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Background: Adequate pain management is important in patients’ recovery from total hip arthroplasty (THA) and total knee arthroplasty (TKA). Objective: To determine whether risk factors for prolonged opioid use are considered when discharge prescriptions for postoperative pain are written following THA and TKA. Methods: Opioid prescriptions written between June 14 and July 9, 2021, for patients who underwent THA or TKA were analyzed. Data were also collected on the patients’ age, sex, type of surgery, type of anesthesia (regional or general), preoperative use of opioids, and preoperative use of antidepressants. Results: Among the 59 patients included in the study, the most common prescriptions were for hydromorphone 2 mg (n = 15, 25%) and hydromorphone 1 mg (n = 15, 25%). At discharge, patients received a median of 400 morphine milligram equivalents (MMEs). There was no significant difference in the quantity of opioids (MMEs) prescribed at discharge in relation to surgery type (p = 0.63), sex (p = 0.44), preoperative antidepressant use (p = 0.22), or preoperative opioid use (p = 0.97). There also appeared to be no correlation between a patient’s age and MMEs at discharge (p = 0.21; r2 = 0.028). None of these variables could be used to predict which patients would receive more than 400 MMEs. Conclusions: Patient-specific factors appeared not to be taken into consideration when opioids were prescribed for postoperative pain among patients who underwent THA or TKA. RÉSUMÉ Contexte : Une gestion adéquate de la douleur est importante pour le rétablissement des patients après une arthroplastie totale de la hanche (ATH) et une arthroplastie totale du genou (ATG). Objectif : Déterminer si les facteurs de risque relatifs à l’utilisation prolongée d’opioïdes sont pris en compte lors de la rédaction d’ordonnances de congé pour douleurs postopératoires après une ATH et une ATG. Méthodes : Les prescriptions d’opioïdes rédigées entre le 14 juin et le 9 juillet 2021 pour les patients ayant subi une ATH ou une ATG ont été analysées. Des données ont également été recueillies sur l’âge, le sexe, le type de chirurgie, le type d’anesthésie (locale ou générale), l’utilisation préopératoire d’opioïdes et l’utilisation préopératoire d’antidépresseurs. Résultats : Parmi les 59 patients compris dans l’étude, les prescriptions les plus fréquentes étaient l’hydromorphone 2 mg (n = 15; 25 %) et l’hydromorphone 1 mg (n = 15; 25 %). Les patients recevaient une médiane de 400 équivalents milligrammes de morphine (MME) au moment du congé. Aucune différence significative quant à la quantité d’opioïdes (mesurée en MME) prescrits au moment du congé en fonction du type de chirurgie (p = 0,63), du sexe (p = 0,44), de l’utilisation préopératoire d’antidépresseurs (p = 0,22) ou de l’utilisation préopératoire d’opioïdes (p = 0,97) n’a été observée. Il ne semblait pas non plus y avoir de corrélation entre l’âge d’un patient et les MME au moment du congé (p = 0,21; r2 = 0,028). Aucune de ces variables ne pouvait être utilisée pour prédire quels patients recevraient plus de 400 MME. Conclusions : Les facteurs spécifiques au patient ne semblaient pas être pris en compte lors de la prescription d’opioïdes pour la douleur postopératoire chez les patients ayant subi une ATH ou une ATG.

Background: High-cost health care users use disproportionate amounts of health care resources relative to the typical patient. It is unclear to what extent poor-quality prescribing, including potentially inappropriate prescribing (PIP), may be contributing to their adverse outcomes and health utilization costs. Objectives: To evaluate the prevalence of PIP and to explore its impact in older adult high-cost health care users. Methods: The charts of older adult high-cost health care users admitted to 2 academic hospitals in Ontario, Canada, in fiscal year 2015/16 were reviewed. Eligible patients were at least 66 years old with at least 5 emergency department visits and 3 hospital admissions in the previous year. A total of 243 patients met these criteria, of whom 100 were randomly selected for review. Cases of PIP were identified using explicit prescribing quality indicators, including the STOPP/START criteria. Types of PIP included potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs). Log–linear regression was used to characterize the relationship between PIP and future health care utilization. Medications were reconciled to determine the proportion of PIP addressed by the time of discharge. Results: Eighty-nine of the 100 patients had at least 1 instance of PIP. In total, 276 PIMs and 54 PPOs were identified. Of the 271 instances of PIP identified on admission, only 38 (14%) were resolved by the time of hospital discharge. Each additional PPO was associated with a 1.43-fold increase in the rate of future emergency department visits (p < 0.001). Conclusions: The rate of PIP among older adult high-cost health care users was high. Despite frequent interactions with the health care system, many opportunities to improve the quality of prescribing for this vulnerable population were missed. Greater attention to medication optimization is needed. RÉSUMÉ Contexte : Les grands utilisateurs de soins de santé consomment une proportion disproportionnée des ressources par rapport aux patients moyens. On ne sait pas vraiment dans quelle mesure la prescription de mauvaise qualité, notamment la prescription potentiellement inappropriée (PPI), contribue aux effets indésirables et aux coûts d’utilisation des soins de santé. Objectifs : Évaluer la prévalence des PPI et étudier ses effets chez les grands utilisateurs des soins de santé âgés. Méthodes : Les dossiers des grands utilisateurs de soins de santé âgés admis dans 2 hôpitaux universitaires en Ontario, au Canada, pendant l’exercice 2015-2016 ont été examinés. Les patients admissibles étaient âgés d’au moins 66 ans, avaient effectué au moins 5 visites à l’urgence et avaient été admis 3 fois à l’hôpital au cours de l’année précédente. Au total, 243 patients répondaient à ces critères, dont 100 ont été sélectionnés au hasard pour un examen. Les cas de PPI ont été identifiés à l’aide d’indicateurs explicites de la qualité de prescription, notamment les critères STOPP/START. Les types de PPI comprenaient des médicaments potentiellement inappropriés (MPI) et les omissions potentielles de prescription (OPP). La régression log-linéaire a été utilisée pour caractériser la relation entre la PPI et l’utilisation future des soins de santé. Un bilan comparatif des médicaments prescrits a été effectué pour déterminer la proportion de PPI traités au moment de la sortie de l’hôpital. Résultats : Quatre-vingt-neuf (89 %) des patients présentaient au moins 1 cas de PPI. Au total, 276 MPI et 54 OPP ont été identifiées. Sur les 271 cas de PPI identifiés au moment de l’admission, seuls 38 (14 %) étaient résolus au moment de la sortie de l’hôpital. Chaque OPP supplémentaire était associée à une augmentation de 1,43 fois du taux de futures visites à l’urgence (p < 0,001). Conclusions : Le taux de PPI chez les grands utilisateurs de soins de santé âgés était élevé. Malgré des interactions fréquentes avec le système de santé, de nombreuses occasions d’amélioration de la qualité des prescriptions pour cette population vulnérable ont été manquées. Une plus grande attention doit être portée à l’optimisation des médicaments.

Introduction: Head computed tomography (CT) interpretation is a vital skill for emergency physicians. Existing literature shows poor concordance between emergency physicians and radiologists in head CT interpretation. Prior studies have used passive learning methods to address this knowledge gap. We created an active learning curriculum for teaching head CT interpretation to emergency medicine (EM) residents and compared its effectiveness to a passive learning strategy. Methods: We conducted a prospective, randomized controlled study of EM residents at a single institution. Three educational sessions were delivered over a three-month period via video conference. The active learning cohort (ALC) scrolled through head CT teaching cases we designed on Pascbin, a web-based radiology picture archiving and communication system. The passive learning cohort (PLC) watched instructional videos that scrolled through the same cases. Both cohorts were given equal time to review the cases and ask an instructor questions. Residents took pre-intervention and post-intervention tests on head CT interpretation. We analyzed scores using paired and unpaired t-tests. Results: Forty-two residents took the pre-intervention test. Mean pre- and post-test scores for the ALC were 43.8% and 59.0% (P

