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Author(s): Liakoni, Evangelia; Tyndale, Rachel F; Jacob, Peyton; Dempsey, Delia A; Addo, Newton; Benowitz, Neal L | Abstract: ObjectivesTo investigate if the nicotine metabolite ratio (NMR, the ratio of nicotine metabolites 3'-hydroxycotinine/cotinine) is a reliable phenotypic biomarker for nicotine clearance across races, and as a function of differences in the rate of nicotine, cotinine and 3'-hydroxycotinine glucuronidation and UGT genotypes.MethodsParticipants [Caucasians (Whites), African Americans (Blacks) and Asian-Americans (Asians)] received an oral solution of deuterium-labeled nicotine and its metabolite cotinine. Plasma and saliva concentrations of nicotine and cotinine were used to determine oral clearances. Rates of glucuronidation were assessed from urine glucuronide/parent ratios, and UGT2B10 and UGT2B17 genotypes from DNA.ResultsAmong the 227 participants, 96 (42%) were White, 67 (30%) Asian and 64 (28%) Black. Compared to the other two races, Whites had higher nicotine and cotinine total oral clearance, Blacks had lower nicotine and cotinine glucuronidation rates and Asians had lower 3'-hydroxycotinine glucuronidation rates. A strong positive correlation (correlations coefficients 0.77-0.84; P l 0.001) between NMR and nicotine oral clearance was found for all three races, and NMR remained a strong predictor for the nicotine oral clearance while adjusting for race, sex and age. Neither the metabolite glucuronidation ratios nor the UGT genotypes had significant effects on the ability of NMR to predict nicotine oral clearance.ConclusionNMR appears to be a reliable phenotypic biomarker for nicotine clearance across races, glucuronidation phenotypes and genotypes. Racial differences in the relationships between NMR, smoking behaviors and addiction are unlikely to be related to an inadequate estimation of nicotine clearance on the basis of NMR.

We have recently demonstrated that a significant proportion of fatal out-of-hospital cardiac arrests (OHCAs) are precipitated by occult overdose, which could benefit from antidote therapy administered adjunctively with other cardiac resuscitation measures. We sought to develop simple decision instruments that EMS providers and other first responders can use to rapidly identify occult opioid overdose-associated OHCAs.We examined data from February 2011 through December 2017 in the Postmortem Systematic Investigation of Sudden Cardiac Death study, in which San Francisco (California) County EMS-attended OHCA deaths received autopsy and expert panel adjudication of cause of death. Using classification tree analyses, we derived highly sensitive and specific decision instruments that predicted our primary outcome of occult opioid OD-associated OHCA. We then calculated screening performance characteristics of these instruments.Of 767 OHCA deaths, 80 (10.4%) were associated with occult opioid overdose. Of the eight models with 100% sensitivity for opioid overdose-associated cardiac arrest, the highest specificity model (23.4%, 95% confidence interval [CI] 20.3-26.7%) was age60 years OR race = black or non-Latinx white OR arrest in public place. The highest specificity instrument (96.3%, 95% CI 94.6-97.5%) consisting of age60 years AND race = black or non-Latinx white AND unwitnessed arrest AND female sex had 25% (95% CI 16-35.9%) sensitivity.We have derived simple decision instruments that can identify patients whose OHCA precipitant was occult opioid overdose. These instruments may be used to guide selective administration of the antidote naloxone in OHCA resuscitations.

ObjectiveIn an urban adolescent population, we evaluated sources of exposure to secondhand smoke exposure (SHS), examined differences in exposure by race/ethnicity, age and sex, and determined the relationship between exposure source(s) and the biomarkers cotinine and NNAL.MethodsParticipants were recruited from a public hospital-based outpatient clinic in San Francisco, CA, USA.ResultsOf a sample of N=298 adolescents screened, 235 were biologically confirmed to be exposed to tobacco smoke. Of those, N=16 were active smokers and N=219 were exposed to SHS; 91 (39%) were heavily SHS exposed (median cotinine=0.76 ng/mL) and 128 (54%) had light SHS exposure (median cotinine=0.11 ng/mL). Within those SHS exposed, the most common source of exposure was in a public area. No significant racial/ethnic differences were found, although African American adolescents were more likely to live in a home that allowed smoking. Older adolescents were more likely to be exposed across several difference sources, and females more likely to be exposed in a car and in public areas. Past 7-day exposure in the home, in a car, and current blunt use were significantly related to biomarkers of exposure.ConclusionsUrban adolescents are exposed to SHS across a variety of sources. Although exposure in a public area is most common, exposure in the home and in cars significantly influences tobacco biomarker levels. Interventions to reduce exposure would have the greatest impact in this population if they focused on reducing exposure in the home and in cars. History of blunt use is a strong determinant of tobacco exposure.

