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Michael J Mello,1,2 Julie R Bromberg,1,2 Steven Rougas,1 Thomas H Chun,1 Linda L Brown,1 Christina S Parnagian,2 Janette Baird1,2 1Department of Emergency Medicine, The Warren Alpert Medical School, Brown University, Providence, RI, USA; 2Injury Prevention Center, Rhode Island Hospital, Providence, RI, USA Introduction: Emergency medicine (EM) providers are in an opportunistic position to identify and intervene with patients at risk for alcohol misuse and related problems. However, alcohol screening, brief intervention, and referral to treatment (SBIRT) services are underutilized within the emergency department. Providing SBIRT training to trainees may help to increase ­utilization of these valuable services in the future. An SBIRT training program for EM faculty and ­trainees was developed and delivered to increase trainees’ skills and practice of SBIRT services. Methods: The SBIRT training program included unique tracks for medical students, physician assistant (PA) students, EM residents and faculty preceptors. Faculty and trainees completed ­performance measures at the end of each training session, 30 days post-training and 12 months later. Results: SBIRT training was provided to 238 trainees and 65 faculty members. At all follow-up time points, satisfaction of training and usefulness varied by trainee type with PA students rating constructs higher than both medical students and EM residents. At the 12-month follow-up survey, there was no significant difference in ratings of sharing the information (χ2 (2)=0.38, P=0.33) between these trainees, with the majority of all trainees (96% of PA students, 83% of residents and 68% of medical students) responding that they had applied what they learned in the training to their work. Conclusion: An SBIRT training curriculum for EM trainees was delivered successfully and utilized 12 months after implementation. Keywords: SBIRT, substance misuse, emergency medicine trainees

OBJECTIVES: Limited research exists describing youth football injuries, and many of these are confined to specific regions or communities. The authors describe U.S. pediatric football injury patterns receiving emergency department (ED) evaluation and compare injury patterns between the younger and older youth football participants. METHODS: A retrospective analysis of ED data on football injuries was performed using the National Electronic Injury Surveillance System-All Injury Program. Injury risk estimates were calculated over a 5-year period (2001-2005) using participation data from the National Sporting Goods Association. Injury types are described for young (7-11 years) and adolescent (12-17 years) male football participants. RESULTS: There were an estimated total of 1,060,823 visits to U.S. EDs for males with football-related injuries. The most common diagnoses in the younger group (7-11 years) were fracture/dislocation (29%), sprain/strain (27%), and contusion (27%). In the older group (ages 12-17 years), diagnoses included sprain/strain (31%), fracture/dislocation (29%), and contusion (23%). Older participants had a significantly higher injury risk of injury over the 5-year study period: 11.0 (95% confidence interval [CI] = 9.2 to 12.8) versus 6.1 (95% CI = 4.8 to 7.3) per 1,000 participants/year. Older participants had a higher injury risk across all categories, with the greatest disparity being with traumatic brain injury (TBI), 0.8 (95% CI = 0.6 to 1.0) versus 0.3 (95% CI = 0.2 to 0.4) per 1,000 participants/year. CONCLUSIONS: National youth football injury patterns are similar to those previously reported in community and cohort studies. Older participants have a significantly higher injury risk, especially with TBI. [ABSTRACT FROM AUTHOR]

Eduardo Jorge da Fonseca Lima,1,2 Débora Ellen Pessoa Lima,3 George Henrique Cordeiro Serra,2 Maria Anaide Zacche S Abreu e Lima,2 Maria Júlia Gonçalves de Mello1,2 1Instituto de Medicina Integral Professor Fernando Figueira – IMIP, Recife, PE, Brazil; 2Faculdade Pernambucana de Saúde – FPS, Recife, PE, Brazil; 3Universidade de Pernambuco, Recife, PE, Brazil Objective: To assess the adequacy of antibiotic prescription in children hospitalized for pneumonia in a reference pediatric hospital in Brazil. Methods: This was a cross-sectional study involving children aged between 1 month and 5 years who were hospitalized between October 2010 and September 2013. The classification of community-acquired pneumonia (CAP) was based on the clinical and radiological criteria of the World Health Organization (WHO). The analysis of antibiotic adequacy was performed according to the main guidelines on CAP treatment, which include the WHO guidelines, Brazilian Society of Pediatrics guidelines, and international guidelines (Pediatrics Infectious Diseases Society, the Infectious Disease Society of America, British Thoracic Society, and Consenso de la Sociedad latinoamericana de Infectología). A multivariate analysis was performed including variables that have statistical significance of P≤0.25 in the bivariate analysis. Results: The majority of the 452 hospitalized children were classified as having severe or very severe CAP (85.18%), and inadequate empiric antimicrobial therapy was started in 26.10% (118/452) of them. Ampicillin was the most used empiric antibiotic therapy (62.17%) for pneumonia, followed by a combination of ampicillin and associated with gentamicin. The initially proposed regimen was modified in 29.6% of the patients, and the most frequent change was the replacement of ampicillin by oxacillin combined with chloramphenicol. The median hospitalization time was 8.5 days, and the lethality rate was 1.55%. There was no statistical difference in adequacy in relation to the severity of pneumonia or degree of malnutrition. In the bivariate analysis, inadequacy of antibiotic therapy regimen was higher in patients undergoing oxygen therapy (P

Eduardo JF Lima,1,2 Maria JG Mello,1,2 Maria FPM Albuquerque,3 Maria IL Lopes,4 George HC Serra,2 Maria AZ Abreu-Lima,2 Jailson B Correia1 1Instituto de Medicina Integral Prof. Fernando Figueira - IMIP Recife; 2Faculdade, Pernambucana de Saúde - FPS Recife; 3Centro de Pesquisas Aggeu Magalhães, FIOCRUZ; 4Hospital das Clínicas, Universidade Federal de Pernambuco - UFPE, Recife, Pernambuco, Brazil Background: Pneumonia is an important cause of morbimortality in Brazil, despite the extensive vaccination coverage and the socioeconomic improvement in the past years. Objective: To describe the epidemiological and clinical characteristics of severe community-acquired pneumonia in children after the introduction of the 10-valent pneumococcal conjugate vaccine (PCV10). Methods: A prospective study included children

OBJECTIVE: To compare the effectiveness of two training strategies for improving essential newborn care in the state of Pernambuco, Brazil. METHODS: Eight hospitals were selected, divided into two groups of four, and paired by geographical, structural, and functional characteristics. Doctors and nurses working at hospitals in Group 1 were given a conventional 5-day training course. Those in Group 2 were given the same manual used by Group 1 but the training course was organized as self-directed learning, with the participants having 5 weeks to complete the course. Participants' knowledge was tested at baseline, immediately after the course, and 3-6 months later. Participants' practices were observed before training and 3-6 months after training during 20 births and by interviewing 20 mothers before discharge at each hospital. FINDINGS: Not all participants completed all of the tests. The scores on the tests of knowledge improved more among those in Group 2 than those in Group 1 when the answers were classified as right or wrong, but there was no difference between groups when a scoring method was used that classified answers as correct, partially correct, incorrect, or missing. Practices related to thermal control after birth improved among those in Group 2 after training but practices related to thermal control on the ward worsened. The promotion of breastfeeding improved in both groups. CONCLUSION: There was no difference between the two training strategies, although self-directed learning was cheaper than conventional training. Neither strategy brought about the expected improvements in the quality of care. Other interventions in addition to training may be needed to improve care. Copyright © 2001 World Health Organization [ABSTRACT FROM AUTHOR]

Background: Micromobility devices like e-scooters have become popular for short trips. Providence, Rhode Island, introduced these devices in 2018. We examine non-fatal injury trends and ED care costs for micromobility-related injuries in Rhode Island (RI) from 2016 to 2021., Methods: Data were obtained from the Healthcare Cost and Utilization Project (HCUP) and the RI State ED Databases (SEDD). Using ICD-10 codes, we identified micromobility-related injuries. The analysis spanned two waves: pre-implementation (2016-2018) and post- implementation (2019-2021). Poisson regression was performed on age-adjusted rates of micromobility injuries to evaluate change over time., Results: From 2016 to 2021, micromobility-related ED visits rose 600%. Bicycle injuries decreased by 20%, while pedestrian and motor vehicle injuries increased by 9% and 13%, respectively., Conclusion: The dramatic rise in micromobility- related injuries reflects their growing usage and the associated risks. Micromobility offers benefits and challenges for cities. Safety measures are crucial for their safe, sustainable use.

