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There is a need to optimize SARS-CoV-2 vaccination rates amongst healthcare workers (HCWs) to protect staff and patients from healthcare-associated COVID-19 infection. During the COVID-19 pandemic, many organizations implemented vaccine mandates for HCWs. Whether or not a traditional quality improvement approach can achieve high-rates of COVID-19 vaccination is not known. Our organization undertook iterative changes that focused on the barriers to vaccine uptake. These barriers were identified through huddles, and addressed through extensive peer outreach, with a focus on access and issues related to equity, diversity and inclusion. The outreach interventions were informed by real-time data on COVID-19 vaccine uptake in our organization. The vaccine rate reached 92.3% by 6 December 2021 with minimal differences in vaccine uptake by professional role, clinical department, facility or whether the staff had a patient facing role. Improving vaccine uptake should be a quality improvement target in healthcare organizations and our experience shows that high vaccine rates are achievable through concerted efforts targeting specific barriers to vaccine confidence., Competing Interests: Competing interests: JAL has received payment for expert testimony requested by hospitals of the Ontario Hospital Association, Seneca College, and Ministry of the Attorney General of Ontario. No other competing interests declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Importance: In order to continue to clarify and maintain their role as eye physicians and surgeons, ophthalmologists may want to understand how they are viewed in the public eye and online., Objective: To determine the representation of ophthalmologists (OMD) and optometrists (ODs) when a Google search for "eye doctor near me" is made from each county in the US., Design, Setting, and Participants: This population-based cross-sectional study used publicly available data on OMDs and ODs and a Google search application programming interface (API) to search the phrase "eye doctor near me" from the geographic coordinates of each county centroid in the US (searched June 30, 2021). The top 10 sites and 3 Google map links, excluding physician ratings sites, were recorded. Data from the US Centers for Medicare and Medicaid Services were used to estimate the real number of OMDs and ODs per county., Main Outcome and Measures: The primary outcome was the mean proportion of OMDs listed by Google search as compared with the real proportion of OMDs for the US overall and for each state and county., Results: A total of 2955 counties from 52 states and territories were included. The overall mean proportion of OMDs (OMDs with ODs) from the Google search of all counties was 4726.97 of 16 345.93 (28.91%), which was also less than the real proportion of ODs (15 778 of 41 975 [37.58%], a difference of 8.67%; 95% CI, 37.13-38.05%; P < .001). OMDs were underrepresented by Google in 35 of 52 states and territories (67.3%)., Conclusions and Relevance: In most counties in the US, Google search of the phrase "eye doctor near me" may underrepresent ophthalmologists. Ophthalmologists may want to pursue search engine optimization to try to achieve balanced representation online.

Background: Catheter-associated bacteremia (CAB) often leads to removal of tunneled dialysis catheters with delayed insertion (RDI). Exchange over a guidewire (ExW) can be considered for access site preservation. Fibrin sheath disruption (FSD) during exchange is not standard practice for infected catheters. Here we present the first analysis of outcomes after such exchanges (ExW-FSD)., Methods: Retrospective analysis of catheter exchanges and removals performed by interventional nephrology for bacteremia in 2008-2011 observed for 20.5 months. Charts were reviewed for recurrent or new bacteremia and death at 3 months, and for occurrence of thrombosis or stenosis along the catheter site. Catheter exchange with central venogram and fibrin sheath disruption was our standard of care in all patients presenting for CAB. RDI was performed either for tunnel infection, non-clearing of infection or at the request of referring physicians., Results: Over 4 years, 66 patients were treated for CAB. Forty-two patients underwent ExW-FSD, which was performed even for Staph. aureus, gram negative bacteremia or candidemia. RDI was performed in 24 cases. Bacteremia recurred in 3 (7%) patients after ExW-FSD, and in 7 (30%) cases after RDI ( p  = 0.02). There was no significant difference in new infections: 5 (12%) after ExW-FSD and 2 (8%) after RDI. There was no death within 3 months after ExW-FSD and 4 (27%) ( p  = 0.005) deaths in the RDI group.There was one new central venous stenosis in the ExW-FSD group (2%) with no loss of access site, and 8 (33%) patients developed thrombosis/stenosis along the prior catheter track after RDI (33%) ( p  = 0.006) with loss of access site in (21%)., Conclusions: In this retrospective analysis of treatment of CAB, ExW-FSD was associated with lower recurrence of bacteremia, lower death rate and a lower incidence of access site loss compared to RDI. These data support ExW-FSD use in patients with CAB.