Objective To categorize multiparametric MRI features of Bacillus Calmette–Guérin (BCG)-related granulomatous prostatitis (GP) and discover potential manifestations for its differential diagnosis from prostate cancer Materials and Methods The cases of BCG-related GP in 24 male (mean age ± standard deviation, 66.0 ± 9.4 years; range, 50–88 years) pathologically confirmed between January 2011 and April 2019 were retrospectively reviewed. All patients underwent intravesical BCG therapy followed by a MRI scan. Additional follow-up MRI scans, including diffusion-weighted imaging (DWI), were performed in 19 patients. The BCG-related GP cases were categorized into three: A, B, or C. The lesions with diffusion restriction and homogeneous enhancement were classified as type A. The lesions with diffusion restriction and a poorly enhancing component were classified as type B. A low signal intensity on high b-value DWI (b = 1000 s/mm2) was considered characteristic of type C. Two radiologists independently interpreted the MRI scans before making a consensus about the types. Results The median lesion size was 22 mm with the interquartile range (IQR) of 18–26 mm as measured using the initial MRI scans. The lesion types were A, B, and C in 7, 15, and 2 patients, respectively. Cohen’s kappa value for the inter-reader agreement for the interpretation of the lesion types was 0.837. On the last follow-up MRI scans of 19 patients, the size decreased (median, 5.8 mm; IQR, 3.4–8.5 mm), and the type changed from A or B to C in 11 patients. The lesions resolved in four patients. In five patients who underwent prostatectomy, caseous necrosis on histopathology matched with the non-enhancing components of type B lesions and the entire type C lesions. Conclusion BCG-related GP demonstrated three imaging patterns on multiparametric MRI. Contrast-enhanced T1-weighted imaging and DWI may play a role in its differential diagnosis from prostate cancer.

Study Objectives Lumbar spinal stenosis is an age-related spine condition that contributes to pain and disability. Decompressive laminectomy (DL) is regularly performed to alleviate symptoms. Insomnia symptoms are common among people living with chronic pain and may affect key DL outcomes, such as healthcare utilization. We examined associations of insomnia symptom severity with post-DL healthcare utilization in veterans with lumbar spinal stenosis. Methods Veterans (N = 200) with lumbar spinal stenosis undergoing DL were recruited into a prospective cohort study and self-reported insomnia symptom severity on the Insomnia Severity Index prior to DL. Post-DL, veterans reported on pain and non-pain-related monthly healthcare office visits, emergency room visits, hospitalizations, and mental health visits for 1 year. Incident rate ratios (IRRs) obtained via negative binomial regression evaluated associations of insomnia symptom severity with healthcare utilization rates. Results Approximately 51% of participants endorsed insomnia symptoms of at least mild severity. Participants who reported at least mild insomnia symptoms had more healthcare office visits (IRR = 1.23, p = .04), general mental health visits (IRR = 3.98, p < .0001), and pain-related mental health visits (IRR = 9.55, p = .01) than those without insomnia symptoms. Adjusting for covariates, rates of mental health visits, overall (IRR = 3.13, p = .001) and pain-related (IRR = 6.93, p = .02), remained statistically significantly higher. Conclusions Insomnia symptoms are associated with postoperative healthcare utilization lending support for future work to examine the value of assessing and intervening on insomnia symptoms prelaminectomy.

BACKGROUND: This study investigated whether neurotypical individuals' judgments that they dislike a person are more common when viewing autistic individuals than when viewing neurotypical individuals. METHODS: Videos of autistic and neurotypical targets were presented to a group of perceivers (neurotypical adults) who were asked whether or not they liked each target and why. RESULTS: It was more common for perceivers to “like” neurotypical than autistic targets. The number of “likes” each target received correlated highly with perceiver ratings of target social favorability. Perceivers cited perceived awkwardness and lack of empathy as being reasons for deciding they disliked targets. CONCLUSIONS: The findings shed light on how neurotypical people (mis)perceive autistic people. Such perceptions may act as a barrier to social integration for autistic people. LAY SUMMARY: WHY WAS THIS STUDY DONE? Previous research has found that nonautistic people tend to form less positive first impressions of autistic people than they do of other nonautistic people. These studies have tended to present questions such as “How trustworthy is this person?” or “How attractive is this person?” along with ratings scales. However, although it is known that nonautistic people tend to give lower ratings on these scales, we do not know whether this amounts to a dislike for autistic people or just lower levels of liking. WHAT WAS THE PURPOSE OF THIS STUDY? This study aimed to find out whether nonautistic people are less likely to say they like (and more likely to say they dislike) autistic people than other nonautistic people. WHAT DID THE RESEARCHERS DO? The researchers presented videos of autistic and nonautistic people to other nonautistic adults. The people watching the videos were not told that some of the people in the videos were autistic. They were asked to decide whether they liked or disliked the person in each video and to say why they had made their decision by choosing from a range of options. WHAT WERE THE RESULTS OF THE STUDY? Nonautistic people were more likely to say they disliked the person in the video if they were autistic, even though they did not know the diagnosis. The most common reasons for disliking a person was that they appeared awkward, and that they appeared to lack empathy. WHAT DO THESE FINDINGS ADD TO WHAT WAS ALREADY KNOWN? It was already known that nonautistic people tend to rate autistic people less positively on ratings scales. This study suggests that when making judgments—of either liking or disliking—they will sometimes go so far as to say they dislike autistic people. WHAT ARE POTENTIAL WEAKNESSES IN THE STUDY? All of the people in the video clips were male, while those watching the videos were mainly female. Therefore, we do not know whether the same observations would be made for perceptions of autistic females. The number of participants watching the videos was relatively small: a larger sample would give more reliable findings. HOW WILL THESE FINDINGS HELP AUTISTIC ADULTS NOW OR IN THE FUTURE? The findings add to previous research showing nonautistic people's misperceptions of autistic people could be a barrier to social integration for autistic people. They highlight the need for interventions at the societal level aimed at reducing misunderstanding and promoting tolerance.

Introduction: Acquiring parental consent is critical to pediatric clinical research, especially in interventional trials. In this study we investigated demographic, clinical, and environmental factors associated with likelihood of parental permission for enrollment in a study of therapies for diabetic ketoacidosis (DKA) in children. Methods: We analyzed data from patients and parents who were approached for enrollment in the Pediatric Emergency Care Applied Research Network (PECARN) Fluid Therapies Under Investigation in DKA (FLUID) trial at one major participating center. We determined the influence of various factors on patient enrollment, including gender, age, distance from home to hospital, insurance status, known vs new onset of diabetes, glycemic control (hemoglobin A1c), DKA severity, gender of the enroller, experience of the enroller, and time of enrollment. Patients whose parents consented to participate were compared to those who declined participation using bivariable and multivariable analyses controlling for the enroller. Results: A total of 250 patient/parent dyads were approached; 177 (71%) agreed to participate, and 73 (29%) declined. Parents of patients with previous episodes of DKA agreed to enroll more frequently than those with a first DKA episode (94.3% for patients with 1-2 previous DKA episodes, 92.3% for > 2 previous episodes, vs 64.9% for new onset diabetes and 63.2% previously diagnosed but no previous DKA). Participation was also more likely with more experienced enrollers (odds ratio [95% confidence interval] of participation for an enroller with more than two years’ experience vs less than two years: 2.46 [1.53, 3.97]). After adjusting for demographic and clinical factors, significant associations between participation and both DKA history and enroller experience remained. Patient age, gender, distance of home from hospital, glycemic control, insurance status, and measures of DKA severity were not associated with likelihood of participation. Conclusion: Familiarity with the disease process (previously diagnosed diabetes and previous experience with DKA) and experience of the enroller favorably influenced the likelihood of parental permission for enrollment in a study of DKA in children.

Introduction: The novel coronavirus disease 2019 (COVID-19) created challenges with access to care including increased burden on healthcare systems and potential exposure risks for vulnerable patients. To address these needs, Rush University Medical Center created a virtual, urgent care program specifically designed to address these challenges during the COVID-19 pandemic. Methods: This was a retrospective study analyzing adult patients with COVID-19-related telemedicine visits performed between March 1–June 30, 2020. COVID-19-related telemedicine visits refer to those who used the “Concern for Coronavirus” module. We assessed the total number of telemedicine visits using this module, percentage with a subsequent emergency department (ED) visit within seven days, and outcomes (ie, hospitalization status, intubation, and death) of patients who presented to the ED for evaluation. Data are presented using descriptive statistics. Results: A total of 2,974 adult patients accessed the program via the COVID-19 module over the four-month period. Of those, 142 patients (4.8%) had an ED visit within seven days. Only 14 patients (0.5%) required admission. One patient was intubated, and there were no deaths among the telemedicine population. Conclusion: The data suggests that telemedicine may be a safe and effective way to screen and treat patients with possible COVID-19, while reducing potential burdens on EDs.