Background: Persons seeking emergency injury care are often from higher-risk and underserved key populations (KPs) and priority populations (PPs) for HIV programming. While facility-based HIV Testing Services (HTS) in Kenya are effective, emergency department (ED) delivery is limited, despite the potential to reach underserved persons., Methods: This quasi-experimental prospective study evaluated implementation of the HIV Enhanced Access Testing in Emergency Departments (HEATED) at Kenyatta National Hospital ED in Nairobi, Kenya. The HEATED program was designed as a multi-component intervention employing setting appropriate strategies for HIV care sensitization and integration, task shifting, resource reorganization, linkage advocacy, skills development and education to promote ED-HTS with a focus on higher-risk persons. KPs included sex workers, gay men, men who have sex with men, transgender persons and persons who inject drugs. PPs included young persons (18-24 years), victims of interpersonal violence, persons with hazardous alcohol use and persons never HIV tested. Data were obtained from systems-level records, enrolled injured patient participants and healthcare providers. Systems and patient-level data were collected during a pre-implementation period (6 March - 16 April 2023) and post-implementation (period 1, 1 May - 26 June 2023). Additional, systems-level data were collected during a second post-implementation (period 2, 27 June - 20 August 2023). HTS data were evaluated as facility-based HIV testing (completed in the ED) and distribution of HIV self-tests independently, and aggregated as ED-HTS. Evaluation analyses were completed across reach, effectiveness, adoption, implementation and maintenance framework domains., Results: All 151 clinical staff were reached through trainings and sensitizations on the HEATED program. Systems-level ED-HTS among all presenting patients increased from 16.7% pre-implementation to 23.0% post-implementation periods 1 and 2 (RR = 1.31, 95% CI: 1.21-1.43; p  < 0.001). Among 605 enrolled patient participants, facilities-based HTS increased from 5.7% pre-implementation to 62.3% post-implementation period 1 (RR = 11.2, 95%CI: 6.9-18.1; p  < 0.001). There were 440 (72.7%) patient participants identified as KPs (5.6%) and/or PPs (65.3%). For enrolled KPs/PPs, facilities-based HTS increased from 4.6% pre-implementation to 72.3% post-implementation period 1 (RR = 13.8, 95%CI: 5.5-28.7, p  < 0.001). Systems and participant level data demonstrated successful adoption and implementation of the HEATED program. Through 16 wk post-implementation a significant increase in ED-HTS delivery was maintained as compared to pre-implementation., Conclusions: The HEATED program increased overall ED-HTS and augmented delivery to KPs/PPs, suggesting that broader implementation could improve HIV services for underserved persons already in contact with health systems.

Objective: Screening, brief intervention, and referral to treatment (SBIRT) for adolescent alcohol and drug (AOD) use is recommended to occur with adolescents admitted to pediatric trauma centers. Most metrics on SBIRT service delivery only reference medical record documentation. In this analysis we examined changes in adolescents' perception of SBIRT services and concordance of adolescent-report and medical record data, among a sample of adolescents admitted before and after institutional SBIRT implementation., Methods: We implemented SBIRT for adolescent AOD use using the Science to Service Laboratory implementation strategy and enrolled adolescents at 9 pediatric trauma centers. The recommended clinical workflow was for nursing to screen, social work to provide adolescents screening positive with brief intervention and referral to their PCP for continued AOD discussions with those. Adolescents screening as high-risk also referred to specialty services. Adolescents were enrolled and contacted 30 days after discharge and asked about their perception of any SBIRT services received. Data were also extracted from enrolled patient's medical record., Results: There were 430 adolescents enrolled, with 424 that were matched to their EHR data and 329 completed the 30-day survey. In this sample, EHR documented screening increased from pre-implementation to post-implementation (16.3%-65.7%) and brief interventions increased (27.1%-40.7%). Adolescents self-reported higher rates of being asked about alcohol or drug use than in EHR data both pre- and post-implementation (80.7%-81%). Both EHR data and adolescent self-reported data demonstrated low referral back to PCP for continued AOD discussions., Conclusions: Implementation of SBIRT at pediatric trauma centers was not associated with change in adolescent perceptions of SBIRT, despite improved documentation of delivery of AOD screening and interventions. Adolescents perceived being asked about AOD use more often than was documented. Referral to PCP or specialty care for continued AOD discussion remains an area of needed attention., Trial Registration: Clinicaltrials.gov NCT03297060., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

This study investigates the association between frailty, measured by the modified five-item frailty index (mFI-5), with inpatient mortality and hospital length of stay for geriatric patients with fall-related injuries. Despite falls being major contributors to morbidity and mortality in those over 65, the interaction between frailty and post-fall outcomes remains underexplored. Data for patients aged 65 and above, admitted between 2014-2020 to Rhode Island Hospital's trauma service for fall-related injuries, were extracted from its Trauma Registry. Frailty scores were retrospectively assigned using mFI-5. Logistic- and linear-regression analyses examined the relationship between mFI-5 scores, mortality, and hospital length-of-stay. Among 6,782 patients (mean age: 81.7 ± 8.66 years), higher frailty scores correlated with increased inpatient mortality (OR: 1.259; 95% CI: 1.14-1.39; P<0.000) and longer hospital stays (Coeff.: 0.460; 95% CI: 0.35-0.57, P<0.000). Notably, age showed a negative association with hospital length of stay but no significant association with inpatient mortality.

Background: Emergency department-based HIV self-testing (ED-HIVST) could increase HIV-testing services to high-risk, under-reached populations., Objectives: This study sought to understand the injury patient acceptability of ED-HIVST., Methods: Injury patients presenting to the Kenyatta National Hospital Accident and Emergency Department were enrolled from March to May 2021. Likert item data on HIVST assessing domains of general acceptability, personal acceptability, and acceptability to distribute to social and/or sexual networks were collected. Ordinal regression was performed yielding adjusted odds ratios (aOR) to identify characteristics associated with high HIVST acceptability across domains., Results: Of 600 participants, 88.7% were male, and the median age was 29. Half reported having primary care providers (PCPs) and 86.2% reported prior HIV testing. For each Likert item, an average of 63.5% of the participants reported they 'Agree Completely' with positive statements about ED-HIVST in general, for themselves, and for others. In adjusted analysis for general acceptability, those <25 (aOR = 1.67, 95%CI:1.36-2.08) and with prior HIV testing (aOR = 1.68, 95%CI:1.27-2.21) had greater odds of agreeing completely. For personal acceptability, those with a PCP (aOR = 3.31, 95%CI:2.72-4.03) and prior HIV testing (aOR = 1.83, 95%CI:1.41-2.38) had greater odds of agreeing completely. For distribution acceptability, participants with a PCP (aOR = 2.42, 95%CI:2.01-2.92) and prior HIV testing (aOR = 1.79, 95%CI: 1.38-2.33) had greater odds of agreeing completely., Conclusions: ED-HIVST is perceived as highly acceptable, and young people with prior testing and PCPs had significantly greater favourability. These data provide a foundation for ED-HIVST programme development in Kenya.