Introduction: The World Health Organization recently recognized the importance of emergency and trauma care in reducing morbidity and mortality. Training programs are essential to improving emergency care in low-resource settings; however, a paucity of comprehensive curricula focusing specifically on pediatric emergency medicine (PEM) currently exists. The African Federation for Emergency Medicine (AFEM) developed a PEM curriculum that was pilot-tested in a non-randomized, controlled study to evaluate its effectiveness in nurses working in a public Tanzanian referral hospital. Methods: Fifteen nurses were recruited to participate in a two-and-a-half-day curriculum of lectures, skill sessions, and simulation scenarios covering nine topics; they were matched with controls. Both groups completed pre- and post-training assessments of their knowledge (multiple-choice test), self-efficacy (Likert surveys), and behavior. Changes in behavior were assessed using a binary checklist of critical actions during observations of live pediatric resuscitations. Results: Participant-rated pre-training self-efficacy and knowledge test scores were similar in both control and intervention groups. However, post-training, self-efficacy ratings in the intervention group increased by a median of 11.5 points (interquartile range [IQR]: 6-16) while unchanged in the control group. Knowledge test scores also increased by a median of three points (IQR: 0-4) in the nurses who received the training while the control group’s results did not differ in the two periods. A total of 1192 pediatric resuscitation cases were observed post-training, with the intervention group demonstrating higher rates of performance of three of 27 critical actions. Conclusion: This pilot study of the AFEM PEM curriculum for nurses has shown it to be an effective tool in knowledge acquisition and improved self-efficacy of pediatric emergencies. Further evaluation will be needed to assess whether it is currently effective in changing nurse behavior and patient outcomes or whether curricular modifications are needed.

OBJECTIVE—: Pediatric focused assessment with sonography for trauma (FAST) is a sequence of ultrasound views rapidly performed by clinicians to diagnose hemorrhage. A technical limitation of FAST is the lack of expertise to consistently acquire all required views. We sought to develop an accurate deep learning view classifier using a large heterogeneous dataset of clinician-performed pediatric FAST. METHODS—: We developed and conducted a retrospective cohort analysis of a deep learning view classifier on real-world FAST studies performed on injured children less than 18 years old in two pediatric emergency departments by 30 different clinicians. FAST was randomly distributed to training, validation, and test datasets, 70:20:10; each child was represented in only one dataset. The primary outcome was view classifier accuracy for video clips and still frames. RESULTS—: There were 699 FAST studies, representing 4925 video clips and 1,062,612 still frames, performed by 30 different clinicians. The overall classification accuracy was 97.8% (95% confidence interval [CI]: 96.0–99.0) for video clips and 93.4% (95% CI: 93.3–93.6) for still frames. Per view still frames were classified with an accuracy: 96.0% (95% CI: 95.9–96.1) cardiac, 99.8% (95% CI: 99.8–99.8) pleural, 95.2% (95% CI: 95.0–95.3) abdominal upper quadrants, and 95.9% (95% CI: 95.8–96.0) suprapubic. CONCLUSION—: A deep learning classifier can accurately predict pediatric FAST views. Accurate view classification is important for quality assurance and feasibility of a multi-stage deep learning FAST model to enhance the evaluation of injured children.

ObjectivesMicroaggressions and implicit bias occur frequently in medicine. No previous study, however, has examined the implicit bias and microaggressions that emergency medicine (EM) providers experience. Our primary objective was to understand how often EM providers experience implicit bias and microaggressions. Our secondary objective was to evaluate the types of microaggressions they experience and whether their own identifying characteristics are risk factors.MethodsA questionnaire was administered to EM providers across the United States. Outcome measures of experiencing or witnessing a microaggression, overt discrimination, or implicit bias were described using frequencies, proportions, and logistic regressions. Where a univariate association between outcome measures and demographic characteristics was found, multivariate regression to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs) was performed. Proportional odds logistic regression models were used to evaluate the specific type of microaggressions experienced and if there was an association with demographic variables.ResultsA total of 277 medical providers (48% trainees-medical students, residents, and fellows-and 52% attending physicians) completed the survey. A total of 181 (65%) respondents reported experiencing a microaggression. Female (OR=5.9 [95% CI=3.1 to 11.2]) and non-White respondents (OR=2.4 [95% CI=1.2 to 4.5]) were more likely to report experiencing any microaggression. Misidentification, the most common form of microaggression, was more common with trainees compared to attending physicians (proportional OR [POR]=2.6 [95% CI=1.7 to 4.0]) and non-White, compared to White, respondents (POR=2.2 [95% CI=1.3 to 3.6]). Misidentification as nonclinician staff was associated with gender (POR=53 [95% CI=24 to 116]) and 52% of female respondents reported being mistaken for nonclinician staff almost daily. Seventy-six percent of respondents reported being called a vulgar term by a patient and 21% by a staff member.ConclusionsEM providers, particularly women and non-Whites, who responded to our survey experienced and witnessed bias and microaggressions, most commonly misidentification, in the ED.