Author(s): Chiu, David T.; Lavoie, Ronald; Nathanson, Larry A.; Sanchez, Leon D. | Abstract: Introduction: Nearly 14% of US adults currently smoke cigarettes. Cigarette smoking causes more than 480,000 deaths each year in the United States. Emergency department (ED) patients are frequently asked for their use of tobacco. Manual selection of pre-formed discharge instructions is the norm for most ED. Providing tobacco cessation discharge instructions to ED patients presents another avenue to combat the tobacco use epidemic we face. The objective of the study is to evaluate the effectiveness of an automated discharge instruction system in increasing the frequency of discharging current tobacco users with instructions for tobacco cessation.Methods: The study was done at an urban academic tertiary care center. A before and after study was used to test the hypothesis that use of an automated discharged instruction system would increase the frequency that patients who use tobacco were discharged with tobacco cessation instructions. Patients that were admitted, left against medical advice, eloped or left without being seen were excluded. The before phase was from 09/21/14-10/21/14 and the after phase was from the same dates one year later, 09/21/15-10/21/15. This was done to account for confounding by time of year, ED volume and other factors. A Fisher’s Exact Test was calculated to compare these two groups.Results: Tobacco cessation DC instructions were received 2/486 (0.4%) of tobacco users in the pre-implementation period compared to 357/371 (96%) in the post-implementation period (p l 0.05).Conclusions: The automated discharge instructions system increases the proportion of tobacco users who receive cessation instructions. Given the public health ramifications of tobacco use, this could prove to be a significant piece in decreasing tobacco use in patients who go to the emergency department.

Background Cannabidiol (CBD), the non-psychotropic compound from Cannabis sativa, shows positive results on controlling several health disturbances; however, comparable data regarding additional chemical from C. sativa, such as cannabidiolic acid (CBDA), is scarce due to its instability. To address this limitation, a stable CBDA analogue, CBDA methyl ester (HU-580), was synthetized and showed CBDA-like effects. Recently, we described that HU-580 increased wakefulness and wake-related neurochemicals. Objective To extend the comprehension of HU-580´s properties on waking, the c-Fos and NeuN expression in a wake-linked brain area, the hypothalamus was evaluated. Methods c-Fos and NeuN expression in hypothalamic sections were analyzed after the injections of HU-580 (0.1 or 100 μg/kg, i.p.). Results Systemic administrations of HU-580 increased c-Fos and neuronal nuclei (NeuN) expression in hypothalamic nuclei, including the dorsomedial hypothalamic nucleus dorsal part, dorsomedial hypothalamic nucleus compact part, and dorsomedial hypothalamic nucleus ventral part. Conclusion HU-580 increased c-Fos and NeuN immunoreactivity in hypothalamus nuclei suggesting that this drug might modulate the sleep–wake cycle by engaging the hypothalamus.

Introduction: Considering the need for information regarding approaches to prevention and treatment of coronavirus disease 2019 (COVID-19), we sought to determine publication lag times of COVID19-related original research articles published in top general medicine and emergency medicine (EM) journals. We further sought to characterize the types of COVID-19 publications within these journals. Methods: We reviewed 125 top-ranked general medicine journals and 20 top-ranked EM-specific journals for COVID-19-related publications. We abstracted article titles and manuscript details for each COVID-19-related article published between January 1–June 30, 2020, and categorized articles as one of the following: original research;case report;review;or commentary. We abstracted data for preprint publications over the same time period and determined whether articles from the general medicine and EM journals had been previously published as preprint articles. Our primary outcomes were the following: 1) lag time (days) between global cumulative World Health Organization (WHO)-confirmed cases of COVID-19 and publications;2) lag times between preprint article publication and peerreviewed journal publication;and 3) lag times between submission and publication in peer-reviewed journals. Our secondary outcome was to characterize COVID-19-related publications. Results: The first original research publications appeared in a general medicine journal 20 days and in an EM journal 58 days after the first WHO-confirmed case of COVID-19. We found median and mean lag times between preprint publications and journal publications of 32 days (19, 49) and 36 days (22) for general medicine journals, and 26 days (16, 36) and 25 days (13) for EM journals. Median and mean lag times between submission and publication were 30 days (19, 45) and 35 days (13) for general medicine journals, and 23 days (11, 39) and 27 days (19) for EM journals. Of 2530 general medicine journal articles and 351 EM journal articles, 28% and 23.6% were original research. We noted substantial closing of the preprint to peer-reviewed publication (160 days pre-pandemic) and peer-reviewed journal submission to publication (194 days pre-pandemic) lag times for COVID-19 manuscripts. Conclusion: We found a rapid and robust response with shortened publication lag times to meet the need for the publication of original research and other vital medical information related to COVID-19 during the first six months of 2020. [ABSTRACT FROM AUTHOR] Copyright of Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health is the property of Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Lockdowns and other preventive measures taken to curb the spread of diseases such as COVID-19 have restricted the use of face-to-face cognitive assessment. Remote testing may be an alternative, but it should first be shown to be comparable to in-person assessment before being used more widely, during and after the pandemic. Our aim was to evaluate the suitability of online, examiner-mediated administration of an open-access battery of executive function tests (the Free Research Executive Evaluation battery, or FREE) that can be adapted considering various characteristics of diverse populations and therefore used worldwide. A total of 96 9–15-year olds (42 girls) were tested, half of whom online through video calls mediated by an examiner. Their performance was compared to that of the other 48 individuals tested face-to-face, who were matched against the online-tested participants for age, pubertal status, sex, and parental schooling. The battery consists of two tests of the following executive domains: Updating (2-Back and Number Memory tests), Inhibition (Stroop Victoria and Stroop Happy-Sad), and Switching (Color Shape and Category Switch). Answers were vocal and self-paced, and the examiner recorded accuracy and time taken to complete in-person and online tasks. Only free software is needed for the assessment. Executive measures obtained from the tasks did not differ statistically between online and in-person tested participants and effects sizes of group effects were small, thus showing that the FREE test battery holds promise for online cognitive assessment, pending confirmation in different samples and further validation studies.

Conspiracy beliefs receive unprecedented public attention during the COVID-19 pandemic. This may be because they could directly affect own and others’ health and economic outcomes due to detrimental effects on preventive behaviour. We aimed to (a) test key hypotheses on the correlates of generic beliefs in conspiracy theories in this high-relevance real-life setting, (b) examine the role of trust in mediating effects on preventive behaviour, and (c) thereby inform the public health response. Using cross-sectional data (N=1,013) from the German COVID-19 monitoring we tested the relationships between conspiracy beliefs and (a) level of education, (b) social and economic worries, (c) trust in media, the government, public health institutions, and science, and (d) hygiene-related and contact-related preventive behaviour. Results were in line with expectations apart from null findings for the relationships with social worries and hygiene-related preventive behaviour. Trust in government mediated effects of conspiracy beliefs on contact-related preventive behaviour., This is a preprint of: Bruder, M., & Kunert, L. (2021). The conspiracy hoax? Testing key hypotheses about the correlates of generic beliefs in conspiracy theories during the COVID‐19 pandemic. International Journal of Psychology. https://doi.org/10.1002/ijop.12769

Author(s): Sutton, James; Gu, Leon; Diercks, Deborah B. | Abstract: Introduction: Patients presenting to the emergency department (ED) with “low-risk” acute coronary syndrome (ACS) symptoms can be discharged with outpatient follow-up. However, follow-up compliance is low for unknown nonclinical reasons. We hypothesized that a patient’s social factors, health literacy, self-perceived risk, and trust in the emergency physician may impact follow-up compliance.Methods: This was a prospective study of a convenience sample of discharged ED patients presenting with chest pain and given a follow-up appointment prior to departing the ED. Patients were asked about social and demographic factors and to estimate their own risk for heart disease; they also completed the Short Assessment of Health Literacy-English (SAHL-E) and the Trust in Physician Scale (TiPS).Results: We enrolled146 patients with a follow-up rate of 36.3%. Patients who had a low self-perceived heart disease risk (10% or less) were significantly less likely to attend follow-up than those with a higher perceived risk (23% vs 44%, P = 0.01). Other factors did not significantly predict follow-up rates.Conclusion: In an urban county ED, in patients who were deemed low risk for ACS and discharged, only self-perception of risk was associated with compliance with a follow-up appointment.

