSTRACT FROM AUTHOR]

The objective of this study was to develop European League Against Rheumatism/American College of Rheumatology classification criteria for polymyalgia rheumatica (PMR). Candidate criteria were evaluated in a 6-month prospective cohort study of 125 patients with new-onset PMR and 169 non-PMR comparison subjects with conditions mimicking PMR. A scoring algorithm was developed based on morning stiffness >45 minutes (2 points), hip pain/limited range of motion (1 point), absence of rheumatoid factor and/or anti-citrullinated protein antibody (2 points), and absence of peripheral joint pain (1 point). A score ≥4 had 68% sensitivity and 78% specificity for discriminating all comparison subjects from PMR. The specificity was higher (88%) for discriminating shoulder conditions from PMR and lower (65%) for discriminating RA from PMR. Adding ultrasound, a score ≥5 had increased sensitivity to 66% and specificity to 81%. According to these provisional classification criteria, patients ≥50 years old presenting with bilateral shoulder pain, not better explained by an alternative pathology, can be classified as having PMR in the presence of morning stiffness >45 minutes, elevated C-reactive protein and/or erythrocyte sedimentation rate, and new hip pain. These criteria are not meant for diagnostic purposes. [ABSTRACT FROM AUTHOR]

ACADEMIC EMERGENCY MEDICINE 2012; 19:217-227 © 2012 by the Society for Academic Emergency Medicine Abstract Objectives: The objective was to compare case ascertainment, agreement, validity, and missing values for clinical research data obtained, processed, and linked electronically from electronic health records (EHR) compared to 'manual' data processing and record abstraction in a cohort of out-of-hospital trauma patients. Methods: This was a secondary analysis of two sets of data collected for a prospective, population-based, out-of-hospital trauma cohort evaluated by 10 emergency medical services (EMS) agencies transporting to 16 hospitals, from January 1, 2006, through October 2, 2007. Eighteen clinical, operational, procedural, and outcome variables were collected and processed separately and independently using two parallel data processing strategies by personnel blinded to patients in the other group. The electronic approach included EHR data exports from EMS agencies, reformatting, and probabilistic linkage to outcomes from local trauma registries and state discharge databases. The manual data processing approach included chart matching, data abstraction, and data entry by a trained abstractor. Descriptive statistics, measures of agreement, and validity were used to compare the two approaches to data processing. Results: During the 21-month period, 418 patients underwent both data processing methods and formed the primary cohort. Agreement was good to excellent (kappa = 0.76 to 0.97; intraclass correlation coefficient [ICC] = 0.49 to 0.97), with exact agreement in 67% to 99% of cases and a median difference of zero for all continuous and ordinal variables. The proportions of missing out-of-hospital values were similar between the two approaches, although electronic processing generated more missing outcomes (87 of 418, 21%, 95% confidence interval [CI] = 17% to 25%) than the manual approach (11 of 418, 3%, 95% CI = 1% to 5%). Case ascertainment of eligible injured patients was greater using electronic methods ( n = 3,008) compared to manual methods ( n = 629). Conclusions: In this sample of out-of-hospital trauma patients, an all-electronic data processing strategy identified more patients and generated values with good agreement and validity compared to traditional data collection and processing methods. [ABSTRACT FROM AUTHOR]