Background: Point-of-care ultrasound (POCUS) is a noninvasive bedside tool with many pediatric applications but is not currently a formal part of pediatric training and practice. Formal needs assessments of general pediatricians regarding POCUS training are lacking. We aimed to quantify the baseline ultrasound experience and training needs of general pediatricians and pediatric residents across different practice settings.Methods: In 2020, we sent an online survey to 485 current faculty, residents, and graduates from an urban pediatric academic medical center in Northern California. Pediatric subspecialists were excluded. Survey questions about baseline experience, comfort, and perceived usefulness of 20 common POCUS applications were developed by two POCUS experts using existing literature. Chi-squared analysis was used to compare residents versus attendings and to compare attendings practicing in inpatient versus outpatient versus mixed settings. Results: Response rate was 20% (98/485). Compared to attendings (n=73), residents (n=25) endorsed more exposure to POCUS in medical school (32% vs 5%, p=0.003) and residency (12% vs 5%, p=0.003). Respondents endorsed low comfort with POCUS (mean 1.3 out of 5 on Likert scale). Of 20 procedural and diagnostic applications, respondents identified abscess drainage, bladder catheterization, soft tissue, neck, advanced abdominal, and constipation as most useful. Overall, 50% of pediatricians (and 70% of pediatric residents) responded that there were opportunities to use POCUS multiple times a week or more in their clinical practice. Conclusions: There is an unmet demand for POCUS training among general pediatricians and trainees in our study. Our results could guide design of ultrasound curricula for general pediatricians.

Background As of March 2019, JUUL electronic cigarettes are the most popular e-cigarette on the U.S. market, but little is known of nicotine exposure and dependence on JUUL and user experience. Methods JUUL users participated in a community-based study involving questionnaires, saliva collection and a qualitative interview. Results Fifteen participants were enrolled (80% male, 53% White) and had an average age of 29.8 (standard deviation = 10) years. Daily exposure to nicotine assessed via salivary cotinine was similar to those reported for other e-cigarette and tobacco cigarette users in general. The majority reported low to moderate nicotine dependence. Qualitative interview themes included: the importance of social networks in adoption and use of the product; device features such as small size and vapor cloud reinforced product use; the product provided satisfaction compared to a tobacco cigarette; and a perceived sense of addiction to the product. Conclusions JUUL e-cigarettes expose users to levels of nicotine similar to other e-cigarettes but may be more satisfying due to unique device features. JUUL may be quite acceptable to tobacco cigarette smokers who are seeking to quit. However, it holds addictive potential and can reinforce long-term nicotine use.

Background Cardiovascular safety is an important consideration regarding the benefits versus risks of electronic cigarette use (EC) for public health. The single‐use cardiovascular effects of EC have been well studied but may not reflect effects of ad libitum use throughout the day. We aimed to compare the circadian hemodynamic effects as well as 24‐hour biomarkers of oxidative stress, and platelet aggregation and inflammation, with ad libitum cigarette smoking (CS) versus EC versus no tobacco product use. Methods and Results Thirty‐six healthy dual CS and EC users participated in a crossover study in a confined research setting. Circadian heart rate, blood pressure and plasma nicotine levels, 24‐hour urinary catecholamines, 8‐isoprostane and 11‐dehydro‐thromboxane B2, and plasma interleukin‐6 and interleukin‐8 were compared in CS, EC, and no nicotine conditions. Over 24 hours, and during daytime, heart rate and blood pressure were higher in CS and EC compared with no tobacco product conditions ( P P Conclusions CS and EC had similar 24‐hour patterns of hemodynamic effects compared with no tobacco product, with a higher average heart rate with CS versus EC, and similar effects on biomarkers of inflammation. EC may pose some cardiovascular risk, particularly to smokers with underlying cardiovascular disease, but may also provide a harm reduction opportunity for smokers willing to switch entirely to EC. Registration URL: https://www.clinicaltrials.gov ; Unique Identifier: NCT02470754.

The pediatric Focused Assessment with Sonography for Trauma (FAST) is a sequence of ultrasound views rapidly performed by the clinician to diagnose hemorrhage. One limitation of FAST is inconsistent acquisition of required views. We sought to develop a deep learning model and classify FAST views using a heterogeneous dataset of pediatric FAST. This study of diagnostic test developed and tested a deep learning model for view classification of archived real-world pediatric FAST studies collected from two pediatric emergency departments. FAST frames were randomly distributed to training, validation, and test datasets in a 70:20:10 ratio; each patient was represented in only one dataset to maintain sample independence. The outcome was the prediction accuracy of the model in classifying FAST frames and video clips. FAST studies performed by 30 different clinicians from 699 injured children included 4,925 videos representing 1,062,612 frames from children who were a median of 9 years old. On test dataset, the overall view classification accuracy for the model was 93.4% (95% CI: 93.3-93.6) for frames and 97.8% (95% CI: 96.0-99.0) for video clips. Frames were correctly classified with an accuracy of 96.0% (95% CI: 95.9-96.1) for cardiac, 99.8% (95% CI: 99.8-99.8) for thoracic, 95.2% (95% CI: 95.0-95.3) for abdominal upper quadrants, and 95.9% (95% CI: 95.8-96.0) for suprapubic. A deep learning model can be developed to accurately classify pediatric FAST views. Accurate view classification is the important first step to support developing a consistent and accurate multi-stage deep learning model for pediatric FAST interpretation.