Introduction: Residency didactic conferences transitioned to a virtual format during the COVID-19 pandemic. This format creates questions about effective educational practices, which depend on learner engagement. In this study we sought to characterize the competitive demands for learner attention during virtual didactics and to pilot methodology for future studies. Methods: This was a prospective, observational, cohort study of attendees at virtual didactics from a single emergency medicine residency, which employed a self-report strategy informed by validated classroom assessments of student engagement. We deployed an online, two-question survey polling across six conference days using random signaled sampling. Participants reported all activities during the preceding five minutes. Results: There were 1303 responses over 40 survey deployments across six nonadjacent days. Respondents were residents (63.4%); faculty (27.5%); fellows (2.3%); students (2%); and others (4.8%). Across all responses, about 85% indicated engagement in the virtual conference within the last five minutes of the polls. The average number of activities engaged in was 2.0 (standard deviation = 1.1). Additional activities included education-related (34.2%), work-related (21.1%), social (18.8%), personal (14.6%), self-care (13.4%), and entertainment (4.4%). Conclusion: Learners engage in a variety of activities during virtual didactics. Engagement appears to fluctuate temporally, which may inform teaching strategies. This information may also provide unique instructor feedback. This pilot study demonstrates methodology for future studies of conference engagement and learning outcomes.

Absence seizures are generalized nonmotor epileptic seizures with abrupt onset and termination. Transient impairment of consciousness and spike-slow wave discharges (SWDs) in EEG are their characteristic manifestations. This type of seizure is severe in two common pediatric syndromes: childhood (CAE) and juvenile (JAE) absence epilepsy. The appearance of low-cost, portable EEG devices has paved the way for long-term, remote monitoring of CAE and JAE patients. The potential benefits of this kind of monitoring include facilitating diagnosis, personalized drug titration, and determining the duration of pharmacotherapy. Herein, we present a novel absence detection algorithm based on the properties of the complex Morlet continuous wavelet transform of SWDs. We used a dataset containing EEGs from 64 patients (37 h of recordings with almost 400 seizures) and 30 age and sex-matched controls (9 h of recordings) for development and testing. For seizures lasting longer than 2 s, the detector, which analyzed two bipolar EEG channels (Fp1-T3 and Fp2-T4), achieved a sensitivity of 97.6% with 0.7/h detection rate. In the patients, all false detections were associated with epileptiform discharges, which did not yield clinical manifestations. When the duration threshold was raised to 3 s, the false detection rate fell to 0.5/h. The overlap of automatically detected seizures with the actual seizures was equal to ~96%. For EEG recordings sampled at 250 Hz, the one-channel processing speed for midrange smartphones running Android 10 (about 0.2 s per 1 min of EEG) was high enough for real-time seizure detection.

Author(s): Leroux, Eric J.; Kaufman, Elizabeth A.; Kontaxis, Christian N.; Lipman, Grant S. | Abstract: Introduction: Pain control is an essential component of musculoskeletal injury treatment in the emergency department (ED). We evaluated the most effective type of cryotherapy for analgesia of acute musculoskeletal injury and the impact on opioid utilization.Methods: This was a prospective, randomized, single-blind controlled trial of adult ED patients who presented with acute musculoskeletal pain. Patients were randomized to either intensive targeted cryotherapy (crushed wetted ice in a plastic bag) or agitated chemical cold pack applied to the injury site for 20 minutes. All other diagnostic and therapeutic orders were at the discretion of the treating physician. Visual analog pain scores were measured at the time of cryotherapy application, at 20 minutes (time of cryotherapy removal), and at 60 minutes (40 minutes after removal).Results: We enrolled 38 patients, 17 randomized to intensive targeted cryotherapy and 21 to chemical cold packs, with well-matched demographics. The intensive targeted cryotherapy group achieved significantly greater pain relief at 20 minutes (2.1 [95% confidence interval (CI), 1.3 – 2.9] vs 0.9 [95% CI, 0.3 – 1.5], P l 0.05) and at 60 minutes (2.7 [95% CI, 1.6 – 3.7] vs 1.2 [95% CI, 0.6 – 1.7], P l 0.05), number need to trial (NNT) = 3.2. Opioid administration in the ED was significantly lower in the intensive targeted cryotherapy group (1 [6%] vs 7 [33%], P l 0.05), NNT = 3.6. Those who received a discharge opiate prescription had significantly higher 60-minute pain scores (7.3 ± 2.2 vs 4.1 ± 2.7, P l 0.05).Conclusion: Intensive targeted cryotherapy provided more effective analgesia than chemical cold packs for acute musculoskeletal injuries in the ED and may contribute to lower opioid usage.

Heparan sulfate (HS) is a glycosaminoglycan found mainly in its protein-conjugated form at the cell surface and the extracellular matrix. Its high sulfation degree mediates functional interactions with positively charged amino acids in proteins. 2-O sulfation of iduronic acid and 3-O sulfation of glucosamine in HS are mediated by the sulfotransferases HS2ST and HS3ST, respectively, which are dysregulated in several cancers. Both sulfotransferases regulate breast cancer cell viability and invasion, but their role in cancer stem cells (CSCs) is unknown. Breast CSCs express characteristic markers such as CD44+/CD24−/low, CD133 and ALDH1 and are involved in tumor initiation, formation, and recurrence. We studied the influence of HS2ST1 and HS3ST2 overexpression on the CSC phenotype in breast cancer cell lines representative of the triple-negative (MDA-MB-231) and hormone-receptor positive subtype (MCF-7). The CD44+/CD24−/low phenotype was significantly reduced in MDA-MB-231 cells after overexpression of both enzymes, remaining unaltered in MCF-7 cells. ALDH1 activity was increased after HS2ST1 and HS3ST2 overexpression in MDA-MB-231 cells and reduced after HS2ST1 overexpression in MCF-7 cells. Colony and spheroid formation were increased after HS2ST1 and HS3ST2 overexpression in MCF-7 cells. Moreover, MDA-MB-231 cells overexpressing HS2ST1 formed more colonies and could not generate spheres. The phenotypic changes were associated with complex changes in the expression of the stemness-associated notch and Wnt-signaling pathways constituents, syndecans, heparanase and Sulf1. The results improve our understanding of breast CSC function and mark a subtype-specific impact of HS modifications on the CSC phenotype of triple-negative and hormone receptor positive breast cancer model cell lines.