Background: Expert consensus recommends prescription opioid safety counseling be provided when prescribing an opioid. This may be especially important for youth with preexistent alcohol and other drug (AOD) use who are at higher risk of developing opioid use disorder. This study examined the frequency that adolescent trauma patients prescribed opioids at hospital discharge received counseling and if this differed by adolescents' AOD use., Method: This study was embedded within a larger prospective stepped-wedge type III hybrid implementation study of AOD screening across a national cohort of pediatric trauma centers. Data were collected during 2018-2021 from admitted adolescent trauma patients (12-17 yo) at seven centers. Patient data were extracted from the electronic health record (EHR) on any prescribed discharged opioids, documentation of counseling delivered on prescribed opioid, who delivered counseling, and patients' AOD screening results. Additionally, adolescents received an online survey within 30 days of hospital discharge that included asking about hospital discussions on safe use of prescription pain medication., Results: Of the 247 adolescent trauma patients enrolled, 158 completed the 30-day survey. AOD screening results were documented in the EHR for 139 patients (88%), with 69 (44.1%) screening AOD-positive. Opioids at discharge were prescribed to 86 (54.4%) adolescent patients, with no significant difference between those screened AOD-positive and AOD-negative (42.4% vs. 46.3%, p = 0.89). Counseling was documented in the EHR for 30 (34.9%) of those prescribed an opioid and was not significantly different by sex, age, race, ethnicity or between adolescent patients with documentation of AOD use (29.3%) versus those who did not (33.3%, p = 0.71). According to the adolescent survey, among those prescribed an opioid, 61.2% reported someone had talked with them about safe use of newly prescribed pain medications with again no difference between AOD-positive and AOD-negative screening results (p = 0.34)., Conclusions: Although adolescent trauma patients recalled discussions on safe use of prescribed pain medication more often than was documented in the EHR, these discussions were not universal and did not differ if adolescents had screened positive or negative for AOD use as documented in the EHR., Trial Registry: clinicaltrials.gov NCT03297060., (© 2023. The Author(s).)

Background: High-risk alcohol use is a common preventable risk factor for postoperative complications, admission to intensive care, and longer hospital stays. Short-term abstinence from alcohol use (2 to 4 weeks) prior to surgery is linked to a lower likelihood of postoperative complications., Objective: The study aimed to explore the acceptability and feasibility of 2 brief counseling approaches to reduce alcohol use in elective surgical patients with high-risk alcohol use in the perioperative period., Methods: A semistructured interview study was conducted with a group of "high responders" (who reduced alcohol use ≥50% postbaseline) and "low responders" (who reduced alcohol use by ≤25% postbaseline) after their completion of a pilot trial to explore the acceptability and perceived impacts on drinking behaviors of the 2 counseling interventions delivered remotely by phone or video call. Interview transcripts were analyzed using thematic analysis., Results: In total, 19 participants (10 high responders and 9 low responders) from the parent trial took part in interviews. Three main themes were identified: (1) the intervention content was novel and impactful, (2) the choice of intervention modality enhanced participant engagement in the intervention, and (3) factors external to the interventions also influenced alcohol use., Conclusions: The findings support the acceptability of both high- and low-intensity brief counseling approaches. Elective surgical patients are interested in receiving alcohol-focused education, and further research is needed to test the effectiveness of these interventions in reducing drinking before and after surgery., Trial Registration: ClinicalTrials.gov NCT03929562; https://clinicaltrials.gov/ct2/show/NCT03929562., (©Lyndsay Chapman, Tom Ren, Jake Solka, Angela R Bazzi, Brian Borsari, Michael J Mello, Anne C Fernandez. Originally published in JMIR Perioperative Medicine (http://periop.jmir.org), 26.07.2023.)

Objective: To understand the epidemiology and clinical outcomes of older adult pedestrian injury in Rhode Island., Methods: Descriptive univariate analysis of data from Rhode Island Hospital's trauma registry on patients admitted for pedestrian-related injuries between 2017-2020., Results: The rate of pedestrian injury in older adults was 1.5 times the rate in adults age 18-49. Injured older adult pedestrians experienced a higher rate of serious adverse events during hospitalization (18.0%) than their younger counterparts (10.3%) and had almost twice the mortality rate (14.9% versus 7.6%). Across ages, pedestrian injury rates are higher in densely populated areas, and those injured disproportionately are male and have comorbid alcohol and substance use disorders., Conclusions: The increased risk of pedestrian injury in older adults is evident and necessitates intervention. Further research is warranted on the root causes of higher pedestrian injury and mortality rates among older adults.

Introduction: Trauma is a leading cause of morbidity and mortality in Kenya. In many countries, substance use is common among patients presenting with injuries to an emergency center (EC)., Objective: To describe the epidemiology of self-reported substance use among adult injured patients seeking ED care in Nairobi, Kenya., Methods: This prospective cross-sectional study, assessed patients presenting with injuries to the Kenyatta National Hospital ED in Nairobi, Kenya from March through June of 2021. Data on substance use, injury characteristics and ED disposition were collected. Substances of interest were alcohol, stimulants, marijuana, and opiates. The Alcohol Use Disorders Identification Test-Concise (AUDIT-C) tool was used to characterize hazardous alcohol use., Results: A total of 1,282 patients were screened for participation, of which 646 were enrolled. Among participants, 322 (49.8%) reported substance use in the past month (AUDIT-C positive, stimulants, opiates, and/or marijuana). Hazardous alcohol use was reported by 271 (42.0%) patients who screened positive with AUDIT-C. Polysubstance use, (≥2 substances) was reported by 87 participants in the past month. Median time from injury to ED arrival was 13.1 h for all enrolees, and this number was significantly higher among substance users (median 15.4 h, IQR 5.5 - 25.5; p  = 0.029)., Conclusions: In the population studied, reported substance use was common with a substantial proportion of injured persons screening positive for hazardous alcohol use. Those with substance use had later presentations for injury care. These data suggest that ED programming for substance use disorder screening and care linkage could be impactful in the study setting., Competing Interests: The authors declare no conflicts of interest., (© 2022 The Authors. Published by Elsevier B.V. on behalf of African Federation for Emergency Medicine.)