OBJECTIVES: Intussusception is a pediatric medical emergency that can be difficult to diagnose. Radiology‐performed ultrasound is the diagnostic study of choice but may lead to delays due to lack of availability. Point‐of‐care ultrasound for intussusception (POCUS‐I) studies have shown excellent accuracy and reduced lengths of stay, but there are limited POCUS‐I training materials for pediatric emergency medicine (PEM) providers. METHODS: We performed a prospective cohort study assessing PEM physicians undergoing a primarily Web‐based POCUS‐I curriculum. We developed the POCUS‐I curriculum using Kern’s six‐step model. The curriculum included a Web‐based module and a brief, hands‐on practice that was developed with a board‐certified pediatric radiologist. POCUS‐I technical skill, knowledge, and confidence were determined by a direct observation checklist, multiple‐choice test, and a self‐reported Likert‐scale survey, respectively. We assessed participants immediately pre‐ and postcourse as well as 3 months later to assess for retention of skill, knowledge, and confidence. RESULTS: A total of 17 of 17 eligible PEM physicians at a single institution participated in the study. For the direct observation skills test, participants scored well after the course with a median (interquartile range [IQR]) score of 20 of 22 (20–21) and maintained high scores even after 3 months (20 [20–21]). On the written knowledge test, there was significant improvement from 57.4% (95% CI = 49.8 to 65.2) to 75.3% (95% CI = 68.1 to 81.6; p

ObjectivesComputed tomography (CT), the reference standard for diagnosis of intraabdominal injury (IAI), carries risk including ionizing radiation. CT-sparing clinical decision rules for children have relied heavily on physical examination, but they did not include focused assessment with sonography for trauma (FAST), which has emerged into widespread use during the past decade. We sought to determine the independent associations of physical examination, laboratory studies, and FAST with identification of IAI in children and to compare the test characteristics of these diagnostic variables. We hypothesized that FAST may add incremental utility to a physical examination alone to more accurately identify children who could forgo CT scan.MethodsWe reviewed a large trauma database of all children with blunt torso trauma presenting to a freestanding pediatric emergency department during a 20-month period. We used logistic regression to evaluate the association of FAST, physical examination, and selected laboratory data with IAI in children, and we compared the test characteristics of these variables.ResultsAmong 354 children, 50 (14%) had IAI. Positive FAST (odds ratio [OR]= 14.8, 95% confidence interval [CI]= 7.5 to 30.8) and positive physical examination (OR= 15.2, 95% CI= 7.7 to 31.7) were identified as independent predictors for IAI. Physical examination and FAST each had sensitivities of 74% (95% CI= 60% to 85%). Combining FAST and physical examination as FAST-enhanced physical examination (exFAST) improved sensitivity and negative predictive value (NPV) over either test alone (sensitivity= 88%, 95% CI= 76% to 96%) and NPV of 97.3% (95% CI= 94.5% to 98.7%).ConclusionsIn children, FAST and physical examinations each predicted the identification of IAI. However, the combination of the two (exFAST) had greater sensitivity and NPV than either physical examination or FAST alone. This supports the use of exFAST in refining clinical predication rules in children with blunt torso trauma.

Background Methods to promote successful trainee participation in quality improvement projects are poorly studied. This project studied the effects of a trainee pay-for-performance program and quality improvement education at a safety-net hospital. Methods In this program, trainees worked with quality improvement faculty, participated in projects aligned with the hospital's priorities, and designed their program-specific project. Each trainee who worked at least 88 days in the institution was eligible to earn $400 for every target achieved for at least six months (maximum of $1,200). Results Among hospitalwide goals, needlestick injuries per quarter decreased from [mean (standard deviation; SD)] 18 (4.6) to 12 (2.6), 95% confidence interval (CI) = -10.1–1.9, p = 0.02; percentage of excellent provider communication improved from 76.8% to [mean (SD)] 80.5% (2.9), 95% CI = 0.8–8.3, p = 0.08; and mean length of stay for discharged emergency department patients requiring specialist consultation decreased from [mean (SD)] 523 (120) to 461 (40) minutes, 95% CI = -162–37.2, p = 0.11. Among resident-initiated projects, the percentage of Family Medicine patients undergoing colorectal screening increased from 65.1% to [mean (SD)] 67.7% (0.4), 95% CI = 1.7–3.5, p = 0.01; percentage of at-risk patients receiving naloxone at hospital discharge increased from 9% to [mean (SD)] 63% (7.2), 95% CI = 36.1–71.9, p = 0.01; percentage of adolescents screened for chlamydia increased from 34% to [mean (SD)] 55.8% (6.4), 95% CI = 5.9–37.6, p = 0.03; and percentage of high-dose opioid prescriptions following cesarean section decreased from 28% to [mean (SD)] 1.7% (2.9), 95% CI = -33.5 to -19.2, p = 0.001. Eleven of 14 programs achieved three goals. All resident-led goals were met. Conclusion A pay-for-performance improvement program that aligns educational and hospital priorities can provide meaningful experiential learning for trainees and improve patient care.