Background: Three large cardiovascular outcome trials have investigated the safety of sodium glucose cotransporter 2 (SGLT2) inhibitors. Objective: To analyze the nationwide dispensing of SGLT2 inhibitors before and after the publication of these trials. Methods: A cross-sectional study was conducted of monthly prescription dispensing of SGLT2 inhibitors from May 23, 2014, to April 30, 2019, using nationwide data for Canada. An autoregressive integrated moving average (ARIMA) model was fitted to the monthly number of tablets dispensed for each SGLT2 inhibitor; the model included a ramp intervention function at the publication dates of interest to estimate the impact on SGLT2 inhibitor dispensing patterns. Results: The rate of canagliflozin and dapagliflozin dispensing declined after publication of results of the empagliflozin cardiovascular trial in September 2015. After publication of results of the canagliflozin trial in June 2017, which indicated a reduction in cardiovascular events and an increase in the risk of lower-limb amputation, canagliflozin remained the most commonly dispensed SGLT2 inhibitor, but its rate of dispensing declined further. In contrast, the rate of empagliflozin dispensing increased, while the rate of dapagliflozin dispensing was unchanged. After publication of the dapagliflozin trial in November 2018, which indicated no clear reduction in cardiovascular events, short-term trends in dispensing of canagliflozin, empagliflozin, and dapagliflozin were largely unaffected. Conclusions: The cardiovascular outcome trials appeared to have an important impact on the dispensing of SGLT2 inhibitors in Canada. RÉSUMÉ Contexte : Trois grands essais portant sur les résultats cardiovasculaires avaient pour objet l’étude de l’innocuité des inhibiteurs du cotransporteur sodium-glucose de type 2 (SGLT2). Objectif : Analyser la délivrance nationale des inhibiteurs du SGLT2 avant et après la publication de ces essais. Méthodes : Une étude transversale a été menée sur la délivrance d’ordonnances mensuelles d’inhibiteurs du SGLT2 du 23 mai 2014 au 30 avril 2019, à l’aide de données nationales pour le Canada. Un modèle de moyenne mobile intégrée autorégressive (ARIMA) a été adapté au nombre mensuel de comprimés distribués pour chaque inhibiteur du SGLT2; le modèle comprenait une fonction d’intervention progressive aux dates de publication d’intérêt pour estimer l’effet sur les schémas de délivrance d’inhibiteurs du SGLT2. Résultats : Le taux de délivrance de canagliflozine et de dapagliflozine a diminué après la publication des résultats de l’essai cardiovasculaire empagliflozine en septembre 2015. Après la publication des résultats de l’essai cardiovasculaire canagliflozine en juin 2017, qui indiquaient une réduction des événements cardiovasculaires et une augmentation du risque d’amputation des membres inférieurs, la canagliflozine est restée l’inhibiteur du SGLT2 le plus couramment délivré, mais son taux de délivrance a encore diminué. En revanche, le taux d’empagliflozine délivré a augmenté, tandis que le taux de délivrance de dapagliflozine est resté identique. Après la publication de l’essai sur la dapagliflozine en novembre 2018, qui n’indiquait aucune réduction nette des événements cardiovasculaires, les tendances à court terme de la délivrance de la canagliflozine, de l’empagliflozine et de la dapagliflozine n’ont pratiquement pas changé. Conclusions : Les essais portant sur les résultats cardiovasculaires semblaient avoir un effet important sur la délivrance des inhibiteurs du SGLT2 au Canada.

Background: Many antimicrobials given by the intravenous (IV) route have oral (PO) formulations with high oral bioavailability. The advantages of using the PO rather than the IV formulation include lower risk of adverse reactions, shorter length of hospital stay, and lower health care costs. Objectives: The primary objective was to determine the proportions of patients who received the IV and PO formulations of antimicrobials with high oral bioavailability. The secondary objectives were to determine the proportion of patients who were eligible to receive PO antimicrobials from the start of treatment, the proportion who qualified for IV-to-PO step-down, and areas of improvement to increase use of PO antimicrobials. Methods: A retrospective chart review was conducted in hospitals in the Fraser Health Authority, British Columbia, between October 18, 2019, and March 5, 2020. Two hundred charts were randomly selected for patients who had received either azithromycin, ciprofloxacin, clindamycin, fluconazole, levofloxacin, linezolid, moxifloxacin, metronidazole, sulfamethoxazole–trimethoprim, or voriconazole. Results: Of the 200 patients, 124 (62.0%) received the PO formulations, while 76 (38.0%) received the IV formulations. Of the 76 patients receiving IV antimicrobials, 39 (51.3%; 95% confidence interval 44.7%–57.9%) were eligible to receive PO antimicrobials from the start of treatment or could have been stepped down from IV to PO administration. Conclusions: More than half of patients who received IV therapy were eligible to receive the PO formulation of antimicrobials known to have high oral bioavailability; relative to earlier studies, this proportion has not improved over time. This finding highlights the need for continued vigilance in encouraging the use of PO rather than IV formulations for hospitalized patients. RÉSUMÉ Contexte : De nombreux antimicrobiens administrés par voie intraveineuse (IV) ont des formulations orales (PO) avec une biodisponibilité orale élevée. Les avantages de l’utilisation de cette formulation plutôt que de la formulation IV comprennent un risque moins élevé d’effets indésirables, une durée d’hospitalisation plus courte et des coûts de soins de santé inférieurs. Objectifs : L’objectif principal visait à déterminer les proportions de patients ayant reçu les formulations IV et PO d’antimicrobiens à haute biodisponibilité orale. Les objectifs secondaires consistaient, quant à eux, à déterminer la proportion de patients pouvant recevoir des antimicrobiens par voie orale dès le début du traitement, la proportion de patients qualifiés pour passer de l’administration IV à l’administration par voie orale et les domaines d’amélioration pour augmenter l’utilisation des antimicrobiens par voie orale. Méthodes : Un examen rétrospectif des dossiers a été effectué dans les hôpitaux de la Fraser Health Authority, en Colombie-Britannique, entre le 18 octobre 2019 et le 5 mars 2020. Deux cents dossiers ont été sélectionnés au hasard pour les patients qui avaient reçu soit de l’azithromycine, de la ciprofloxacine, de la clindamycine, du fluconazole, de la lévofloxacine, du linézolide, de la moxifloxacine, du métronidazole, de la sulfaméthoxazole-triméthoprime ou du voriconazole. Résultats : Sur les 200 patients, 124 (62,0 %) ont reçu les formulations PO, tandis que 76 (38,0 %) ont reçu les formulations IV. Sur les 76 patients recevant des antimicrobiens par voie intraveineuse, 39 (51,3 %; intervalle de confiance à 95 % 44,7 % à 57,9 %) étaient admissibles pour recevoir des antimicrobiens par voie orale dès le début du traitement ou auraient pu passer de l’administration IV à l’administration par voie orale. Conclusions : Plus de la moitié des patients ayant reçu une thérapie IV étaient admissibles pour recevoir la formulation PO d’antimicrobiens connus pour avoir une biodisponibilité orale élevée; par rapport aux études antérieures, cette proportion ne s’est pas améliorée avec le temps. Cette découverte souligne la nécessité d’une vigilance continue pour encourager l’utilisation de formulations PO plutôt que IV pour les patients hospitalisés.

Introduction Leadership positions occupied by women within academic emergency medicine have remained stagnant despite increasing numbers of women with faculty appointments. We distributed a multi-institutional survey to women faculty and residents to evaluate categorical characteristics contributing to success and differences between the two groups. Methods An institutional review board-approved electronic survey was distributed to women faculty and residents at eight institutions and were completed anonymously. We created survey questions to assess multiple categories: determination; resiliency; career support and obstacles; career aspiration; and gender discrimination. Most questions used a Likert five-point scale. Responses for each question and category were averaged and deemed significant if the average was greater than or equal to 4 in the affirmative, or less than or equal to 2 in the negative. We calculated proportions for binary questions. Results The overall response rate was 55.23% (95/172). The faculty response rate was 54.1% (59/109) and residents’ response rate was 57.1% (36/63). Significant levels of resiliency were reported, with a mean score of 4.02. Childbearing and rearing were not significant barriers overall but were more commonly reported as barriers for faculty over residents (P