Empirical observations of how labs conduct research indicate that the adoption rate of open practices for transparent, reproducible, and collaborative science remains in its infancy. This is at odds with the overwhelming evidence for the necessity of these practices and their benefits for individual researchers, scientific progress, and society in general. To date, information required for implementing open science practices throughout the different steps of a research project is scattered among many different sources. Even experienced researchers in the topic find it hard to navigate the ecosystem of tools and to make sustainable choices. Here, we provide an integrated overview of community-developed resources that can support collaborative, open, reproducible, replicable, robust and generalizable neuroimaging throughout the entire research cycle from inception to publication and across different neuroimaging modalities. We review tools and practices supporting study inception and planning, data acquisition, research data management, data processing and analysis, and research dissemination. An online version of this resource can be found at https://oreoni.github.io. We believe it will prove helpful for researchers and institutions to make a successful and sustainable move towards open and reproducible science and to eventually take an active role in its future development., Competing Interests: Declaration of Competing Interest The authors declare no conflict of interest related to this work., (Copyright © 2022. Published by Elsevier Inc.)

Competing Interests: The BMJ thanks Wendy Levinson and Karen Born at Choosing Wisely for valuable advice and supporting the selection of topics. Choosing Wisely had no input into the peer review process or editorial decision. Competing interests: The authors have no conflicts of interest to declare.

Objective: COVID-19 has caused a massive surge in telemedicine utilization as patients and physicians tried to minimize in-person contact to avoid the spread and impact of the pandemic. This study aims to expand on the knowledge of telemedicine during and beyond the COVID-19 era as it pertains to its use, efficacy, and patient and provider satisfaction through surveys., Methods: This is a retrospective study involving 93 patients and 33 Neurosurgery physicians who anonymously participated in the survey about their experience with telemedicine visits., Results: Most respondents indicated extreme satisfaction with their telemedicine encounters during the pandemic (77%). As for how comfortable physicians are in providing a diagnosis via telemedicine compared to clinic visits, 7 (21.9%) physicians felt extremely comfortable, 13 (40.6%) felt somewhat comfortable, 2 (6.4%) were neutral, 9 (28.1%) felt somewhat uncomfortable and 1 (3.1%) felt extremely uncomfortable. Physical examination was the main tool that telemedicine didn't provide (n = 21, 100%)., Conclusion: Telemedicine has become a major force in the health care system under the circumstances the world is witnessing. Physicians and patients have displayed high levels of satisfaction with telemedicine which could be pivotal to improving healthcare access to underprivileged areas beyond the pandemic., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Large-scale datasets present unique opportunities to perform scientific investigations with unprecedented breadth. However, they also pose considerable challenges for the findability, accessibility, interoperability, and reusability (FAIR) of research outcomes due to infrastructure limitations, data usage constraints, or software license restrictions. Here we introduce a DataLad-based, domain-agnostic framework suitable for reproducible data processing in compliance with open science mandates. The framework attempts to minimize platform idiosyncrasies and performance-related complexities. It affords the capture of machine-actionable computational provenance records that can be used to retrace and verify the origins of research outcomes, as well as be re-executed independent of the original computing infrastructure. We demonstrate the framework's performance using two showcases: one highlighting data sharing and transparency (using the studyforrest.org dataset) and another highlighting scalability (using the largest public brain imaging dataset available: the UK Biobank dataset)., (© 2022. The Author(s).)

Introduction: Decreasing unnecessary cranial computed tomography (CT) use in pediatric head trauma patients remains important for emergency departments (EDs) across the US. Our study evaluated CT use in children with minor blunt head trauma in 21 community EDs within an integrated health-care system., Methods: We studied all children younger than 18 years old presenting to 21 community EDs between 2016 through 2018 with acute minor blunt head trauma, defined by an algorithm of ED chief complaints and diagnoses. We excluded patients with traumatic brain injuries diagnosed in the prior year, a CT within 24 hours prior to the ED visit, or an ED Glasgow Coma Scale score of less than 14., Results: Among 39,792 pediatric minor head trauma ED visits, the aggregate CT use proportion across all EDs was 12.9% [95% confidence interval (CI), 12.6-13.3%; facility-level range, 5.4-21.6%]. The 7 facilities that had previously received a clinical decision support system intervention implementing the Pediatric Emergency Care Applied Research Network rules during 2013 through 2014 had an aggregate mean CT ordering rate of 11.2% (95% CI, 10.7-11.7%; facility-level range, 5.4-14.3%) compared to 14.1% (95% CI, 13.6-14.5%; facility-level range, 7.3-21.6%) for the nonintervention facilities., Conclusion: CT use for children with minor blunt head trauma in the community EDs of an integrated health-care system was low and stable across facilities from 2016 through 2018. This may be indicative of the safe stewardship of resources in the system, including the absence of financial or medicolegal incentives to scan very low-risk patients as well the availability of resources for close patient follow-up.