Importance: In 2020, homicides in the United States saw a record single-year increase, with firearm injuries becoming the leading cause of death for children, adolescents, and young adults. It is critical to understand the magnitude of this crisis to formulate an effective response., Objective: To evaluate whether young adult males living in parts of 4 major US cities faced a firearm-related death and injury risk comparable with risks encountered during recent wartime service in Iraq and Afghanistan., Design, Setting, and Participants: In this cross-sectional study of young adult males aged 18 to 29 years living in the top 10% most violent zip codes in each domestic setting (as measured by fatal shooting rates), fatal and nonfatal shooting data for 2020 and 2021 were aggregated at the zip code level for 4 of the largest US cities (Chicago, Illinois; Los Angeles, California; New York, New York; and Philadelphia, Pennsylvania). Wartime mortality and combat injury rates for the conflicts in Iraq and Afghanistan were used to assess relative risk., Main Outcomes and Measures: The relative risk of firearm-related death and nonfatal shootings in each setting as compared with combat death and injury in the comparator setting., Results: Of 129 826 young adult males aged 18 to 29 years living in the top 10% most violent zip codes in the 4 cities studied, 45 725 (35.2%) were Black, 71 005 (54.7%) were Hispanic, and 40 355 (31.1%) were White. Among this population, there were 470 homicides and 1684 firearm-related injuries. Young adult males living in the most violent zip code of Chicago (2585 individuals aged 20-29 y) and Philadelphia (2448 individuals aged 18-29 y) faced a higher risk of firearm-related homicide than US soldiers who were deployed to Afghanistan, with risk ratios of 3.23 (95% CI, 2.47-4.68) and 1.91 (95% CI, 1.32-3.46), respectively. In expanding the analysis to the top 10% of the cities' most violent zip codes, the risks in Chicago likewise exceeded those of combat death faced by military service members, with a risk ratio of 2.10 (95% CI, 1.82-2.46), and the risks in Philadelphia were comparable with those of deployment to war 1.15 (95% CI, 0.98-1.39). Nonfatal shooting risks were comparable with, or exceeded, the injury risk of combat in Iraq, producing a combined annual firearm risk of 5.8% in Chicago and 3.2% in Philadelphia. However, these findings were not observed in the most violent zip codes of Los Angeles and New York City, where young men faced a 70% to 91% lower risk than soldiers in the Afghanistan war across fatal and nonfatal categories (eg, fatal shooting in most violent zip code in Los Angeles: risk ratio, 0.30; 95% CI, 0.26-0.34; nonfatal shooting in top 10% most violent zip codes in New York: risk ratio, 0.09; 95% CI, 0.08-0.10). The risk of violent death and injury observed in the zip codes studied was almost entirely borne by individuals from minoritized racial and ethnic groups: Black and Hispanic males represented 96.2% of those who were fatally shot (452 individuals) and 97.3% of those who experienced nonfatal injury (1636 individuals) across the 4 settings studied., Conclusions and Relevance: In this cross-sectional study, for young adult men in several of the communities studied, firearm violence carried morbidity and mortality risks that exceeded those of war. Health equity requires prioritizing effective responses.

Emergency departments (EDs) in Africa are contact points for key groups for HIV testing services (HTS) but understanding of ED-testing delivery is limited which may impeded program impacts. This study evaluated the offering and uptake of standard HTS among injured persons seeking ED care at Kenyatta National Hospital (KNH) in Nairobi, Kenya. An ED population of adult injured persons was prospectively enrolled (1 March-25 May 2021) and followed through ED disposition. Participants requiring admission were followed through hospital discharge and willing participants were contacted at 28-days for follow up. Data on population characteristics and HTS were collected by personnel distinct from clinicians responsible for standard HTS. Descriptive analyses were performed and prevalence values with 95% confidence intervals (CI) were calculated for HIV parameters. The study enrolled 646 participants. The median age was 29 years with the majority male (87.8%). Most ED patients were discharged (58.9%). A prior HIV diagnosis was reported by 2.3% of participants and 52.7% reported their last testing as >6 months prior. Standard ED-HTS were offered to 49 or 8.6% of participants (95% CI: 5.8-9.9%), among which 89.8% accepted. For ED-tested participants 11.4% were newly diagnosed with HIV (95% CI: 5.0-24.0%). Among 243 participants admitted, testing was offered to 6.2% (95% CI: 3.9-9.9%), with 93.8% accepting. For admitted participants tested 13.3% (95% CI: 4.0-35.1%) were newly diagnosed (all distinct from ED cases). At 28-day follow up an additional 22 participants reported completing testing since ED visitation, with three newly diagnosed. During the full follow-up period the HIV prevalence in the population tested was 10.3% (95% CI: 5.3-19.0%); all being previously undiagnosed. Offering of standard HTS was infrequent, however, when offered, uptake and identification of new HIV diagnoses were high. These data suggest that opportunities exist to improve ED-HTS which could enhance identification of undiagnosed HIV., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Aluisio et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objectives: The primary objective of this study was to examine opioid prescription frequency and identify differences across a national cohort of pediatric trauma centers in rates of prescribing opioids to injured adolescents at discharge., Methods: This was a retrospective observational study using electronic health records of injured adolescents (12-17 years) admitted to one of 10 pediatric trauma centers., Results: Of the 1345 electronic health records abstracted, 720 (53.5%, 95% CI 50.8 to 56.2) patients received opioid prescriptions at discharge with variability across sites (28.6%-72%). There was no association between patient factors and frequency of prescribing opioids. Center's trauma volume was significantly positively correlated with a higher rate of opioid prescribing at discharge (r=0.92, p=0.001). There was no significant difference between the frequency of opioid prescriptions at discharge among alcohol and other drugs (AOD)-positive patients (53.8%) compared with AOD-negative patients (53.5%)., Conclusions: Across a sample of 10 pediatric trauma centers, just over half of adolescent trauma patients received an opioid prescription at discharge. Prescribing rates were similar for adolescent patients screening positive for AOD use and those screening negative. The only factor associated with a higher frequency of prescribing was trauma center volume. Consensus and dissemination of outpatient pain management best practices for adolescent trauma patients is warranted., Level of Evidence: III-prognostic., Trial Registration Number: NCT03297060., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Study Objective: Emergency department (ED)-based naloxone distribution and peer-based behavioral counseling have been shown to be feasible, but little is known about utilization maintenance over time and clinician, patient, and visit level factors influencing implementation., Methods: We conducted a retrospective cohort study of an ED overdose prevention program providing take-home naloxone, behavioral counseling, and treatment linkage for patients treated for an opioid overdose at two Rhode Island EDs from 2017 to 2020: one tertiary referral center and a community hospital. Utilizing a Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, we evaluated program reach, adoption, implementation modifiers, and maintenance using logistic and Poisson regression., Results: Seven hundred forty two patients were discharged after an opioid overdose, comprising 966 visits (median: 32 visits per month; interquartile range: 29, 41). At least one intervention was provided at most (86%, 826/966) visits. Take-home naloxone was provided at 69% of visits (637/919). Over half (51%, 495/966) received behavioral counseling and treatment referral (65%, 609/932). Almost all attending physicians provided take-home naloxone (97%, 105/108), behavioral counseling (95%, 103/108), or treatment referral (95%, 103/108) at least once. Most residents and advanced practice practitioners (APPs) provided take home naloxone (78% residents; 72% APPs), behavioral counseling (76% residents; 67% APPs), and treatment referral (80% residents; 81% APPs) at least once. Most clinicians provided these services for over half of the opioid overdose patients they cared for. Patients were twice as likely to receive behavioral counseling when treated by an attending in combination with a resident and/or APP (adjusted odds ratio: 2.29; 95% confidence interval, 1.68, 3.12) compared to an attending alone. There was no depreciation in use over time., Conclusions: ED naloxone distribution, behavioral counseling, and referral to treatment can be successfully integrated into usual emergency care and maintained over time with high reach and adoption. Further work is needed to identify low-cost implementation strategies to improve services use and dissemination across clinical settings., (© 2021 by the Society for Academic Emergency Medicine.)