Study Objectives: The surge and long tail of patients in acute respiratory distress during the coronavirus-19 (CoVID19) pandemic has inspired new innovations in diagnosing, treating and dispositioning patients during high census conditions with constrained resources During the first wave of the pandemic, we deployed an artificial intelligence (AI) algorithm for assisted interpretation of chest x-ray for use by radiologists and emergency department (ED) physicians We report first experiences of physician interaction with this novel AI algorithm designed to enhance physician abilities to identify ground glass and consolidation on chest radiographs Methods: Design: We created a fully-automated pipeline into the clinical environment to provide AI augmentation of chest x-rays, utilizing a previously developed deep learning-based AI algorithm Trained with 22,000 annotations by radiologists, the algorithm overlays X-rays with color-coded maps that indicate pneumonia probability This was provided alongside standard chest x-ray images for physicians to use in real-time at the point of care with existing imaging software For this prospective observational study, we developed a 3-point survey to characterize experiences with the tool regarding ease of use and impact on clinical decision-making Setting: Surveys were conducted during a one-month period surrounding the projected CoVID-19 surge locally (April 8-May 9) at two academic hospitals in Southern California A federal declaration of emergency occurred March 13, 2020 and the tool was urgently deployed on March 25 Types of Participants: Emergency medicine resident and attending physicians surveyed in real time by telephone Results: Of the 5,125 total visits and 1,960 chest radiographs obtained in the ED during the study period, 1,855 were analyzed by the algorithm Among these, emergency physicians were surveyed for their experiences on 202 Real-time computation and delivery of the tool took four minutes on average Overall, 86% either strongly agreed or somewhat agreed that the intervention was easy to use in the existing workflow 20% of all respondents reported that the algorithm impacted their clinical decision making In general, resident physicians found the AI implementation easier to use than attendings (Mann Whitney U, p=0 005) Descriptive statistics regarding further impact are summarized below (table 1) Conclusion: This AI technology was rapidly deployed in a large academic health system in the first wave of a global pandemic Surveyed ED physicians found this implementation easy to use within existing workflows Twenty percent of physicians reported that the tool changed clinical decision making, and approximately one third of those found that it impacted diagnostic testing decisions and treatment plans Several physicians reported ordering COVID-19 PCR testing as a direct result of the AI, resulting in positive tests and subsequent quarantining of patients who otherwise might not have been appropriately diagnosed To our knowledge, this is the first published study evaluating the impact of medical imaging AI on clinical decision making in the ED setting and may prove to be a powerful tool during the pandemic response [Formula presented]

This was a survey of the general non-healthcare-worker USA population regarding their knowledge and attitudes toward the COVID-19 pandemic. Almost everyone practiced social distancing. Women were significantly more likely to be worried about contracting the virus than men (65% vs. 43%, p = 0.0272). There was also a linear trend with age, with older Americans being more worried about contracting the virus. Women were also significantly likely to have received the influenza vaccine this past season compared to men (60% vs. 37%, p = .0167). Similarly, women were significantly more likely to get the influenza vaccine next season than men (77% vs. 46%, p = .0014.). Overall, across every age group, geographic part of the USA and gender, more (or the same) Americans plan on getting the influenza vaccine next season compared to last, but not fewer. This may reflect more awareness of preventative health brought on by the COVID-19 pandemic.

Objective We sought to identify sub‐groups of “low‐risk” HEART score patients (history, ECG, age, risk factors, and troponin) at elevated risk of acute myocardial infarction or death within 30 days. Methods We performed a secondary analysis of prospective emergency department (ED) encounters for suspected acute coronary syndrome in a large health system with low‐risk HEART scores (0–5 points). Logistic regression using the 5 components of the HEART score analyzed the increase risk attributable to points from each of the 5 score components. Results Of 30,971 encounters among 28,992 unique patients, 135 (0.44%, 95% confidence interval [CI] = 0.37–0.51) experienced acute myocardial infarction or death. Risk increased for each component of the HEART score from 0 to 1 to 2 points (history, 0.4% to 0.5% to 0.6%; ECG, 0.3% to 0.7% to 0.7%; age, 0.2% to 0.3% to 0.7%; risk factors, 0.1% to 0.4% to 0.8%), except troponin, which had the highest risk with 1 point (troponin, 0.4% to 2.7% to 0.9%). Odds ratios from our regression, which adjusts for other components, showed a similar pattern (from 1 vs 0 and 2 vs 0 points, respectively: history, 1.0 and 1.8; ECG, 2.2 and 3.5; age, 1.2 and 2.1; risk factors, 2.4 and 4.2; and troponin, 6.0 and 3.6). Conclusion Among “low‐risk” suspected acute coronary syndrome encounters, increasing points within each of the 5 categories demonstrated small increases in risk of death or acute myocardial infarction, with the troponin and ECG components representing the largest risk increases.

Background: Slow-wave activity (SWA) during non-rapid eye movement (NREM) sleep reflects synaptic potentiation during preceding wakefulness. Epileptic activity may induce increases in state-dependent SWA in human brains, therefore, localization of SWA may prove useful in the presurgical workup of epileptic patients. We analyzed high-density electroencephalography (HDEEG) data across vigilance states from a reflex epilepsy patient with a clearly localizable ictal symptomatogenic zone to provide a proof-of-concept for the testability of this hypothesis. Methods: Overnight HDEEG recordings were obtained in the patient during REM sleep, NREM sleep, wakefulness, and during a right facial motor seizure then compared to 10 controls. After preprocessing, SWA (i.e., delta power; 1–4 Hz) was calculated at each channel. Scalp level and source reconstruction analyses were computed. We assessed for statistical differences in maximum SWA between the patient and controls within REM sleep, NREM sleep, wakefulness, and seizure. Then, we completed an identical statistical comparison after first subtracting intrasubject REM sleep SWA from that of NREM sleep, wakefulness, and seizure SWA. Results: The topographical analysis revealed greater left hemispheric SWA in the patient vs. controls in all vigilance states except REM sleep (which showed a right hemispheric maximum). Source space analysis revealed increased SWA in the left inferior frontal cortex during NREM sleep and wakefulness. Ictal data displayed poor source-space localization. Comparing each state to REM sleep enhanced localization accuracy; the most clearly localizing results were observed when subtracting REM sleep from wakefulness. Conclusion: State-dependent SWA during NREM sleep and wakefulness may help to identify aspects of the potential epileptogenic zone. Future work in larger cohorts may assess the clinical value of sleep SWA to help presurgical planning.

Objective Decontamination protocols for victims of mass casualty events are well documented and emphasized to protect physicians, nurses and facilities. Decontamination practices outside of mass casualty events are unknown. This pilot study was undertaken to assess the current practices of burn patient decontamination outside of mass casualty events within level I and II trauma center emergency departments in the state of Michigan. Methods Using the Michigan Trauma Quality Improvement Project membership, a 10‐question online survey was sent to trauma program managers at all level I and II trauma centers in Michigan. Survey questions focused on institutional decontamination protocols and consistency of use. Results Survey response was 50%. Of the responding facilities, 31% did not decontaminate burn patients. Of the centers who indicated that they did decontaminate burn patients, 31% did not follow a standardized protocol. Our survey revealed that 69% of facilities used a protocol for decontamination: 45% used the protocol consistently on all burns, and 55% at physician discretion. Products used most frequently to decontaminate burn patients included water (100%) followed by soap (44%). Conclusion This pilot survey of level I and II trauma centers in the state of Michigan revealed variability in the use of burn patient decontamination protocols and consistency of use. Additional research is warranted to determine if our results are reflective of trauma centers nationally.

Introduction: The American Hospital Association (AHA) has hospital-level data, while the Centers for Medicare & Medicaid Services (CMS) has patient-level data. Merging these with other distinct databases would permit analyses of hospital-based specialties, units, or departments, and patient outcomes. One distinct database is the National Emergency Department Inventory (NEDI), which contains information about all EDs in the United States. However, a challenge with merging these databases is that NEDI lists all US EDs individually, while the AHA and CMS group some EDs by hospital network. Consolidating data for this merge may be preferential to excluding grouped EDs. Our objectives were to consolidate ED data to enable linkage with administrative datasets and to determine the effect of excluding grouped EDs on ED-level summary results. Methods: Using the 2014 NEDI-USA database, we surveyed all New England EDs. We individually matched NEDI EDs with corresponding EDs in the AHA and CMS. A “group match” was assigned when more than one NEDI ED was matched to a single AHA or CMS facility identification number. Within each group, we consolidated individual ED data to create a single observation based on sums or weighted averages of responses as appropriate. Results: Of the 195 EDs in New England, 169 (87%) completed the NEDI survey. Among these, 130 (77%) EDs were individually listed in AHA and CMS, while 39 were part of groups consisting of 2–3 EDs but represented by one facility ID. Compared to the individually listed EDs, the 39 EDs included in a “group match” had a larger number of annual visits and beds, were more likely to be freestanding, and were less likely to be rural (all P

Objectives Overdiagnosis of urinary tract infections (UTI) among people living with dementia is a nationally recognized problem associated with morbidity from antibiotics as well as multidrug‐resistant bacteria. However, whether this problem also exists in the emergency department (ED) is currently unknown. Methods To examine the association between dementia and UTI diagnosis in the ED we performed a retrospective analysis of Medicare beneficiaries older than 65 years old who presented to an ED in 2016. A diagnosis of UTI was present in 58,580 beneficiaries, and 321,479 beneficiaries without a diagnosis of UTI served as the comparison group. Our logistic regression model controlled for dementia, older age, female sex, Medicaid status, skilled nursing facility residence, history of prostate cancer, recent urinary catheter use, recurrent UTI, and multiple comorbidities. Results In our model, people living with dementia had over twice the odds (odds ratio = 2.27, 95% confidence interval = 2.21, 2.33) of being diagnosed with a UTI in the ED compared to those without dementia despite their lower prevalence of symptoms and signs localizing to the genitourinary tract (3.8% vs 8.9%, respectively). Conclusion This is the first study from a national database that examines the association of dementia with UTI diagnosis among older adults who visit the ED. Our study could not establish whether the UTI diagnoses in the ED were accurate but does imply a disproportionate burden of UTI diagnoses in people living with dementia despite their lower prevalence of clinical criterion. Antimicrobial stewardship in the ED should address the complexity of UTI diagnosis in dementia.