Background Resource utilization among emergency department (ED) patients with possible coronary chest pain is highly variable. Methods and Results Controlled cohort study amongst 21 EDs of an integrated healthcare system examining the implementation of a graded coronary risk stratification algorithm (RISTRA-ACS [risk stratification for acute coronary syndrome]). Thirteen EDs had access to RISTRA-ACS within the electronic health record (RISTRA sites) beginning in month 24 of a 48-month study period (January 2016 to December 2019); the remaining 8 EDs served as contemporaneous controls. Study participants had a chief complaint of chest pain and serum troponin measurement in the ED. The primary outcome was index visit resource utilization (observation unit or hospital admission, or 7-day objective cardiac testing). Secondary outcomes were 30-day objective cardiac testing, 60-day major adverse cardiac events (MACE), and 60-day MACE-CR (MACE excluding coronary revascularization). Difference-in-differences analyses controlled for secular trends with stratification by estimated risk and adjustment for risk factors, ED physician and facility. A total of 154 914 encounters were included. Relative to control sites, 30-day objective cardiac testing decreased at RISTRA sites among patients with low (≤2%) estimated 60-day MACE risk (-2.5%, 95% CI -3.7 to -1.2%, P <0.001) and increased among patients with non-low (>2%) estimated risk (+2.8%, 95% CI +0.6 to +4.9%, P =0.014), without significant overall change (-1.0%, 95% CI -2.1 to 0.1%, P =0.079). There were no statistically significant differences in index visit resource utilization, 60-day MACE or 60-day MACE-CR. Conclusions Implementation of RISTRA-ACS was associated with better allocation of 30-day objective cardiac testing and no change in index visit resource utilization or 60-day MACE. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03286179.

Background: Coronavirus disease 2019 (COVID-19), the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has extracted devastating tolls. Despite its pervasiveness, robust information on disease characteristics in the emergency department (ED) and how that information predicts clinical course remain limited., Methods: We conducted a retrospective cohort study of the first ED visit from SARS-CoV-2-positive patients in our health system, from February 21, 2020 to April 5, 2020. We reviewed each patient's ED visit(s) and included the first visit with symptoms consistent with COVID-19. We collected demographic, clinical, and treatment variables from electronic health records and structured manual chart review. We used multivariable logistic regression to examine the association between patient characteristics and 2 primary outcomes: a critical outcome and hospitalization from index visit. Our critical outcome was defined as death or advanced respiratory support (high flow nasal cannula or greater) within 21 days., Results: Of the first 1030 encounters, 801 met our inclusion criteria: 15% were over age 75 years, 47% were female, and 24% were non-Hispanic white. We found 161 (20%) had a critical outcome and 393 (49%) were hospitalized. Independent predictors of a critical outcome included a history of hypertension, abnormal chest x-ray, elevated neutrophil to lymphocyte ratio, elevated blood urea nitrogen (BUN), measured fever, and abnormal respiratory vital signs (respiratory rate, oxygen saturation). Independent predictors of hospitalization included abnormal pulmonary auscultation, elevated BUN, measured fever, and abnormal respiratory vital signs., Conclusions: In this large, diverse study of ED patients with COVID-19, we have identified numerous clinical characteristics that have independent associations with critical illness and hospitalization., Competing Interests: The authors declare no conflicts of interest., (© 2021 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

As the global health crisis unfolded, many academic conferences moved online in 2020. This move has been hailed as a positive step towards inclusivity in its attenuation of economic, physical, and legal barriers and effectively enabled many individuals from groups that have traditionally been underrepresented to join and participate. A number of studies have outlined how moving online made it possible to gather a more global community and has increased opportunities for individuals with various constraints, e.g., caregiving responsibilities. Yet, the mere existence of online conferences is no guarantee that everyone can attend and participate meaningfully. In fact, many elements of an online conference are still significant barriers to truly diverse participation: the tools used can be inaccessible for some individuals; the scheduling choices can favour some geographical locations; the set-up of the conference can provide more visibility to well-established researchers and reduce opportunities for early-career researchers. While acknowledging the benefits of an online setting, especially for individuals who have traditionally been underrepresented or excluded, we recognize that fostering social justice requires inclusivity to actively be centered in every aspect of online conference design. Here, we draw from the literature and from our own experiences to identify practices that purposefully encourage a diverse community to attend, participate in, and lead online conferences. Reflecting on how to design more inclusive online events is especially important as multiple scientific organizations have announced that they will continue offering an online version of their event when in-person conferences can resume., (© The Author(s) 2021. Published by Oxford University Press on behalf of GigaScience. 2021.)

Objective: Familial risk for bipolar disorder (BD) or major depressive disorder (MDD) may lead to differential emotion processing signatures, resulting in unique neural vulnerability., Method: Healthy offspring of a parent with BD (n = 29, "BD-risk") or MDD (n = 44, "MDD-risk") and healthy control youths without any personal or family psychopathology (n = 28, "HC") aged 8 to 17 years (13.64 ± 2.59 years) completed an implicit emotion-perception functional magnetic resonance imaging task. Whole-brain voxelwise and psychophysiological interaction analyses examined neural differences in activation and connectivity during emotion processing. Regression modeling tested for neural associations with behavioral strengths and difficulties and conversion to psychopathology at follow-up (3.71 ± 1.91 years)., Results: BD-risk youth showed significantly reduced bilateral putamen activation, and decreased connectivity between the left putamen and the left ventral anterior cingulate cortex (vACC) and the right posterior cingulate cortex (PCC) during positive-valence emotion processing compared to MDD-risk and HC (Z >2.3; p <.001). Decreased left putamen-right PCC connectivity correlated with subsequent peer problems in BD-risk (β = -2.90; p <.05) and MDD-risk (β = -3.64; p < .05) groups. Decreased left (β = -0.09; p < .05) and right putamen activation (β = -0.07; p = .04) were associated with conversion to a mood or anxiety disorder in BD-risk youths. Decreased left putamen-right PCC connectivity was associated with a higher risk of conversion in BD-risk (HR = 8.28 , p < .01) and MDD-risk (HR = 2.31, p = .02) groups., Conclusion: Reduced putamen activation and connectivity during positive emotion processing appear to distinguish BD-risk youths from MDD-risk and HC youths, and may represent a marker of vulnerability., (Copyright © 2020 American Academy of Child and Adolescent Psychiatry. Published by Elsevier Inc. All rights reserved.)