ACADEMIC EMERGENCY MEDICINE 2012; 19:121-131 © 2012 by the Society for Academic Emergency Medicine Abstract Objectives: Crotalidae polyvalent immune Fab (ovine) (FabAV) is commonly used in the treatment of symptomatic North American crotaline snake envenomation. When approved by the U.S. Food and Drug Administration in 2000, the incidences of immediate hypersensitivity reactions and serum sickness were reported as 0.14 and 0.18, respectively. The objective of this meta-analysis was to evaluate the incidence of immediate hypersensitivity reactions and serum sickness reported in studies of patients treated with FabAV therapy after North American crotaline envenomation. Methods: The authors searched PubMed, Ovid MEDLINE, and EMBASE from January 1, 1997, to September 20, 2010, for English-language medical literature and cross-referenced bibliographies of reviewed articles. The published abstracts of the major toxicology conferences were also searched. All prospective and retrospective cohort studies with patients receiving FabAV therapy for North American crotaline envenomations were eligible for data abstraction. Two content experts reviewed full-text articles and extracted relevant study design and outcome data. Proportions of immediate hypersensitivity and serum sickness for each study were analyzed in a random-effects model to produce an overall estimate of immediate hypersensitivity and serum sickness incidence associated with FabAV administration. Results: The literature search revealed 11 unique studies of patients who received FabAV that contained information on immediate hypersensitivity reactions and serum sickness. The meta-analysis produced a combined estimate of the incidence of immediate hypersensitivity of 0.08 (95% confidence interval [CI] = 0.05 to 0.11) and a combined estimate of the incidence of serum sickness of 0.13 (95% CI = 0.07 to 0.21). Conclusions: In this systematic literature review and meta-analysis, the combined estimates of the incidence of immediate hypersensitivity reactions and serum sickness from FabAV in the treatment of symptomatic North American crotaline envenomations appear to be lower than previously reported, at 0.08 and 0.13, respectively. [ABSTRACT FROM AUTHOR]

Objectives: During disasters, the public expects that emergency care will be available at a moment's notice. As such, an emergency medical services (EMS) workforce that is trained and prepared for disasters is imperative. The primary objectives of this study were to quantify the amount of individual-level training EMS professionals receive in terrorism and disaster-preparedness, as well as to assess EMS professionals' participation in multiagency disaster drills across the United States. Characteristics of those most likely to have received individual-level training or participated in multiagency disaster drills were explored. The secondary objectives were to assess EMS professional's perception of preparedness and to determine whether the amount of training individuals received was correlated with their perceptions of preparedness. Methods: A structured survey was administered to nationally certified EMT-Basics and paramedics as part of their 2008 recertification paperwork. Outcome variables included individual-level preparedness training, participation in multiagency disaster drills, and perception of preparedness. Descriptive statistics and logistic regression modeling were used to quantify the amount of training received. Spearman rank correlation coefficients were used to analyze whether training was correlated with an individual's perception of preparedness. Results: There were 46,127 EMS professionals who had the opportunity to complete the recertification questionnaire; 30,570 (66.3%) responded. A complete case analysis was performed on 21,438 respondents. Overall, 19,551 respondents (91.2%) reported receiving at least 1 hour of individual-level preparedness training, and 12,828 respondents (59.8%) reported participating in multiagency disaster drills, in the prior 24 months. Spearman rank correlation coefficients revealed that hours of individual-level preparedness training were significantly correlated with the perception of preparedness. Conclusions: While areas where EMS should focus attention for improvement were identified, a majority of nationally certified EMT-Basics and paramedics reported participating in both individual and multiagency disaster-preparedness training. A large majority of respondents reported feeling adequately prepared to respond to man-made and natural disasters and the perception of preparedness correlated with hours of training. [ABSTRACT FROM AUTHOR]

Objectives: In preparation for development of a clinical decision rule (CDR) to promote more efficient use of computed tomography (CT) for diagnosing orbital fractures, the authors sought to estimate the annual incidence of orbital fractures in emergency departments (EDs) and the usage of CT to make these diagnoses. The authors also sought to evaluate a mandatory electronic data collection instrument (EDCI) administered to providers to facilitate CDR data collection. Methods: National estimates were made by analyzing the 2007 National Hospital Ambulatory Medical Care Survey (NHAMCS) database, while hospital billing system and coding data were used to make local estimates. An EDCI was integrated into the CT ordering system such that providers had to complete the form to perform a CT. Because the EDCI had to be filled out for every CT ordered, data collection efficiency was measured by compliance (counting the number of unrealistic data collection instrument answers) and by timing a convenience sample of providers completing the EDCI. Results: Out of 116.8 million ED visits in the United States in 2007, 4.1 million patients were treated for injuries of the eye and face. Of those, 820,252 patients underwent CT imaging, with 102,999 patients (12.5%) diagnosed with an orbital fracture. In our local hospital system with 122,500 annual ED visits, 752 CTs of orbits were performed, with 172 (23%) orbital fractures. The EDCI compliance rate was 94.9% and took less than 5 minutes to complete. Conclusions: National and local data demonstrate a low yield for CT imaging in identifying orbital fractures. Data collection using a mandatory EDCI linked to computerized provider order entry can provide prospective, consecutive patient data that are needed to develop a CDR for the selective use of CT imaging in orbital trauma. Such a decision rule could increase the efficiency in diagnosing orbital fractures, thereby improving patient care, reducing radiation exposure, and decreasing costs. [ABSTRACT FROM AUTHOR]