Objective The objective of this study was to determine whether instituting an alternative to opioids (ALTO) protocol significantly reduced opioid use in emergency departments (EDs). The secondary objective was to determine whether patient‐reported pain and satisfaction were affected. Methods Electronic health records for 10 EDs in Colorado were retrospectively examined for the 6 months before the intervention and for the same 6 months the following year after the intervention, which consisted of systemic and educational initiatives in line with the Colorado American College of Emergency Physicians 2017 Opioid Prescribing and Treatment Guidelines. Results Of the total preintervention and postintervention unique patient visits, 47.2% received 1 of the drugs of interest, an opioid or ALTO, while in the ED. In aggregate, the EDs decreased opioid usage, measured in morphine equivalent units per 1000 ED visits, by 37.4% (95% confidence interval, 33.6%–76.2%; P < 0.0001) after the intervention. Statistically significant decreases were seen in every type of opioid. Statistically significant increases in ALTO usage were also noted across all study hospitals. There were no significant changes observed in Hospital Consumer Assessment of Healthcare Providers and Systems patient satisfaction scores before and after the intervention in the hospitals with Hospital Consumer Assessment of Healthcare Providers and Systems data (preintervention mean, 3.74; postintervention mean, 3.74; P = 0.637), and there was a small but statistically significant improvement in pain scores (preintervention mean, 3.62; postintervention mean, 3.66; P = 0.002). In a subgroup analysis of patients presenting with chief complaints of long bone fractures and malignant neoplasms, there were no significant reductions in opioid use. Conclusions This study demonstrated the feasibility and effectiveness of implementing ALTO protocols to reduce opioid use in the ED setting without an overall reduction in patient perception of pain or satisfaction with care.

Introduction: Our goal in this study was to estimate rates of emergency department (ED) visits for fever by children

Objective Emergency department (ED)–initiated buprenorphine may prevent overdose. Microdosing is a novel approach that does not require withdrawal, which can be a barrier to standard inductions. We aimed to evaluate the feasibility of an ED‐initiated buprenorphine/naloxone program providing standard‐dosing and microdosing take‐home packages and of randomizing patients to either intervention. Methods We broadly screened patients ≥18 years old for opioid use disorder at a large, urban ED. In a first phase, we provided consecutive patients with 3‐day standard‐dosing packages, and then we provided a subsequent group with 6‐day microdosing packages. In a second phase, we randomized patients to standard dosing or microdosing. We attempted 7‐day telephone follow‐ups and 30‐day in‐person community follow‐ups. The primary feasibility outcome was number of patients enrolled and accepting randomization. Secondary outcomes were numbers screened, follow‐up rates, and 30‐day opioid agonist therapy retention. Results We screened 3954 ED patients and identified 94 with opioid use disorders. Of the patients, 26 (27.7%) declined participation: 10 identified a negative prior experience with buprenorphine/naloxone as the reason, 5 specifically cited precipitated withdrawal, and none cited randomization. We enrolled 68 patients. A total of 14 left the ED against medical advice, 8 were excluded post‐enrollment, 21 received standard dosing, and 25 received microdosing. The 7‐day and 30‐day follow‐up rates were 9/46 (19.6%) and 15/46 (32.6%), respectively. At least 5/21 (23.8%) provided standard dosing and 8/25 (32.0%) provided microdosing remained on opioid agonist therapy at 30 days. Conclusions ED‐initiated take‐home standard‐dosing and microdosing buprenorphine/naloxone programs are feasible, and a randomized controlled trial would be acceptable to our target population.

Objective Resident physicians must develop competence in interpersonal and communication skills, but workplace‐based assessment of these skills remains challenging. We explored the feasibility of the Resident Communication Assessment Program (ReCAP) for eliciting patient feedback about resident physician communication in the emergency department (ED). Methods This study is a prospective, observational study conducted in the ED of a university‐based hospital from December 2018 through April 2019. ReCAP is a program that interviews patients prior to discharge from the ED using the Communication Assessment Tool (CAT). CAT consists of 14 Likert style questions and 3 open‐ended questions for patient feedback about residents’ communication. Open‐text, narrative responses from patients were coded using a modified version of the Completed Clinical Evaluation Report Rating tool. Results We collected data from 42 subjects who completed the CAT, and provided 32 open‐text, narrative responses about 20 resident physicians. Patient responses were overwhelmingly positive with 551/588 (94%) CAT responses scoring “Very Good,” the highest category. Open‐text, narrative comments analyzed using CCERR were unbalanced, favoring residents' strengths rather than areas for improvement. Patient comments offered more examples of strengths than weaknesses, and few subjects provided recommendations to improve resident performance. Conclusion ReCAP represents a feasible method for eliciting patient feedback about resident communication skills in the ED. The CAT can be used to structure brief patient interviews by trained staff but generally elicits only positive feedback. Further studies are needed to identify more discriminatory assessment tools.

Objectives Little academic investigation has been done to describe emergency department (ED) practice structure and quality improvement activities. Our objective was to describe staffing, payment mechanisms, and quality improvement activities among EDs in a nationwide quality improvement network and also stratify results to descriptively compare (1) single‐ versus multi‐site EDs and (2) small‐group versus large‐group EDs. Methods Observational study examining EDs that completed activities for the 2018 wave of the Emergency Quality Network (E‐QUAL), a voluntary network of EDs nationwide that self‐report quality improvement activities. EDs were defined as single‐site or multi‐site based on self‐reported billing practices; additionally, EDs were defined as large‐group if they and a majority of other sites with the same group name also identified as multi‐site. All other sites were deemed small‐group. Results Data from 377 EDs were included. For staffing, the median number of clinicians was 17 overall (16 single‐site; 19 multi‐site). For payment, 376 of 377 EDs (99.7%) participated in the Merit‐Based Incentive Payment System. Thirty‐five EDs (9.2%) participated in a federal alternative payment model, and 19 (5.0%) participated in a commercial alternative payment model. For quality improvement, single‐ and multi‐site EDs reported similar progress on quality improvement strategies; however, small‐group EDs reported more advanced quality improvement strategies compared to large‐group EDs for 8/10 quality improvement strategies included in a survey (eg, “achieved a formal plan to eliminate waste”). Conclusion Among EDs in E‐QUAL, staffing, payment, and quality improvement activities are similar between single‐ and multi‐site EDs. Group‐level analysis suggests that practice structure may influence adoption of quality improvement strategies. Future work is needed to further evaluate practice structure and its influence on quality improvement activities and quality.

Background Medical cannabis users report that their knowledge regarding cannabis is predominantly from their own personal experiences and the Internet. Objective We summarize and describe information found through Internet searches on medical cannabis in English language websites. Methods We used terms related to medical cannabis in the Google search engine between November and December 2019. Resulting websites were catalogued and coded for content, including mentions of health and medical conditions, pharmacology, dosage, harmful or adverse effects, harm reduction techniques, cautions or warnings, products for sale, and credentials. Results We coded 344 web pages on 179 unique websites. Cannabis was mentioned for the treatment of 151 different medical and health conditions, only four of the twenty most frequently mentioned conditions have received substantial empirical support for cannabis or cannabinoid treatment. Information content varied widely across sites, only a small proportion of sites included information on pharmacology, dosage, risks, and other aspects that are requirements for pharmaceutical drugs. Information provided was only moderately related to conclusions in the emerging scientific literature. Conclusions Given the rise in cannabis use within the U.S. and the reliance on the Internet as a source of information, considerable efforts are needed to provide accurate on-line cannabis education to minimize harms and maximize benefits for individuals and society.