Background Coronary risk stratification is recommended for emergency department patients with chest pain. Many protocols are designed as "rule-out" binary classification strategies, while others use graded-risk stratification. The comparative performance of competing approaches at varying levels of risk tolerance has not been widely reported. Methods and Results This is a prospective cohort study of adult patients with chest pain presenting between January 2018 and December 2019 to 13 medical center emergency departments within an integrated healthcare delivery system. Using an electronic clinical decision support interface, we externally validated and assessed the net benefit (at varying risk thresholds) of several coronary risk scores (History, ECG, Age, Risk Factors, and Troponin [HEART] score, HEART pathway, Emergency Department Assessment of Chest Pain Score Accelerated Diagnostic Protocol), troponin-only strategies (fourth-generation assay), unstructured physician gestalt, and a novel risk algorithm (RISTRA-ACS). The primary outcome was 60-day major adverse cardiac event defined as myocardial infarction, cardiac arrest, cardiogenic shock, coronary revascularization, or all-cause mortality. There were 13 192 patient encounters included with a 60-day major adverse cardiac event incidence of 3.7%. RISTRA-ACS and HEART pathway had the lowest negative likelihood ratios (0.06, 95% CI, 0.03-0.10 and 0.07, 95% CI, 0.04-0.11, respectively) and the greatest net benefit across a range of low-risk thresholds. RISTRA-ACS demonstrated the highest discrimination for 60-day major adverse cardiac event (area under the receiver operating characteristic curve 0.92, 95% CI, 0.91-0.94, P <0.0001). Conclusions RISTRA-ACS and HEART pathway were the optimal rule-out approaches, while RISTRA-ACS was the best-performing graded-risk approach. RISTRA-ACS offers promise as a versatile single approach to emergency department coronary risk stratification. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03286179.

There is a critical need to better understand the neural basis of antidepressant medication (ADM) response with respect to both symptom alleviation and quality of life (QoL) in major depressive disorder (MDD). Reward neurocircuitry has been implicated in QoL, the neural basis of MDD, and the mechanisms of ADM response. Yet, we do not know whether change in reward neurocircuitry as a function of ADM is associated with change in symptoms and QoL. To address this gap in knowledge, we analyzed data from 128 patients with MDD who participated in the iSPOT-D trial and were assessed with functional neuroimaging pre- and post-ADM treatment (randomized to sertraline, venlafaxine-XR, or escitalopram). 58 matched healthy controls were scanned at the same time points. We quantified functional connectivity (FC) of reward neurocircuitry using nucleus accumbens (NAc) seed regions of interest, and then characterized how changes in FC relate to symptom response (primary outcome) and QoL response (secondary outcome). Symptom responders showed an increase in NAc-dorsal anterior cingulate cortex (ACC) FC relative to non-responders (p < 0.001) which was associated with improvement in physical QoL (p < 0.0003), and a decrease in NAc-inferior parietal lobule FC relative to controls (p < 0.001). QoL response was characterized by increases in FC between NAc-ventral ACC for environmental, NAc-thalamus for physical, and NAc-paracingulate gyrus for social domains (p < 0.001). Symptom responders to sertraline were distinguished by a decrease in NAc-insula FC (p < 0.001) and to venlafaxine-XR by an increase in NAc-inferior temporal gyrus FC (p < 0.005). Findings suggest that change in reward neurocircuitry may underlie differential ADM response profiles with respect to symptoms and QoL in depression.

Introduction: International rates of hospitalization for atrial fibrillation and flutter (AFF) from the emergency department (ED) vary widely without clear evidence to guide the identification of high-risk patients requiring inpatient management. We sought to determine (1) variation in hospital admission and (2) modifiable factors associated with hospitalization of AFF patients within a U.S. integrated health system., Methods: This multicenter prospective observational study of health plan members with symptomatic AFF was conducted using convenience sampling in 7 urban community EDs from 05/2011 to 08/2012. Prospective data collection included presenting symptoms, characteristics of atrial dysrhythmia, ED physician impression of hemodynamic instability, comorbid diagnoses, ED management, and ED discharge rhythm. All centers had full-time on-call cardiology consultation available. Additional variables were extracted from the electronic health record. We identified factors associated with hospitalization and included predictors in a multivariate Poisson Generalized Estimating Equations regression model to estimate adjusted relative risks while accounting for clustering by physician., Results: Among 1,942 eligible AFF patients, 1,074 (55.3%) were discharged home and 868 (44.7%) were hospitalized. Hospitalization rates ranged from 37.4% to 60.4% across medical centers. After adjustment, modifiable factors associated with increased hospital admission from the ED included non-sinus rhythm at ED discharge, no attempted cardioversion, and heart rate reduction., Discussion: Within an integrated health system, we found significant variation in AFF hospitalization rates and identified several modifiable factors associated with hospital admission. Standardizing treatment goals that specifically address best practices for ED rate reduction and rhythm control may reduce hospitalizations.