Background: Emergency departments (ED) interface with large numbers of patients that are often missed by conventional HIV testing approaches. ED-based HIV self-testing (HIVST) is an innovative engagement approach which has potential for testing gains among populations that have failed to be reached. This systematic review and meta-analysis evaluated acceptability and uptake of HIVST, as compared to standard provider-delivered testing approaches, among patients seeking care in ED settings., Methods: Six electronic databases were systematically searched (Dates: January 1990-May 2021). Reports with data on HIVST acceptability and/or testing uptake in ED settings were included. Two reviewers identified eligible records (κ= 0.84); quality was assessed using formalized criteria. Acceptability and testing uptake metrics were summarized, and pooled estimates were calculated using random-effects models with assessments of heterogeneity., Results: Of 5773 records identified, seven met inclusion criteria. The cumulative sample was 1942 subjects, drawn from three randomized control trials (RCTs) and four cross-sectional studies. Four reports assessed HIVST acceptability. Pooled acceptability of self-testing was 92.6% (95% confidence interval [CI]: 88.0%-97.1%). Data from two RCTs demonstrated that HIVST significantly increased testing uptake as compared to standard programs (risk ratio [RR] = 4.41, 95% CI: 1.95-10.10, I 2  = 25.8%). Overall, the quality of evidence was low (42.9%) or very low (42.9%), with one report of moderate quality (14.2%)., Conclusions: Available data indicate that HIVST may be acceptable and may increase testing among patients seeking emergency care, suggesting that expanding ED-based HIVST programs could enhance HIV diagnosis. However, given the limitations of the reports, additional research is needed to better inform the evidence base., (© 2021 Society for Academic Emergency Medicine.)

Altered composition or function of the human micro- biome, termed dysbiosis, has been associated with a variety of immune-mediated diseases. Antibiotic use is a well-studied cause of dysbiosis. We conducted an electronic survey of 351 antibiotic-prescribing clinicians in Rhode Island to evaluate antibiotic prescription patterns, knowledge and opinions regarding the importance of the human microbiome and its relation to antibiotics and the immune system. We found that clinicians view the health of the human microbiome as important when prescribing antibiotics; however, they do not feel well-informed or confident in their knowledge about the microbiome or its relevance to patient health. A higher level of self- reported knowledge about the microbiome was associated with increased importance placed on the microbiome and its relevance to medical practice. Our results indicate that clinicians may benefit from continuing medical education on the link between antibiotic-induced dysbiosis and immune-mediated disease.

Background: Emergency physicians require competence performing critical and routine procedures. The clinical practice of emergency medicine (EM) alone may be insufficient for the acquisition and maintenance of skills. Prior studies suggest the presence of trainees in academic settings and/or the low frequency of procedures increase the risk of skills attrition among faculty. We sought to develop a valid needs assessment survey to inform a faculty procedural skills (FPS) maintenance curriculum., Methods: A Web-based FPS survey was designed to assess experiences performing procedures, self-reported confidence with procedures, and learning preferences for skills maintenance. The survey was administered at a large academic department of EM. Responses were analyzed to determine survey construct validity, faculty attitudes about procedural attrition, and preferred learning methods., Results: Among EM faculty, confidence was significantly higher for common versus uncommon procedures (p < 0.001). EM faculty respondents reported significantly greater confidence than pediatric EM (PEM) faculty for both common adult procedures (EM mean = 3.7 [±0.3], PEM = 3.0 [±0.4], p  < 0.001), and uncommon adult procedures (EM = 2.7 [±0.4], PEM = 2.1 [±0.5], p  < 0.001). PEM faculty reported significantly greater confidence with pediatric procedures than EM faculty (PEM mean [±SD] = 3.5 [±0.8], EM = 2.2 [±0.8], p  < 0.001). Nearly all faculty (93% [52/56]) agreed that procedural attrition is a concerning problem, and 80% (44/56) had personally experienced it. The most preferred learning methods were task trainers and simulation. Faculty preferred learning environments with faculty peers (91%) over mixed groups with trainees (50%)., Conclusions: Significant differences in procedural skills confidence between common and uncommon procedures, and between EM and PEM faculty, indicate that the FPS survey displayed appropriate construct validity. The finding that skills attrition is prevalent among EM and PEM faculty highlights the need for skill maintenance programming, preferably in peer groups employing task trainers and simulation., Competing Interests: The authors have no potential conflicts to disclose., (© 2021 by the Society for Academic Emergency Medicine.)

Introduction: Healthcare contributes 10% of greenhouse gases in the United States and generates two milion tons of waste each year. Reducing healthcare waste can reduce the environmental impact of healthcare and lower hospitals' waste disposal costs. However, no literature to date has examined US emergency department (ED) waste management. The purpose of this study was to quantify and describe the amount of waste generated by an ED, identify deviations from waste policy, and explore areas for waste reduction., Methods: We conducted a 24-hour (weekday) ED waste audit in an urban, tertiary-care academic medical center. All waste generated in the ED during the study period was collected, manually sorted into separate categories based on its predominant material, and weighed. We tracked deviations from hospital waste policy using the hospital's Infection Control Manual, state regulations, and Health Insurance Portability and Accountability Act standards. Lastly, we calculated direct pollutant emissions from ED waste disposal activities using the M+WasteCare Calculator., Results: The ED generated 671.8 kilograms (kg) total waste during a 24-hour collection period. On a per-patient basis, the ED generated 1.99 kg of total waste per encounter. The majority was plastic (64.6%), with paper-derived products (18.4%) the next largest category. Only 14.9% of waste disposed of in red bags met the criteria for regulated medical waste. We identified several deviations from waste policy, including loose sharps not placed in sharps containers, as well as re-processable items and protected health information thrown in medical and solid waste. We also identified over 200 unused items. Pollutant emissions resulting per day from ED waste disposal include 3110 kg carbon dioxide equivalent and 576 grams of other criteria pollutants, heavy metals, and toxins., Conclusion: The ED generates significant amounts of waste. Current ED waste disposal practices reveal several opportunities to reduce total waste generated, increase adherence to waste policy, and reduce environmental impact. While our results will likely be similar to other urban tertiary EDs that serve as Level I trauma centers, future studies are needed to compare results across EDs with different patient volumes or waste generation rates.

Background: Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based method to identify, reduce, and prevent the harmful use of alcohol and illicit substances. However, SBIRT remains underused by physicians and other healthcare providers. Integrating interprofessional SBIRT training in medical curricula may better prepare future providers to care for patients with substance use disorders., Methods: The authors report the development and outcomes of a longitudinal, interprofessional SBIRT curriculum organized in partnership with health professions' schools in nursing, pharmacy, and social work. Primary results: From October 2015 to April 2017, 1,327 students were trained in SBIRT, resulting in the screening of 4,520 individuals and interventions in 897 individuals. 553 (42%) trainees were medical students, providing 3,330 (74%) screenings and 412 (46%) interventions., Principal Conclusions: These initial data demonstrate the feasibility of including SBIRT in undergraduate medical curricula. Broadly implemented, SBIRT training offers potential to normalize its practice as part of standard, evidenced-based patient care.