Author(s): Harvanko, Arit M; St Helen, Gideon; Nardone, Natalie; Addo, Newton; Benowitz, Neal L | Abstract: Background and aimsRelative pharmacological effects of e-cigarettes and cigarettes during 24nhours of ad-libitum use have not been described. In this study, 24-hour blood plasma nicotine concentrations and 48-hour subjective effects with use of cigarettes and e-cigarettes were measured among dual users.DesignTwo-arm within-subject cross-over design with preferred e-cigarette or cigarette ad-libitum use over 48nhours.SettingHospital research ward in San Francisco, California, USA.ParticipantsThirty-six healthy dual users of e-cigarettes and cigarettes (nn=n8, 25% females).MeasurementsTwenty-four-hour blood plasma nicotine and cotinine concentrations and 48-hour self-reported nicotine withdrawal symptoms and rewarding effects.FindingsAnalyses used analysis of variance (ANOVA)-based mixed models with order of product (e-cigarette or cigarette) and product type (combustible cigarette or type of e-cigarette) as fixed effects, and subject as a repeated effect. During a 24-hour period, e-cigarettes produced lower nicotine exposure than cigarettes for the majority of users, although 25% received more nicotine from e-cigarettes, which was predicted by more frequent e-cigarette use or greater dependence. Compared to cigarette smoking, nicotine exposure for variable-power tank users was similar, while cig-a-like (t(30) n=n2.71, Pn=n0.011, dn=n0.745) and fixed-power tank users (t(30) n=n3.37, Pn=n0.002, dn=n0.993) were exposed to less nicotine. Cigarettes were rated higher than e-cigarettes on some desirable subjective effects (e.g. psychological reward, t(322) n=n7.24 Pnln0.001, dn=n0.432), but withdrawal symptom reduction was comparable. No differences were found between e-cigarette types, but Bayes factors indicate that these measures were insensitive.ConclusionsDuring a 24-hour period in a hospital setting in the United States, nicotine exposure for dual users of e-cigarettes and cigarettes was similar when using cigarettes or variable-power tank devices only but was lower for those using cig-a-like or fixed-power devices only. Despite lower nicotine levels, all types of e-cigarette were effective in preventing withdrawal symptoms. E-cigarettes were rated less rewarding than cigarettes.

Purpose Results of a study to determine whether i.v. administration of a single dose of 4 mg of ondansetron was associated with QT interval prolongation in emergency department (ED) patients are reported. Methods In a prospective observational study conducted at an urban academic medical center ED, a convenience sample of adult ED patients treated with ondansetron 4 mg i.v. were enrolled. A 12-lead electrocardiogram (ECG) was obtained immediately before and 5 minutes after ondansetron administration. Measurements of heart rate–corrected QT interval (QTc measurements) provided by ECG machines were evaluated. An electrophysiologist analyzed all ECGs for adverse electrical events and verified the accuracy of QTc values. The primary objective was to measure the QTc change from baseline after ondansetron administration. The secondary objective was to describe adverse electrical cardiac events. Interactions between ondansetron and patients’ home medications or ED-provided medications were analyzed. Results Among patients included in the data analysis ( n = 20), ondansetron administration was associated with a mean QTc increase of 16.2 msec (95% confidence interval, 4.2–28.2 msec; p = 0.01) and a median increase of 12 msec (interquartile range, 5.5–18.0 msec; p Conclusion Significant QTc prolongation occurred in ED patients receiving a single 4-mg i.v. dose of ondansetron. None of the patients had an ondansetron-related cardiac adverse event.

ObjectiveRecent studies have clarified the role of alpha-blockers, such as tamsulosin, for patients diagnosed with ureteral stones

Background Assessing the prevalence and level of exposure (dose) of tobacco and marijuana use is important in studies of harm from use of these substances. We used biochemical analysis of urine to quantitatively assess exposure to nicotine and delta 9-tetrahydrocannabinol (THC) in adolescents receiving medical care in a public hospital Methods Participants were 686 adolescents between 12 and 21 years old seen at Zuckerberg San Francisco General Hospital between 2012 and 2014. Urine samples were assayed using high sensitivity liquid chromatographic assays for cotinine, a major metabolite of nicotine, and 11-nor-9-carboxy-delta 9-THC (THC−COOH), a major metabolite of THC. A commonly used immunoassay screen for THC−COOH was also performed. Results The THC−COOH immunoassay substantially underestimated THC exposure, as measured with the high sensitivity assay. THC use was detected in 25% of participants, with higher prevalence with increasing age and in non-Hispanic blacks. Active tobacco smokers had an 80% prevalence of THC use (odds ratio for cigarette smoking predicting THC use 13.2). Urine cotinine and THC−COOH were significantly correlated (r = 0.60). Conclusions The use of a high sensitivity chromatographic urine assay provides a much more complete picture of adolescent tobacco use compared to a commonly used immunoassay. The immunoassay provides high specificity but moderate sensitivity. We confirm high concordance of tobacco and marijuana use and the high predictive value of cigarette smoking in predicting marijuana use, and provide novel data on the quantitative correlation between level of exposure to nicotine and THC. Quantitative screening of nicotine and THC exposure may enhance our understanding of addiction and harm from single and dual product use.