Tracking of eye movements is an established measurement for many types of experimental paradigms. More complex and more prolonged visual stimuli have made algorithmic approaches to eye-movement event classification the most pragmatic option. A recent analysis revealed that many current algorithms are lackluster when it comes to data from viewing dynamic stimuli such as video sequences. Here we present an event classification algorithm-built on an existing velocity-based approach-that is suitable for both static and dynamic stimulation, and is capable of classifying saccades, post-saccadic oscillations, fixations, and smooth pursuit events. We validated classification performance and robustness on three public datasets: 1) manually annotated, trial-based gaze trajectories for viewing static images, moving dots, and short video sequences, 2) lab-quality gaze recordings for a feature-length movie, and 3) gaze recordings acquired under suboptimal lighting conditions inside the bore of a magnetic resonance imaging (MRI) scanner for the same full-length movie. We found that the proposed algorithm performs on par or better compared to state-of-the-art alternatives for static stimulation. Moreover, it yields eye-movement events with biologically plausible characteristics on prolonged dynamic recordings. Lastly, algorithm performance is robust on data acquired under suboptimal conditions that exhibit a temporally varying noise level. These results indicate that the proposed algorithm is a robust tool with improved classification accuracy across a range of use cases. The algorithm is cross-platform compatible, implemented using the Python programming language, and readily available as free and open-source software from public sources.

DataLad is a Python-based tool for the joint management of code, data, and their relationship, built on top of a versatile system for data logistics (git-annex) and the most popular distributed version control system (Git). It adapts principles of open-source software development and distribution to address the technical challenges of data management, data sharing, and digital provenance collection across the life cycle of digital objects. DataLad aims to make data management as easy as managing code. It streamlines procedures to consume, publish, and update data, for data of any size or type, and to link them as precisely versioned, lightweight dependencies. DataLad helps to make science more reproducible and FAIR (Wilkinson et al., 2016). It can capture complete and actionable process provenance of data transformations to enable automatic re-computation. The DataLad project (datalad.org) delivers a completely open, pioneering platform for flexible decentralized research data management (RDM) (Hanke, Pestilli, et al., 2021). It features a Python and a command-line interface, an extensible architecture, and does not depend on any centralized services but facilitates interoperability with a plurality of existing tools and services. In order to maximize its utility and target audience, DataLad is available for all major operating systems, and can be integrated into established workflows and environments with minimal friction., Competing Interests: Conflicts of interest There are no conflicts to declare.

Purpose of Review: In this review we provide an overview of definitions and determinants of resilience in the context of neuroimaging research in major depressive disorder (MDD). We summarize emerging literature on functional neuroimaging biomarkers of resilience in MDD and discuss their clinical relevance and implications for future research., Recent Findings: Resilience in MDD is characterized by dissociable profiles of activation and functional connectivity within brain networks involved in cognitive control, emotion regulation, and reward processing. Increased activation of frontal cortical brain regions implicated in cognitive appraisal and emotion regulation is a common characteristic of resilient individuals at high risk for MDD and of individuals with MDD with a favorable illness course. Furthermore, significant associations between fronto-striato-limbic functional connectivity and both positively interpreted stressful life events in resilient high-risk individuals and a favorable response to first-line treatments in depressed individuals suggest that neuro-compensatory changes and experience-dependent plasticity underlie resilience in MDD., Summary: Emerging research has identified functional neuroimaging biomarkers of resilience in MDD. A continued focus on identifying neurobiological underpinnings of resilience, in the context of dynamic environmental and developmental influences, will advance our understanding of resilience and improve approaches to prevention and treatment of MDD.