Study Objective or Background: To assess Rhode Island (RI) physician knowledge, attitudes, and confidence to succeed in Accountable Care Organizations (ACOs). Study Design and Methods: We surveyed RI physicians' attitudes and beliefs about ACOs, including scales measuring Physician Knowledge (7 Multiple Choice and True/False items), Attitudes (8 Likert scale items), and Confidence (7 Likert Scale Items), and examined how physician characteristics related to these measures. Primary Results: The response rate was 6 percent (72/1183). Means (100-point scale) and standard deviations were calculated for Knowledge 65.3 (22), Attitudes for ACO participants 56.3 (13.2) and ACO non-participants 42.7 (14.3), and Confidence 32.4 (25.9). Primary care physicians had higher Attitudes compared with specialists among ACO participants (60.2 vs. 51.8, p=.047) and ACO non-participants (48.2 vs. 34.4, p=.030). Principal Conclusions: RI Physicians have low scores in Knowledge, Attitudes, and Confidence scales in ACOs. Primary care physicians have more positive Attitudes about ACOs than specialists. This study is limited by its low response rate. [Full article available at http://rimed.org/rimedicaljournal-2019-03.asp].

Objective: Rising rates of opioid overdose deaths require innovative programs to prevent and reduce opioid-related morbidity and mortality. This study evaluates adoption, utilization, and maintenance of an emergency department (ED) take-home naloxone and peer recovery coach consultation program for ED patients at risk of opioid overdose., Methods: Using a Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework, we conducted a retrospective provider survey and electronic medical record (EMR) review to evaluate implementation of a naloxone distribution and peer recovery coach consultation program at two EDs. Provider adoption was measured by self-report using a novel survey instrument. EMRs of discharged ED patients at risk for opioid overdose were reviewed in three time periods: preimplementation, postimplementation, and maintenance. Primary study outcomes were take-home naloxone provision and recovery coach consultation. Secondary study outcome was referral to treatment. Chi-square analysis was used for study period comparisons. Logistic regression was conducted to examine utilization moderators. Poisson regression modeled utilization changes over time., Results: Most providers reported utilization (72.8%, 83/114): 95.2% (79/83) provided take-home naloxone and 85.5% (71/83) consulted a recovery coach. There were 555 unique patients treated and discharged during the study periods: 131 preimplementation, 376 postimplementation, and 48 maintenance. Postimplementation provision of take-home naloxone increased from none to more than one-third (35.4%, p < 0.001), one-third received consultation with a recovery coach (33.1%, 45/136), and discharge with referral to treatment increased from 9.16% to 20.74% (p = 0.003). Take-home naloxone provision and recovery coach consultation did not depreciate over time., Conclusions: ED naloxone distribution and consultation of a community-based peer recovery coach are feasible and acceptable and can be maintained over time., (© 2018 by the Society for Academic Emergency Medicine.)

: Adolescents/young adults, and especially men, are high-risk key populations that have been systematically missed by HIV services in low and middle-income countries (LMICs). Because these groups are also more likely to suffer injuries in LMICs, there are significant opportunities to engage these hard-to-reach persons via integrated HIV-injury programming provided during commonly sought acute/emergency care treatments of injuries. However, current facilities based HIV testing and treatment programs have failed to adequately capture these high-risk individuals. As such, research to address the knowledge gaps in HIV care delivery among the injured is needed and has great potential to inform interventions that would identify and treat adolescents/young adults, many of whom have the greatest individual and societal margins for long-term benefits with HIV care globally.

Objective . Injury is the leading cause of death and long-term disability in children. Longitudinal cohorts are designed to follow subjects longitudinally in order to determine if early-life exposures are related to certain health outcomes. Methods . We conducted a systematic review to identify studies of children from birth through 5 years who were followed longitudinally with unintentional injury as an outcome of interest. Results . Of the 1892 unique references based on the search criteria, 12 (published between 2000 and 2013) were included. The studies varied on the population of focus, injury definition, and incidence rates. Existing studies that longitudinally follow children aged 0 to 5 years are limited in number, scope, and generalizability. Conclusions . Further study using population-based longitudinal cohorts is necessary to more comprehensively estimate incidence of injury in young children., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The American College of Surgeons mandates universal screening for alcohol misuse and delivery of an intervention for those screening positive as a requirement for certification as a level 1 trauma center. Though this requirement has been mandated for over a decade, its implementation has been challenging. Our research team completed an implementation study supporting seven pediatric trauma centers' compliance with the requirement by developing and implementing an institutional alcohol Screening, Brief Intervention and Referral to Treatment (SBIRT) policy for adolescent trauma patients. A mixed-methods approach indicated that SBIRT adoption rates increased at all sites; however, providers' fidelity to the SBIRT intervention was variable, and providers reported a number of barriers to SBIRT implementation. The goal of this study is to conduct a fully powered type III hybrid effectiveness-implementation trial to test the effectiveness of a comprehensive implementation strategy in increasing the implementation of SBIRT for alcohol and other drug use (AOD) in pediatric trauma centers., Methods: Our implementation strategy is based on the Science to Service Laboratory (SSL), an approach developed by the SAMHSA-funded Addiction Technology Transfer Centers that consists of three core elements (i.e., didactic training + performance feedback + leadership coaching). Utilizing a stepped wedge design, a national cohort of 10 pediatric trauma centers will receive the SSL implementation strategy. At six distinct time points, each of the 10 sites will provide data from 30 electronic medical records (n = 1800 in total). A subset of adolescents will also report on fidelity of intervention delivery and linkage to care (i.e., continued AOD discussion and/or treatment with a primary care provider) 1 month after hospital discharge. In addition, nurses, social workers, and leaders will report on organizational readiness for implementation at four distinct time points., Discussion: This protocol proposes a unique opportunity to examine whether a comprehensive implementation strategy can improve the fidelity of SBIRT delivery across a national cohort of pediatric trauma centers. With injured adolescents, this could optimize the detection and intervention of AOD use and improve adolescent health., Trial Registration: Clinicaltrials.gov NCT03297060 .

Introduction: Survey data regarding the prevalence of risky substance use in the emergency department (ED) is not consistent. The objective of this study was to identify the prevalence of risky substance use among injured ED patients based on the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST v3.0). A secondary objective was to report on the feasibility of administering the ASSIST to this population, based on the time to conduct screening., Methods: This cross-sectional study used screening data from a randomized controlled trial. Injured ED patients completed the ASSIST on a tablet computer, and an ASSIST score was computed that indicated the need for a brief or intensive treatment intervention (risky use) for alcohol and other substances. For a subsample, data on time to complete each step of screening was recorded., Results: Between July 2010 and March 2013, 5,695 patients completed the ASSIST. Most (92%) reported lifetime use of at least one substance and 51% reported current risky use of at least one substance. Mean time to complete the ASSIST was 5.4 minutes and screening was considered feasible even when paused for clinical care to proceed., Conclusion: Estimates of risky substance use based on the ASSIST in our large sample of injured ED patients were higher than previously reported in other studies of ED patients, possibly due to the current focus on an injured population. In addition, it was feasible to administer the ASSIST to patients in the course of their clinical care., Competing Interests: Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. Research reported in this publication was supported by the National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health under award number R01AA017895. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Background: Pneumonia plays an important role in children's morbidity and mortality. In Brazil, epidemiological and social changes occurred concomitantly with the universal introduction of the 10-valent pneumococcal conjugate vaccine. This study identified risk factors for pneumonia following the implementation of a pneumococcal vaccination program., Methods: A hospital-based, case-control study involving incident cases of pneumonia in children aged 1-59 months was conducted between October 2010 and September 2013 at a tertiary hospital in northeastern Brazil. The diagnosis of pneumonia was based on the World Health Organization (WHO) criteria. The control group consisted of children admitted to the day-hospital ward for elective surgery. Children with comorbidities were excluded. The risk factors for pneumonia that were investigated were among those classified by the WHO as definite, likely and possible. A multivariate analysis was performed including variables that were significant at p ≤ 0.25 in the bivariate analysis., Results: The study evaluated 407 children in the case group and 407 children in the control group. Household crowding (OR = 2.15; 95 % CI, 1,46-3,18) and not having been vaccinated against the influenza virus (OR = 3.59; 95 % CI, 2,62-4.91) were the only factors found to increase the likelihood of pneumonia. Male gender constituted a protective factor (OR = 0.53; 95 % CI, 0,39-0,72)., Conclusion: Changes on risk factors for pneumonia were most likely associated with the expansion of the vaccination program and social improvements; however, these improvements were insufficient to overcome inequalities, given that household crowding remained a significant risk factor. The protection provided by the influenza vaccine must be evaluated new etiological studies. Furthermore, additional risk factors should be investigated.