Author(s): Li-Sauerwine, Simiao; Rebillot, Katie; Melamed, Matthew; Addo, Newton; Lin, Michelle | Abstract: Introduction: There is a high prevalence of burnout among emergency medicine (EM) residents. The Maslach Burnout Inventory - Human Services Survey (MBI-HSS) is a widely used tool to measure burnout. The objective of this study was to compare the MBI-HSS and a two-question tool to determine burnout in the EM resident population.Methods: Based on data from the 2017 National Emergency Medicine Resident Wellness Survey study, we determined the correlation between two single-item questions with their respective MBI subscales and the full MBI-HSS. We then compared a 2-Question Summative Score to the full MBI-HSS with respect to primary, more restrictive, and more inclusive definitions of burnout previously reported in the literature.Results: Of 1,522 residents who completed the survey 37.0% reported “I feel burned out from my work,” and 47.1% reported “I have become more callous toward people since I took this job” once a week or more (each item g3 on a scale of 0-6). A 2-Question Summative Score totaling g3 correlated most closely with the primary definition of burnout (Spearman’s rho 0.65 [95% confidence interval 0.62-0.68]). Using the summative score, 77.7% of residents were identified as burned out, compared to 76.1% using the full MBI-HSS, with a sensitivity and specificity of 93.6% and 73.0%, respectively.Conclusion: An abbreviated 2-Question Summative Score correlates well with the full MBI-HSS tool in assessing EM resident physician burnout and could be considered a rapid screening tool to identify at-risk residents experiencing burnout.

Comparisons of systemic exposure to toxicants during monitored cigarette smoking, electronic cigarette (e-cigarette) use, and abstention are needed to enhance our understanding of the risks of e-cigarette use (vaping). In a cross-over study, we measured 10 mercapturic acid metabolites of volatile organic compounds (VOCs) in 24-hour urine samples collected from 36 dual users (8 women) of e-cigarettes and cigarettes during 2 days of ad libitum vaping or cigarette-only use, and 2 days of enforced abstention. Concentrations of VOC metabolites were higher during smoking compared with vaping, except for the methylating agents' metabolite. The fold-difference in concentrations when smoking relative to vaping ranged from 1.31 (1.06–1.61; geometric mean, 95% confidence interval; 1,3-butadiene) to 7.09 (5.88–8.54; acrylonitrile). Metabolites of acrylamide [fold difference of 1.21 (1.03–1.43)] and benzene [1.46 (1.13–1.90)] were higher during vaping compared with abstention. The 1,3-butadiene and propylene oxide metabolites were higher in variable-power tank users compared with users of cig-a-likes. E-cigarettes expose users to lower levels of toxic VOCs compared with cigarette smoking, supporting their harm reduction potential among smokers. However, some e-cigarettes expose users to VOCs such as acrylamide, benzene, and propylene oxide, and may pose health risks to nonsmoking users. The results of our study will inform regulators in assessing e-cigarettes with respect to the balance between its potential harm reduction for adult smokers and risk to nonsmoking users.

Objective The study objective was to identify biobehavioral variables associated with greater intake of nicotine and a tobacco carcinogen among Black light smokers who smoke 1 to 10 cigarettes per day (CPD). Methods We analyzed baseline data collected from 426 Black light smokers enrolled in Kick It at Swope III (KIS III), a smoking cessation trial for Black smokers. We examined differences in concentrations of tobacco biomarkers, including urinary total nicotine equivalents (TNE) and total 4-(methylnitrosamino)-1-(3)pyridyl-1-butanonol (NNAL; a human carcinogen), across gender, age, plasma nicotine metabolite ratio (NMR), CPD, and measures of tobacco dependence, including time to first cigarette (TFC), using ANOVA. Results Tobacco biomarker levels were significantly higher among those who smoked more CPD (6–10 vs 1–5 CPD) and those with greater reported physical dependence on tobacco. Concurrently, those who smoked 1–5 CPD smoked each cigarette more intensely than those who smoked 6–10 CPD. While we found no gender differences overall, among those who smoked 1–5 CPD, women had higher NNAL levels compared to men. The rate of nicotine metabolism, measured by the nicotine metabolite ratio, was not significantly related to TNE or NNAL levels. Conclusion Among Black Light smokers, higher cigarette consumption and greater physical dependence—but not rate of nicotine metabolism, menthol use, or socioeconomic status—were associated with greater toxicant exposure and thus a likely increased risk of tobacco-related diseases. The lack of data on light smokers, and specifically on Blacks, make this observation important given the disproportionate burden of lung cancer in this population.