Objectives: There is a growing awareness of the effects of patient death on physician well-being, and the importance of cultural and educational changes to improve coping mechanisms. The objective of this study was to explore both the effects of patient death on academic emergency physicians (EPs) and the coping mechanisms they use to deal with these events. Methods: Faculty at a convenience sample of four emergency medicine (EM) residency programs were questioned about their responses to patient death in a 15-question on-line survey. Descriptive analysis of the data was performed. Independent variables were analyzed for differences in complaints of physical symptoms or consideration of important life changes after patient death. Results: Of 207 EPs surveyed, 145 (70%) responded. Patient death was experienced frequently, with 95 (66%) witnessing a death at least every month. No training on coping with patient death had occurred for 35 (24%); 93 (64%) had less than 6 hours of training. The most common coping mechanisms included talking with colleagues (113; 78%) or friends and family (100; 69%), as well as simply continuing to work (89; 61%). Postdeath debriefing occurred rarely or never for 93 (64%) of respondents. Most EPs had experienced physical responses to patient death, the most common being insomnia (54; 37%) and fatigue (21; 14%). Common emotional responses included sadness (112; 70%) and disappointment (55; 38%). No significant differences in response rates for physical symptoms or consideration of life changes were found for any of the variables. Conclusions: Patient death was reported to lead to both physical and emotional symptoms in academic EPs. Postdeath debriefing appears to happen infrequently in teaching settings, and most respondents reported that they themselves received limited training in coping with patient death. Further study is needed to both identify coping mechanisms that are feasible and effective in emergency department settings and develop teaching strategies to incorporate this information into EM residency training. [ABSTRACT FROM AUTHOR]

Objectives: The objective was to describe the emergency department (ED) resource burden of the spring 2009 H1N1 influenza pandemic at U.S. children's hospitals by quantifying observed-to-expected utilization. Methods: The authors performed an ecologic analysis for April through July 2009 using data from 23 EDs in the Pediatric Health Information System (PHIS), an administrative database of widely distributed U.S. children's hospitals. All ED visits during the study period were included, and data from the 5 prior years were used for establishing expected values. Primary outcome measures included observed-to-expected ratios for ED visits for all reasons and for influenza-related illness (IRI). [ABSTRACT FROM AUTHOR]

Objectives: Acute gastroenteritis is a very common emergency department (ED) diagnosis accounting for greater than 1.5 million outpatient visits and 200,000 hospitalizations annually among children in the United States. Although guidelines exist to assist clinicians, they do not clearly address topics for which evidence is new or limited, including the use of antiemetic agents, probiotics, and intravenous (IV) fluid rehydration regimens. This study sought to describe the ED treatments administered to children with acute gastroenteritis and to compare management between Canadian and U.S. physicians practicing pediatric emergency medicine (PEM). Methods: Members of PEM research networks located in Canada and the United States were invited to participate in a cross-sectional, Internet-based survey. Participants were included if they are attending physicians and provide care to patients < 18 years of age in an ED. Results: In total, 235 of 339 (73%) eligible individuals responded. A total of 103 of 136 Canadian physicians (76%) report initiating oral rehydration therapy (ORT) in children with moderate dehydration, compared with 44 of 94 (47%) of their U.S. colleagues (p < 0.001). The latter more often administer antiemetic agents to children with vomiting (67% vs. 45%; p = 0.001). American physicians administer larger IV fluid bolus volumes (p < 0.001) and over shorter time periods (p = 0.001) and repeat the fluid boluses more frequently (p < 0.001). Probiotics are routinely recommended by only 35 of 230 respondents (15%). Conclusions: The treatment of pediatric gastroenteritis varies by geographic location and differs significantly between Canadian and American PEM physicians. Oral rehydration continues to be underused, particularly in the United States. Probiotic use remains uncommon, while ondansetron administration has become routine. Children frequently receive IV rehydration, with the rate and volume administered being greater in the United States. [ABSTRACT FROM AUTHOR]