Although booster phone calls have been used to enhance the impact of brief interventions in the emergency department, there has been less number of studies describing the content of these boosters. We conducted a qualitative analysis of booster calls occurring two weeks after an initial Web-based intervention for drug use and intimate partner violence (IPV) among women presenting for emergency care, with the objective of identifying the following: progress toward goals set during the initial emergency department visit, barriers to positive change, and additional resources and services needed in order to inform improvements in future booster sessions. The initial thematic framework was developed by summarizing codes by major themes and subthemes; the study team collaboratively decided on a final thematic framework. Eighteen participants completed the booster call. Most of them described a therapeutic purpose for their drug use. Altering the social milieu was the primary means of drug use change; this seemed to increase isolation of women already in abusive relationships. Women described IPV as interwoven with drug use. Participants identified challenges in attending substance use treatment service and domestic violence agencies. Women with substance use disorders and in abusive relationships face specific barriers to reducing drug use and to seeking help after a brief intervention.

Objective: To assess the adequacy of antibiotic prescription in children hospitalized for pneumonia in a reference pediatric hospital in Brazil., Methods: This was a cross-sectional study involving children aged between 1 month and 5 years who were hospitalized between October 2010 and September 2013. The classification of community-acquired pneumonia (CAP) was based on the clinical and radiological criteria of the World Health Organization (WHO). The analysis of antibiotic adequacy was performed according to the main guidelines on CAP treatment, which include the WHO guidelines, Brazilian Society of Pediatrics guidelines, and international guidelines (Pediatrics Infectious Diseases Society, the Infectious Disease Society of America, British Thoracic Society, and Consenso de la Sociedad latinoamericana de Infectología). A multivariate analysis was performed including variables that have statistical significance of P≤0.25 in the bivariate analysis., Results: The majority of the 452 hospitalized children were classified as having severe or very severe CAP (85.18%), and inadequate empiric antimicrobial therapy was started in 26.10% (118/452) of them. Ampicillin was the most used empiric antibiotic therapy (62.17%) for pneumonia, followed by a combination of ampicillin and associated with gentamicin. The initially proposed regimen was modified in 29.6% of the patients, and the most frequent change was the replacement of ampicillin by oxacillin combined with chloramphenicol. The median hospitalization time was 8.5 days, and the lethality rate was 1.55%. There was no statistical difference in adequacy in relation to the severity of pneumonia or degree of malnutrition. In the bivariate analysis, inadequacy of antibiotic therapy regimen was higher in patients undergoing oxygen therapy (P<0.05), which was given to 219 patients (48.45%). Pleural effusion was observed in 118 patients (26.11%) and was associated with higher prescription inadequacy, and it was the only factor that remained in the multivariate analysis (odds ratio =8.89; 95% confidence interval 5.20-15.01)., Conclusion: Adherence to the main guidelines for antimicrobial therapy according to the childhood CAP was unsatisfactory. Compliance with the guidelines is essential for both the management of pneumonia cases and the decrease in bacterial resistance and it is one of the cornerstone of WHO police of controlling antibiotic resistance.

Introduction: Lower urinary tract dysfunction (LUTD) are voiding dysfunctions without anatomical or neurological defects. The diagnosis is primarily clinical, with symptoms standardized by the International Children's Continence Society. Few studies relate quality of life of patients with cognitive and school performance., Objective: To evaluate milestones of bladder control, daily problems, quality of life (QoL), cognitive function and school performance of children with LUTD., Methods: Case series of patients followed in the Pediatric Nephrology tertiary hospital with assessment of QoL (Pediatric Quality of Life Inventory - PedsQoL version 4), School Performance Test (TDE) and Raven Progressive Matrices test., Results: Girls of lower social class were (90.9%) of eligible children. The mean age was 9.1 ± 4.8 years old. The most common symptoms were urge incontinence (81%), holding maneuvers (77.3%) and enuresis (59.1%) associated with the elimination disorder syndrome (63.6%). Caregivers considered volunteers urinary losses and/ or symptoms, and fought and/or beat the child. Children had been subjected to embarrassing situations such as warnings of teachers, they hid symptoms and/or the dirty clothes. Mean score of QoL was 71.0 ± 12.6 with the lowest mean score on the school dimension. In TDE 55% had lower performance and in Raven Matrices 60% were intellectually in the medium level. It was observed lower QoL scores in the medium and lower level of TDE and average intellectual capacity/below average in Raven matrices., Conclusion: LUTD may negatively affect family and social relationships, school performance and QoL of children with the dysfunction.

Objectives: Develop and internally validate a survey tool to assess emergency department (ED) physician attitudes, clinical practice, and willingness to perform opiate harm reduction (OHR) interventions and to identify barriers and facilitators in translating willingness to action., Methods: This study was an anonymous, Web-based survey based on the Theory of Planned Behavior of ED physicians at three tertiary referral centers. Construction and internal validation of scaled questions was assessed through principal component and Cronbach's alpha analyses. Stepwise linear regression was conducted to measure impact of physician knowledge, attitudes, confidence, and self-efficacy on willingness to perform OHR interventions including opioid overdose education; naloxone prescribing; and referral to naloxone, methadone, and syringe access programs., Results: A total of 200 of 278 (71.9%) physicians completed the survey. Principal component analysis yielded five components: attitude, confidence, self-efficacy, professional impact factors, and personal impact factors. Overall, respondents were willing to perform OHR interventions, but few actually do. Willingness was correlated with attitude, confidence, and self-efficacy (R(2)  = 0.50); however, overall physicians lacked confidence (mean = 3.06 of 5, 95% confidence interval [CI] = 2.94 to 3.18]). Knowledge, time, training, and institutional support were all prohibitive barriers. Physicians reported that research evidence, professional organization recommendations, and opinions of ED leaders would strongly influence a change in their clinical practice to incorporate OHR interventions (mean = 4.25 of 5, 95% CI = 4.18 to 4.32)., Conclusions: Compared to prior studies, emergency medicine physicians had increased willingness to perform OHR interventions, but there remains a disparity between willingness and clinical practice. Influential factors that may move physicians from "willing" to "doing" include dissemination of supportive research evidence; professional organization endorsement; ED leadership opinion; and addressing time, knowledge, and institutional barriers., (© 2016 by the Society for Academic Emergency Medicine.)