Objectives: Pediatric appendicitis remains a challenging diagnosis in the emergency department (ED). Available risk prediction algorithms may contribute to excessive ED imaging studies. Incorporation of physician gestalt assessment could help refine predictive tools and improve diagnostic imaging decisions., Methods: This study was a subanalysis of a parent study that prospectively enrolled patients ages 5 to 20.9 years with a chief complaint of abdominal pain presenting to 11 community EDs within an integrated delivery system between October 1, 2016, and September 30, 2018. Prior to diagnostic imaging, attending emergency physicians enrolled patients with ≤5 days of right-sided or diffuse abdominal pain using a Web-based application embedded in the electronic health record. Predicted risk (gestalt) of acute appendicitis was prospectively entered using a sliding scale from 1% to 100%. As a planned secondary analysis, we assessed the performance of gestalt via c-statistics of receiver operating characteristic (ROC) curves; tested associations between gestalt performance and patient, physician, and facility characteristics; and examined clinical characteristics affecting gestalt estimates., Results: Of 3,426 patients, 334 (9.8%) had confirmed appendicitis. Physician gestalt had excellent ROC curve characteristics (c-statistic = 0.83, 95% confidence interval = 0.81 to 0.85), performing particularly well in the low-risk strata (appendicitis rate = 1.1% in gestalt 1%-10% range, negative predictive value of 98.9% for appendicitis diagnosis). Physicians with ≥5 years since medical school graduation demonstrated improved gestalt performance over those with less experience (p = 0.007). All clinical characteristics tested, except pain <24 hours, were significantly associated with physician gestalt value (p < 0.05)., Conclusion: Physician gestalt for acute appendicitis diagnosis performed well, especially in low-risk patients and when employed by experienced physicians., (© 2020 by the Society for Academic Emergency Medicine.)

Depression remains an underdiagnosed comorbidity which significantly decreases the quality of life in amyotrophic lateral sclerosis (ALS) patients. We aimed to investigate the prevalence of depression in a cohort of ALS patients with more than one year of disease evolution. A total of 50 ALS patients were evaluated with the Beck Depression Inventory II (BDI-II) and cognition, using the Mini-Cog Standardized Instrument (MCSI). The clinical disability was evaluated using the ALS Functional Rating Scale (ALSFRS). The prevalence of depression was 42.8%. A lower BDI-II score was significantly correlated with a higher education level, the spouse as a caregiver, spiritual devotion, and employment status ( p < 0.05). A multiple linear regression analysis between the BDI-II score as the dependent variable and various independent variables such as spirituality, caregiver status, educational level, and occupational status revealed that only the type of caregiver (spouse or parent/child) significantly affected the BDI-II total score ( p = 0.006). The functional disability significantly correlated with loss of appetite and loss of libido ( p < 0.001). A high education, spiritual devotion, high ALSFRS, and the presence of the spouse as the caregiver were associated with the absence of depression.

Purpose of Review: This review summarizes (1) recent trends in delta-9-tetrahydrocannabionol [THC] and cannabidiol (CBD) content in cannabis products, (2) neurobiological correlates of cannabis use on the developing adolescent brain, (3) effects of cannabis on psychiatric symptoms and daily functioning in youth (i.e., academic performance, cognition, sleep and driving), (4) cannabis products used to relieve or treat medical issues in youth, and (5) available treatments for cannabis use disorder in adolescence., Recent Findings: Despite marked increases in THC content and availability of cannabis, there has been a decline in perceived risk and an increase in use of THC extract products among youth in the United States. The primary psychiatric symptoms associated with cannabis use in youth are increased risk for addiction, depressive, and psychotic symptoms. Cannabis alters endocannabinoid system function which plays a central role in modulating the neurodevelopment of reward and stress systems. To date, few studies have examined neurobiological mechanisms underlying the psychiatric sequalae of cannabis exposure in youth. Adolescent cannabis exposure results in impaired cognition, sleep, and driving ability. There are very limited FDA-approved cannabinoid medications, none of them supporting their use for the treatment of psychiatric symptoms. Behavioral therapies are currently the mainstay of treating cannabis misuse, with no pharmacotherapies currently approved by the FDA for cannabis use disorder in youth., Summary: Here, we summarize the most up-to-date knowledge on the neurobiological psychiatric, and daily function effects of the most commonly used cannabinoids, delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD). We then review FDA approved medical use of cannabinoid treatments as well as pharmacological and psychological treatments for cannabis use disorder in youth. Our current understanding of the effects of cannabis on the developing brain and treatments for cannabis misuse in youth remain limited. Future research aimed at examining the neurobiological effects of cannabis, with objective measures of exposure, over the course of pediatric development and in relation to psychiatric symptoms are needed., Competing Interests: Conflict of Interest Dr. Singh receives research support from Stanford’s Maternal Child Health Research Institute and Department of Psychiatry, National Institute of Mental Health, National Institute of Aging, Allergan, Johnson and Johnson, and the Brain and Behavior Research Foundation. She is on the advisory board for Sunovion and is a consultant for Google X and Limbix and receives royalties from the American Psychiatric Association Publishing. Dr. Fischer received grants from the Klingenstein Third Generation Foundation. Drs. Louie, Tapert, and Schatzberg report no conflicts of interest.