Objectives: Rotating (non-emergency medicine [EM]) residents perform clinical rotations in many academic emergency departments (EDs). The primary objective of this work was to quantify characteristics of rotating residents and the didactic curricula offered to them during their EM rotations. Secondary objectives were to identify barriers to instituting such didactics and to establish ideal curricular contents. Methods: A Web-based survey was administered by e-mail to residency directors of all U.S. allopathic EM residency programs. Consent was obtained in the first part of the survey, and the study was deemed exempt from full review by the institutional review board. Questions solicited information regarding type and quantity of rotating residents in their main EDs, the 'didactic educational format' available to rotating residents, and ideal and actual didactic curricular contents. Statistics were reported as proportions and means with 95% confidence intervals (CIs) and medians with interquartile ranges (IQRs). Results: Surveys were sent to 143 programs, and the response rate was 71%. Ninety-nine percent of respondents had rotating residents in their EDs, and the median number per month was 4 (IQR = 3-6). Five percent of respondents had established didactic curricula specifically for rotating residents, and 64% sent them to either EM resident or medical student lectures. Thirty-one percent of programs reported no didactics, and 65% of these felt there was no need for such education. Resuscitation, trauma, and toxicology were cited as the most important subjects for actual and ideal curricula. Conclusions: Most academic EDs have rotating residents, but very few provide didactic education specific to their learning needs and almost a third provide no didactics. ACADEMIC EMERGENCY MEDICINE 2010; 17:S49-S53 © 2010 by the Society for Academic Emergency Medicine [ABSTRACT FROM AUTHOR]

ACADEMIC EMERGENCY MEDICINE 2010; 17:940–950 © 2010 by the Society for Academic Emergency Medicine Objectives: The objectives of this study were to determine concordance of emergency department (ED) management of acute myocardial infarction (AMI) with guideline recommendations and to identify ED and patient characteristics predictive of higher guideline concordance. Methods: The authors conducted a chart review study of ED AMI care as part of the National Emergency Department Safety Study (NEDSS). Using a primary hospital discharge diagnosis of AMI (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM], codes 410.XX), a random sample of ED visits for AMI in 58 urban EDs across 20 U.S. states between 2003 and 2006 were identified. Concordance with American College of Cardiology/American Heart Association (ACC/AHA) guideline recommendations was evaluated using five individual quality measures and a composite concordance score. Concordance scores were calculated as the percentage of eligible patients who received guidelines-recommended care. These percentage scores were rescaled from 0 to 100, with 100 indicating perfect concordance. Results: The cohort consisted of 3,819 subjects; their median age was 65 years, and 62% were men. The mean (± standard deviation [SD]) ED composite concordance score was 61 ± 8), with a broad range of values (42 to 84). Except for aspirin use (mean concordance, 82), ED concordance scores were low (beta-blocker use, 56; timely electrocardiogram [ECG], 41; timely fibrinolytic therapy, 26; timely ED disposition for primary percutaneous coronary intervention [PCI] candidates, 43). In multivariable analyses, older age (beta-coefficient per 10-year increase, −1.5; 95% confidence interval [CI] = −2.4 to −0.5) and southern EDs (beta-coefficient, −5.2; 95% CI = −9.6 to −0.9) were associated with lower guideline concordance, whereas ST-segment elevation on initial ED ECG was associated with higher guideline concordance (beta-coefficient, 3.6; 95% CI = 1.5 to 5.7). Conclusions: Overall ED concordance with guideline-recommended processes of care was low to moderate. Emergency physicians should continue to work with other stakeholders in AMI care, such as emergency medical services (EMS) and cardiologists, to develop strategies to improve care processes. [ABSTRACT FROM AUTHOR]

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