Objective: Evaluate the efficacy of a child passenger safety (CPS) educational intervention on the CPS-related knowledge, attitude and anticipatory guidance behaviors of pediatric interns., Methods: All subjects were surveyed at baseline and 6 months. Intervention interns attended a CPS training module which included viewing an educational video, observing a car seat inspection appointment, hands-on practice and completion of a post-intervention survey., Results: All 16 intervention interns completed the initial survey, the intervention and the immediate-post questionnaire. Thirteen (81%) completed the 6-month follow-up. The baseline survey was completed by 27/40 (67%) of control interns, 28/40 (70%) submitted a follow-up. The proportion of intervention interns who self-reported giving CPS guidance at all well-child visits increased by 31.3% (95% CI 6.1,56.5%); the control group had no change. Similar results were seen with self-reported knowledge and attitude., Conclusions: A CPS training module increases pediatric interns' knowledge, improves attitudes, and self-reported behaviors regarding CPS-related anticipatory guidance.

Background: Adults over the age of 65 are involved in more motor vehicle collisions per mile driven than those under 65., Objective: This study aimed to determine the prevalence of sedating medication use among older drivers, and their recall of advice given by medical professionals about potential for these medications to cause driving impairment., Methods: This was a cross-sectional study of older adults (age ≥ 65) who had driven in the last 30 days, presenting at an urban emergency department., Results: Of the 76 participants, 34 (44.7% [95%CI: 38.7, 50.7]) reported currently using sedating medications. No participants using sedating medications reported being advised by their prescriber about potential driving impairment caused by these medications., Conclusions: Given that none of the participants on sedating medications reported previous advice regarding the potential for these medications to cause driving impairment, this at-risk group might benefit from more thorough instruction to limit driving when using sedating medication.

Dengue cases have increased in younger age groups in Brazil. Maternal anti-dengue antibodies can have a protective effect in the first months of life, but their decline can increase the risk of severe dengue. A prospective birth cohort was established in 2011-2012 in the city of Recife, Pernambuco State, Brazil, to determine the incidence of serotype-specific dengue infection and the kinetics of transferred maternal anti-dengue antibodies in the first years of life. This article describes the design, methods and preliminary results of this cohort study. 354 children underwent clinical and laboratory monitoring for two years, with 15% losses to follow-up. The overall rate of new infections was approximately 10% in the first year of follow-up. Information on the force of serotype-specific dengue infection and the evaluation of transferred maternal antibodies can contribute to understanding dengue etiopathogenesis.

Objectives: To evaluate prevalences of Treponema pallidum, human immunodeficiency virus (HIV), human T-lymphotropic virus (HTLV), and hepatitis B virus (HBV) infections and coinfections during prenatal screening in an urban Northeastern Brazilian population through a large dataset., Methods: Secondary data were obtained from the Maceió (Alagoas, Brazil) municipal prenatal screening program from June 2007 to May 2012. Dried blood serum tests from 54,813 pregnant women were examined to determine prevalences of T. pallidum, HIV, HTLV, and HBV infections and coinfections, and the seroconversion rates for syphilis and HIV infection. Socio-demographic variables associated with syphilis and HIV infection were identified., Results: The prevalences of syphilis, HIV, HTLV, and HBV infections were 2.8%, 0.3%, 0.2%, and 0.4%, respectively. Pregnant women infected with T. pallidum had a 4.62-fold greater risk of HIV coinfection, and pregnant women infected with HIV had a 5.71-fold greater risk of T. pallidum coinfection. Seroconversion for syphilis and HIV during pregnancy occurred in 0.5% and 0.06% of women, respectively. Among the women carrying HTLV, 4.2% also had an HBV infection., Conclusions: Syphilis was twice as prevalent among pregnant women in Maceió, compared to the national average, and coinfections with syphilis/HIV and HTLV/HBV were significantly associated among these pregnant women., (Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Additional knowledge, attitudes and skills are required for the next generation of medical students as they expand the traditional focus on individual patients to include population-based health and scholarly investigation. The Warren Alpert Medical School of Brown University (AMS) is initiating a master's degree program as a key component of the new Primary Care-Population Medicine program at AMS leading to both a Doctorate in Medicine (MD) and Master of Science in Population Medicine (ScM) degrees in four years. The ScM is composed of a series of nine courses, integrated into the four-year MD curriculum, as well as a thesis. Additional attention will be given to leadership and quality improvement training. The goal is to produce graduates competent in the care of individual patients, panels, communities, and populations.

Objective: To determine the effectiveness of 20 twice-weekly sessions of parasacral transcutaneous electrical neural stimulation (TENS) for treatment of urinary urgency and urge-incontinence in children and adolescents., Methods: A Phase II clinical trial was carried out with patients with urinary urgency or urge-incontinence aged between 5 and 14 years. Twenty TENS sessions were conducted, twice weekly, using a Quark® Dualpex 961 apparatus. The variables analyzed were daily micturition, dynamics ultrasonography of the lower urinary tract pre-and post-treatment and responses to a questionnaire on urinary leakage applied during each session., Results: The mean age of the 25 children participating in the study was 7.80 ± 2.22 years, most were female (92%) and had urge-incontinence (92%). The difference in urinary leakage pre- and post-treatment was statistically significant ( p = 0.04); a decline in the symptom of urinary leakage was reported by all caregivers in children who completed the 20th session; the ultrasound parameters, although not statistically significant, showed a reduction in the percentage of children with detrusor contractions (from 62.5% to 43.5%); and a more adequate pre-micturition bladder volume of 4.2% post-treatment compared with 19.0% prior to treatment., Discussion: The electro-stimulation carried out during the twice weekly sessions appeared to be effective and urinary incontinence declined in half of the patients from the 12th session onwards. However, there is a need for a study involving a larger number of patients to confirm the results obtained.

Introduction: Motor vehicle crashes (MVCs) are a leading cause of injury in the United States (U.S.). Detailed knowledge of MVC eye injuries presenting to U.S. emergency departments (ED) will aid clinicians in diagnosis and management. The objective of the study was to describe the incidence, risk factors, and characteristics of non-fatal motor vehicle crash-associated eye injuries presenting to U.S. EDs from 2001 to 2008., Methods: Retrospective cross-sectional study using the National Electronic Injury Surveillance System All Injury Program (NEISS-AIP) from 2001 to 2008 to assess the risk of presenting to an ED with a MVC-associated eye injury in relation to specific occupant characteristics, including age, gender, race/ethnicity, disposition, and occupant (driver/passenger) status., Results: From 2001 to 2008, an estimated 75,028 MVC-associated eye injuries presented to U.S. EDs. The annual rate of ED-treated eye injuries resulting from MVCs declined during this study period. Males accounted for 59.6% of eye injuries (95% confidence interval [CI] 56.2%-63.0%). Rates of eye injury were highest among 15-19 year olds (5.8/10,000 people; CI 4.3-6.0/10,000) and among African Americans (4.5/10,000 people; CI 2.0-7.1/10,000). Drivers of motor vehicles accounted for 62.2% (CI 58.3%-66.1%) of ED-treated MVC eye injuries when occupant status was known. Contusion/Abrasion was the most common diagnosis (61.5%; CI 56.5%-66.4%). Among licensed U.S. drivers, 16-24 year olds had the highest risk (3.7/10,000 licensed drivers; CI 2.6-4.8/10,000)., Conclusion: This study reports a decline in the annual incidence of ED-treated MVC-associated eye injuries. The risk of MVC eye injury is greatest among males, 15 to 19 year olds and African Americans.