BACKGROUND: Computerized physician order entry and clinical decision support systems are electronic prescribing strategies that are increasingly used to improve patient safety. Previous reviews show limited effect on patient outcomes. Our objective was to assess the impact of electronic prescribing strategies on medication errors and patient harm in hospitalized patients. METHODS: MEDLINE, EMBASE, CENTRAL, and CINAHL were searched from January 2007 to January 2018. We included prospective studies that compared hospital-based electronic prescribing strategies with control, and reported on medication error or patient harm. Data were abstracted by two reviewers and pooled using random effects model. Study quality was assessed using the Effective Practice and Organisation of Care and evidence quality was assessed using Grading of Recommendations Assessment, Development, and Evaluation. RESULTS: Thirty-eight studies were included; comprised of 11 randomized control trials and 27 non-randomized interventional studies. Electronic prescribing strategies reduced medication errors (RR 0.24 (95% CI 0.13, 0.46), I(2) 98%, n = 11) and dosing errors (RR 0.17 (95% CI 0.08, 0.38), I(2) 96%, n = 9), with both risk ratios significantly affected by advancing year of publication. There was a significant effect of electronic prescribing strategies on adverse drug events (ADEs) (RR 0.52 (95% CI 0.40, 0.68), I(2) 0%, n = 2), but not on preventable ADEs (RR 0.55 (95% CI 0.30, 1.01), I(2) 78%, n = 3), hypoglycemia (RR 1.03 (95% CI 0.62–1.70), I(2) 28%, n = 7), length of stay (MD − 0.18 (95% − 1.42, 1.05), I(2) 94%, n = 7), or mortality (RR 0.97 (95% CI 0.79, 1.19), I(2) 74%, n = 9). The quality of evidence was rated very low. DISCUSSION: Electronic prescribing strategies decrease medication errors and adverse drug events, but had no effect on other patient outcomes. Conservative interpretations of these findings are supported by significant heterogeneity and the preponderance of low-quality studies. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-019-05236-8) contains supplementary material, which is available to authorized users.

Author(s): St Helen, Gideon; Nardone, Natalie; Addo, Newton; Dempsey, Delia; Havel, Christopher; Jacob, Peyton; Benowitz, Neal L | Abstract: AimTo describe systemic nicotine exposure and subjective effects of electronic cigarettes (e-cigarettes) in people who use both e-cigarettes and cigarettes (dual users), including within-subject comparisons of e-cigarette and cigarette use.DesignTwo-arm, counterbalanced cross-over study. Participants used their usual brand of e-cigarette or cigarette during a standardized session in a 2-week study.SettingHospital research ward, San Francisco, CA, USA.ParticipantsThirty-six healthy (eight women, 28 men) participants.MeasurementsPlasma nicotine was analyzed by gas chromatography-tandem mass spectrometry; nicotine withdrawal, urge to smoke and vape, affective states, craving, satisfaction and psychological reward were measured by standardized questionnaires.FindingsCompared with cigarettes, average maximum plasma nicotine concentration (Cmax ) was lower with e-cigarettes [6.1 ± 5.5 ng/ml, mean ± standard deviation (SD) versus 20.2 ± 11.1 ng/ml, P l 0.001] and time of maximal concentration (Tmax ) was longer (6.5 ± 5.4 versus 2.7 ± 2.4 minutes, P l 0.001). Use of both products resulted in a reduction in the severity of withdrawal symptoms, negative affect and urge to use either product. E-cigarettes were less rewarding and satisfying and reduced craving to a lesser degree than cigarettes. We were not able to detect any differences in withdrawal symptoms, affective states and urge to smoke cigarettes between e-cigarette and cigarette use.ConclusionSystemic nicotine exposure was, on average, lower with single use of e-cigarettes compared with cigarettes, and e-cigarettes were judged to be less satisfying and rewarding and reduced craving less than cigarettes.

Introduction: The World Health Organization recently recognized the importance of emergency and trauma care in reducing morbidity and mortality. Training programs are essential to improving emergency care in low-resource settings; however, a paucity of comprehensive curricula focusing specifically on pediatric emergency medicine (PEM) currently exists. The African Federation for Emergency Medicine (AFEM) developed a PEM curriculum that was pilot-tested in a non-randomized, controlled study to evaluate its effectiveness in nurses working in a public Tanzanian referral hospital. Methods: Fifteen nurses were recruited to participate in a two-and-a-half-day curriculum of lectures, skill sessions, and simulation scenarios covering nine topics; they were matched with controls. Both groups completed pre- and post-training assessments of their knowledge (multiple-choice test), self-efficacy (Likert surveys), and behavior. Changes in behavior were assessed using a binary checklist of critical actions during observations of live pediatric resuscitations. Results: Participant-rated pre-training self-efficacy and knowledge test scores were similar in both control and intervention groups. However, post-training, self-efficacy ratings in the intervention group increased by a median of 11.5 points (interquartile range [IQR]: 6-16) while unchanged in the control group. Knowledge test scores also increased by a median of three points (IQR: 0-4) in the nurses who received the training while the control group’s results did not differ in the two periods. A total of 1192 pediatric resuscitation cases were observed post-training, with the intervention group demonstrating higher rates of performance of three of 27 critical actions. Conclusion: This pilot study of the AFEM PEM curriculum for nurses has shown it to be an effective tool in knowledge acquisition and improved self-efficacy of pediatric emergencies. Further evaluation will be needed to assess whether it is currently effective in changing nurse behavior and patient outcomes or whether curricular modifications are needed.