Background: Transthoracic echocardiography is routinely performed in patients with stroke or transient ischemic attack (TIA) to help plan secondary stroke management, but recent data evaluating its usefulness in this context are lacking. We sought to evaluate the value of echocardiography for identifying clinically actionable findings for secondary stroke prevention., Methods: We conducted a multicentre cohort study of patients admitted to hospital with stroke or TIA between 2010 and 2015 at 2 academic hospitals in Toronto, Ontario, Canada. Clinically actionable echocardiographic findings for secondary stroke prevention included cardiac thrombus, patent foramen ovale, atrial myxoma or valvular vegetation. We identified patient characteristics associated with clinically actionable findings using logistic regression., Results: Of the 1862 patients with stroke or TIA we identified, 1272 (68%) had at least 1 echocardiogram. Nearly all echocardiograms were transthoracic; 1097 (86%) were normal, 1 (0.08%) had an atrial myxoma, 2 (0.2%) had a valvular vegetation, 11 (0.9%) had a cardiac thrombus and 66 (5.2%) had a PFO. Patent foramen ovale was less likely among patients older than 60 years (adjusted odds ratio [OR] 0.34, 95% confidence interval [CI] 0.20-0.57), with prior stroke or TIA (adjusted OR 0.31, 95% CI 0.09-0.76) or with dyslipidemia (adjusted OR 0.39, 95% CI 0.15-0.84). Among the 130 patients with cryptogenic stroke who had an echocardiogram ( n = 110), a PFO was detected in 19 (17%) on transthoracic echocardiogram., Interpretation: Most patients with stroke or TIA had a normal echocardiogram, with few having clinically actionable findings for secondary stroke prevention. Clinically actionable findings, specifically PFO, were more common in patients with cryptogenic stroke., Competing Interests: Competing interests: Amol Verma and Fahad Razak report that they are part-time employee of Health Quality Ontario, as the Provincial Clinical Leads for Quality Improvement in General Internal Medicine. No other competing interests were declared., (© 2019 Joule Inc. or its licensors.)

Background: Appendicitis is a common surgical emergency in children, yet diagnosis can be challenging. An electronic health record (EHR) based, clinical decision support (CDS) system called Appy CDS was designed to help guide management of pediatric patients with acute abdominal pain within the Health Care Systems Research Network (HCSRN)., Objectives: To describe the development and implementation of a clinical decision support tool (Appy CDS) built independently but synergistically at two large HCSRN affiliated health systems using well-established platforms, and to assess the tool's Triage component, aiming to identify pediatric patients at increased risk for appendicitis., Results: Despite differences by site in design and implementation, such as the use of alerts, incorporating gestalt, and other workflow variations across sites, using simple screening questions and automated exclusions, both systems were able to identify a population with similar appendicitis rates (11.8 percent and 10.6 percent), where use of the full Appy CDS would be indicated., Discussion: These 2 HCSRN sites designed Appy CDS to capture a population at risk for appendicitis and deliver CDS to that population while remaining locally relevant and adhering to organizational preferences. Despite different approaches to point-of-care CDS, the sites have identified similar cohorts with nearly identical background rates of appendicitis., Next Steps: The full Appy CDS tool, providing personalized risk assessment and tailored recommendations, is undergoing evaluation as part of a pragmatic cluster randomized trial aiming to reduce reliance on advanced diagnostic imaging. The novel approaches to CDS we present could serve as the basis for future ED interventions., Competing Interests: The authors have no competing interests to declare.

Objectives: Behavioral health conditions and social problems are common yet underrecognized among emergency department (ED) patients. Traditionally, ED-based behavioral health screening is limited. We evaluated the feasibility of expanded behavioral health screening by a trained nonclinician., Study Design: Prospective observational study of a convenience sample of ED patients., Methods: A research assistant (RA) approached a convenience sample of adult ED patients within an integrated healthcare delivery system. Patients completed a paper screening instrument (domains: mood, anxiety, alcohol use, drug use, sleep, intimate partner violence, and chronic pain) and reviewed responses with the RA, who shared positive screening results with the treating ED physician. We abstracted behavioral health and medical diagnoses from the electronic health record (EHR), comparing the screened cohort with the eligible population. We used χ2 tests to assess differences in demographics and comorbidities between screened patients and the eligible group and differences between self-reported symptoms and EHR diagnoses among screened patients., Results: Among 598 screened patients, the prevalence of self-reported symptoms was higher than that of associated EHR diagnoses in the year prior to the ED visit (anxiety, 45% vs 19% [P <.001]; depression, 40% vs 22% [P <.001]; drug use, 7% vs 4% [P = .011]; risky alcohol use, 12% vs 5% [P <.001]; chronic pain, 47% vs 30% [P <.001]; and sleep problems, 47% vs 4% [P <.001])., Conclusions: A dedicated RA was able to integrate screening into patient idle times in the ED visit. The prevalence of behavioral health problems was higher than indicated in the EHR.