© 2018 American College of Emergency Physicians Study objective: Although traditional teachings in regard to pneumothorax and hemothorax generally recommend chest tube placement and hospital admission, the increasing use of chest computed tomography (CT) in blunt trauma evaluation may detect more minor pneumothorax and hemothorax that might indicate a need to modify these traditional practices. We determine the incidence of pneumothorax and hemothorax observed on CT only and the incidence of isolated pneumothorax and hemothorax (pneumothorax and hemothorax occurring without other thoracic injuries), and describe the clinical implications of these injuries. Methods: This was a planned secondary analysis of 2 prospective, observational studies of adult patients with blunt trauma, NEXUS Chest (January 2009 to December 2012) and NEXUS Chest CT (August 2011 to May 2014), set in 10 Level I US trauma centers. Participants’ inclusion criteria were older than 14 years, presentation to the emergency department (ED) within 6 hours of blunt trauma, and receipt of chest imaging (chest radiograph, chest CT, or both) during their ED evaluation. Exposure(s) (for observational studies) were that patients had trauma and chest imaging. Primary measures and outcomes included the incidence of pneumothorax and hemothorax observed on CT only versus on both chest radiograph and chest CT, the incidence of isolated pneumothorax and hemothorax (pneumothorax and hemothorax occurring without other thoracic injuries), and admission rates, hospital length of stay, mortality, and frequency of chest tube placement for these injuries. Results: Of 21,382 enrolled subjects, 1,064 (5%) had a pneumothorax and 384 (1.8%) had a hemothorax. Of the 8,661 patients who received both a chest radiograph and a chest CT, 910 (10.5%) had a pneumothorax, with 609 (67%) observed on CT only; 319 (3.7%) had a hemothorax, with 254 (80%) observed on CT only. Of 1,117 patients with pneumothorax, hemothorax, or both, 108 (10%) had isolated pneumothorax or hemothorax. Patients with pneumothorax observed on CT only had a lower chest tube placement rate (30% versus 65%; difference in proportions [Δ] -35%; 95% confidence interval [CI] –28% to 42%), admission rate (94% versus 99%; Δ 5%; 95% CI 3% to 8%), and median length of stay (5 versus 6 days; difference 1 day; 95% CI 0 to 2 days) but similar mortality compared with patients with pneumothorax observed on chest radiograph and CT. Patients with hemothorax observed on CT had only a lower chest tube placement rate (49% versus 68%; Δ -19%; 95% CI –31% to -5%) but similar admission rate, mortality, and median length of stay compared with patients with hemothorax observed on chest radiograph and CT. Compared with patients with other thoracic injury, those with isolated pneumothorax or hemothorax had a lower chest tube placement rate (20% versus 43%; Δ -22%; 95% CI –30% to -13%), median length of stay (4 versus 5 days; difference -1 day; 95% CI –3 to 1 days), and admission rate (44% versus 97%; Δ -53%; 95% CI –62% to -43%), with an admission rate comparable to that of patients without pneumothorax or hemothorax (49%). Conclusion: Under current imaging protocols for adult blunt trauma evaluation, most pneumothoraces and hemothoraces are observed on CT only and few occur as isolated thoracic injury. The clinical implications (admission rates and frequency of chest tube placement) of pneumothorax and hemothorax observed on CT only and isolated pneumothorax or hemothorax are lower than those of patients with pneumothorax and hemothorax observed on chest radiograph and CT and of those who have other thoracic injury, respectively.

Background: Many adolescents are exposed to tobacco smoke, from either active smoking (CS) or secondhand smoke (SHS) exposure. Tobacco-specific biomarkers of exposure include cotinine (detects use in past 2–4 days) and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL; detects use for a month or longer). NNAL is expected to detect more intermittent tobacco exposure. We compared NNAL and cotinine as biomarkers of exposure to tobacco in urban adolescents and determined the optimal NNAL cutoff point to distinguish CS from SHS exposure. Methods: Surplus urine samples, collected from 466 adolescents attending pediatric well or urgent care visits at Zuckerberg San Francisco General Hospital in 2013 to 2014, were assayed for cotinine and NNAL. Results: Ninety-four percent of adolescents had measurable levels of NNAL compared with 87% for cotinine. The optimal NNAL cutoff point to distinguish CS from SHS was 9.6 pg/mL by latent class or 14.4 pg/mL by receiver-operating characteristic analysis. Cotinine and NNAL were strongly correlated, but the correlation slopes differed for active versus SHS-exposed adolescents. Among nonsmokers, NNAL levels were significantly higher in African American (median, 3.3 pg/mL) compared with other groups (0.9–1.9 pg/mL), suggesting greater exposure to SHS. Conclusions: Urine NNAL screening finds a large majority (94%) of urban adolescents are exposed to tobacco. African Americans are exposed to higher levels of SHS than other ethnic/racial groups. Impact: SHS is associated with significant medical morbidity in adolescents. Routine biochemical screening with NNAL or cotinine detects high prevalence of SHS exposure and should be considered as a tool to reduce SHS exposure in high-risk populations. Cancer Epidemiol Biomarkers Prev; 27(3); 254–61. ©2018 AACR.