Objective: Adoption of clinical decision support (CDS) tools by clinicians is often limited by workflow barriers. We sought to assess characteristics associated with clinician use of an electronic health record-embedded clinical decision support system (CDSS)., Methods: In a prospective study on emergency department (ED) activation of a CDSS tool across 14 hospitals between 9/1/14 to 4/30/15, the CDSS was deployed at 10 active sites with an on-site champion, education sessions, iterative feedback, and up to 3 gift cards/clinician as an incentive. The tool was also deployed at 4 passive sites that received only an introductory educational session. Activation of the CDSS - which calculated the Pulmonary Embolism Severity Index (PESI) score and provided guidance - and associated clinical data were collected prospectively. We used multivariable logistic regression with random effects at provider/facility levels to assess the association between activation of the CDSS tool and characteristics at: 1) patient level (PESI score), 2) provider level (demographics and clinical load at time of activation opportunity), and 3) facility level (active vs. passive site, facility ED volume, and ED acuity at time of activation opportunity)., Results: Out of 662 eligible patient encounters, the CDSS was activated in 55%: active sites: 68% (346/512); passive sites 13% (20/150). In bivariate analysis, active sites had an increase in activation rates based on the number of prior gift cards the physician had received (96% if 3 prior cards versus 60% if 0, p<0.0001). At passive sites, physicians < age 40 had higher rates of activation (p=0.03). In multivariable analysis, active site status, low ED volume at the time of diagnosis and PESI scores I or II (compared to III or higher) were associated with higher likelihood of CDSS activation., Conclusions: Performing on-site tool promotion significantly increased odds of CDSS activation. Optimizing CDSS adoption requires active education., Competing Interests: The authors declare that they have no conflicts of interest in the research.

Introduction: Historically, emergency department (ED) patients with pulmonary embolism (PE) have been admitted for several days of inpatient care. Growing evidence suggests that selected ED patients with PE can be safely discharged home after a short length of stay. However, the optimal timing of follow up is unknown. We hypothesized that higher-risk patients with short length of stay (<24 hours from ED registration) would more commonly receive expedited follow up (≤3 days)., Methods: This retrospective cohort study included adults treated for acute PE in six community EDs. We ascertained the PE Severity Index risk class (for 30-day mortality), facility length of stay, the first follow-up clinician encounter, unscheduled return ED visits ≤3 days, 5-day PE-related readmissions, and 30-day all-cause mortality. Stratifying by risk class, we used multivariable analysis to examine age- and sex-adjusted associations between length of stay and expedited follow up., Results: The mean age of our 175 patients was 63.2 (±16.8) years. Overall, 93.1% (n=163) of our cohort received follow up within one week of discharge. Fifty-six patients (32.0%) were sent home within 24 hours and 100 (57.1%) received expedited follow up, often by telephone (67/100). The short and longer length-of-stay groups were comparable in age and sex, but differed in rates of low-risk status (63% vs 37%; p<0.01) and expedited follow up (70% vs 51%; p=0.03). After adjustment, we found that short length of stay was independently associated with expedited follow up in higher-risk patients (adjusted odds ratio [aOR] 3.5; 95% CI [1.0-11.8]; p=0.04), but not in low-risk patients (aOR 2.2; 95% CI [0.8-5.7]; p=0.11). Adverse outcomes were uncommon (<2%) and were not significantly different between the two length-of-stay groups., Conclusion: Higher-risk patients with acute PE and short length of stay more commonly received expedited follow up in our community setting than other groups of patients. These practice patterns are associated with low rates of 30-day adverse events.

Introduction: The adoption of electronic medical records (EMRs) in emergency departments (EDs) has changed the way that healthcare information is collected, charted, and stored. A challenge for researchers is to determine how EMRs may be leveraged to facilitate study data collection efforts. Our objective is to describe the use of a unique data collection system leveraging EMR technology and to compare data entry error rates to traditional paper data collection., Methods: This was a retrospective review of data collection methods during a multicenter study of ED, anti-coagulated, head injury patients. On-shift physicians at 4 centers enrolled patients and prospectively completed data forms. These physicians had the option of completing a paper data form or an electronic "dotphrase" (DP) data form. A feature of our Epic®-based EMR is the ability to use DPs to assist in medical information entry. A DP is a preset template that may be inserted into the EMR when the physician types a period followed by a code phrase (in this case ".ichstudy"). Once the study DP was inserted at the bottom of the electronic ED note, it prompted enrolling physicians to answer study questions. Investigators then extracted data directly from the EMR., Results: From July 2009 through December 2010, we enrolled 883 patients. DP data forms were used in 288 (32.6%; 95% confidence interval [CI] 29.5, 35.7%) cases and paper data forms in 595 (67.4%; 95% CI 64.3, 70.5%). Sixty-six (43.7%; 95% CI 35.8, 51.6%) of 151 physicians enrolling patients used DP data entry at least once. Using multivariate analysis, we found no association between physician age, gender, or tenure and DP use. Data entry errors were more likely on paper forms (234/595, 39.3%; 95% CI 35.4, 43.3%) than DP forms (19/288, 6.6%; 95% CI 3.7, 9.5%), difference in error rates 32.7% (95% CI 27.9, 37.6%, P < 0.001)., Conclusion: DP data collection is a feasible means of data collection. DP data forms maintain all study data within the secure EMR environment, obviating the need to maintain and collect paper data forms. This innovation was embraced by many of our emergency physicians and resulted in lower data entry error rates.