Objective There is minimal evidence describing outcomes for emergency department (ED) patients with suspected coronavirus disease 2019 (COVID‐19) infection who are not hospitalized. The study objective was to assess 30‐day outcomes (ED revisit, admission, ICU admission, and death) for low‐risk patients discharged after ED evaluation for COVID‐19. Methods This was a retrospective cohort study of patients triaged to a COVID‐19 surge area within an urban ED and discharged between March 12 and April 6. Physicians were encouraged to discharge patients if they were well‐appearing with few comorbidities. Data were collected from review of medical records and phone follow‐up, and the analysis was descriptive. Results Of 452 patients, the median age was 38, and 61.7% had no comorbidities. Chest radiographs were performed for 50.4% of patients and showed infiltrates in 14% of those tested. Polymerase chain reaction testing was performed for 28.3% of patients during the index ED visit and was positive in 35.9% of those tested. Follow‐up was achieved for 75.4% of patients. ED revisits occurred for 13.7% of patients. The inpatient admission rate at 30 days was 4.6%, with 0.7% requiring intensive care. Median number of days between index ED evaluation and return for admission was 5 (interquartile range 3–7, range 1–17). There were no known deaths. Conclusions A minority of low‐risk patients with suspected COVID‐19 will require hospitalization after being discharged home from the ED. Outpatient management is likely safe for well‐appearing patients with normal vital signs, but patients should be instructed to return for worsening symptoms including labored breathing. Future work is warranted to develop and validate ED disposition guidelines.

Background: The SARS-CoV-2 (COVID-19) virus has wide community spread. The aim of this study was to describe patient characteristics and to identify factors associated with COVID-19 among emergency department patients under investigation for COVID-19 who were admitted to the hospital. Methods: This was a retrospective observational study from eight emergency departments within a nine-hospital health system. Patients with COVID-19 testing around the time of hospital admission were included. The primary outcome measure was COVID-19 test result. Patient characteristics were described and a multivariable logistic regression model was used to identify factors associated with a positive COVID-19 test. Results: During the study period from March 1, 2020 to April 8, 2020, 2,182 admitted patients had a test resulted for COVID-19. Of these patients, 786 (36%) had a positive test result. For COVID positive patients, 63 (8.1%) died during hospitalization. COVID-19 positive patients had lower pulse oximetry (0.91 [95%CI], [0.88-0.94]), higher temperatures (1.36 [1.26-1.47]), and lower leukocyte counts than negative patients (0.78 [0.75-0.82]). Chronic lung disease (OR 0.68, [0.52-0.90]) and histories of alcohol (0.64 [0.42-0.99]) or substance abuse (0.39 [0.25-0.62]) were less likely to be associated with a positive COVID-19 result. Conclusion: We observed a high percentage of positive results among an admitted emergency department cohort under investigation for COVID-19. Patient factors may be useful in early differentiation of patients with COVID-19 from similarly presenting respiratory illnesses although no single factor will serve this purpose. This article is protected by copyright. All rights reserved.

Objectives Emergency departments (EDs) are called to implement public health and prevention initiatives, such as infectious disease screening. The perception that ED resources are insufficient is a primary barrier. Resource needs are generally conceptualized in terms of total number of ED encounters, without formal calculation of the number of encounters for which a service is required. We illustrate potential differences in the estimated volume of service need relative to ED census using the examples of HIV and hepatitis C (HCV) screening. Methods This cross‐sectional analysis adjusted the proportion of ED encounters in which patients are eligible for HIV and HCV screening according to a cascade of successively more restrictive patient selection criteria, presuming full implementation of each criterion. Parameter estimates for the proportion satisfying each selection criterion were derived from the electronic health records of an urban academic facility and its ED HIV and HCV screening program during 2 time periods. The primary outcome was the estimated reduction in proportion of ED visits eligible for screening after application of the entire cascade. Results There were 76,104 ED encounters during the study period. Applying all selection criteria reduced the number of required screens by 97.1% (95% confidence interval, 97.0–97.2) for HIV and 86.1% (95% confidence interval, 85.9–86.3) for HCV. Conclusions Using the example of HIV and HCV screening, the application of eligibility metrics reduces the volume of service need to a smaller, more feasible number than estimates from ED census alone. This approach might be useful for clarifying perceived service need and guiding operational planning.

Objective Essential oils are plant‐derived oils and are widely used as an over‐the‐counter remedy for common ailments. Many essential oils are found to have proconvulsant effects. Here we report a small case series of 3 adults with eseential oil‐related status epilepticus. Methods This was an observational study conducted in a tertiary care hospital in south India from January 2018 to December 2019. We collected the demographic, clinical, and imaging features of all cases of status epilepticus resulting from exposure to essential oils. Cases of status epilepticus secondary to all other causes were excluded. Results There were 3 young adults with essential oil‐related status epilepticus. Two had de novo generalized tonic–clonic status epilepticus, and 1 with posttraumatic occipital lobe epilepsy had focal‐impaired awareness status epilepticus. The first 2 cases presented with histories of ingestion of eucalyptus oil. The third case had focal‐impaired awareness status epilepticus after topical application of various balms containing eucalyptus and camphor. Conclusions Proconvulsant essential oils of eucalyptus and camphor can cause both generalized and focal status epilepticus. Physicians dealing with patients of status epilepticus should enquire about the exposure to proconvulsant essential oils.

Objectives This study evaluates aerosol production with high flow nasal cannula (HFNC) and noninvasive positive pressure ventilation (NIPPV) compared to six liters per minute by low‐flow nasal cannula. Methods Two healthy volunteers were randomized to control (six liters per minute by low‐flow nasal cannula), NIPPV, or HFNC using block randomization. NIPPV conditions were studied using continuous positive airway pressures of 5, 10, and 15 cm H2O with an FiO2 of 1.0 delivered via full‐face mask. HFNC conditions included flow rates of 30 and 40 liters per minute with an FiO2 of 1.0 with and without coughing. HFNC and low‐flow nasal cannula conditions were repeated with and without participants wearing a surgical mask. Six aerosol sizes (0.3, 1.0, 2.5, 5, and 10 μm) and total aerosol mass were measured at two feet and six feet from the participant's nasopharynx. Results There was no significant difference in aerosol production between either HFNC or NIPPV and control. There was also no significant difference with the use of procedural mask over the HFNC. There was significant variation between the two participants, but in neither case was there a difference compared to control. There was an aerosol‐time trend, but there does not appear to be a difference between either flow rate, pressure, or control. Furthermore, there was no accumulation of total aerosol particles over the total duration of the experiment in both HFNC and NIPPV conditions. Conclusions HFNC and NIPPV did not increase aerosol production compared to six liters per minute by low‐flow nasal cannula in this experiment involving healthy volunteers. This article is protected by copyright. All rights reserved

The informative value of time and temporal structure often remains neglected in cognitive assessments. However, next to information about stimulus identity we can exploit temporal ordering principles, such as regularity, periodicity, or grouping to generate predictions about the timing of future events. Such predictions may improve cognitive performance by optimising adaptation to dynamic stimuli. Here, we investigated the influence of temporal structure on verbal working memory by assessing immediate recall performance for aurally presented digit sequences (forward digit span) as a function of standard (1000 ms stimulus-onset-asynchronies, SOAs), short (700 ms), long (1300 ms) and mixed (700-1300 ms) stimulus timing during the presentation phase. Participant's digit spans were lower for short and mixed SOA presentation relative to standard SOAs. This confirms an impact of temporal structure on the classic "magical number seven," suggesting that working memory performance can in part be regulated through the systematic application of temporal ordering principles.

Introduction SARS-CoV-2, a novel coronavirus, manifests as a respiratory syndrome (COVID-19) and is the cause of an ongoing pandemic. The response to COVID-19 in the United States has been hampered by an overall lack of diagnostic testing capacity. To address uncertainty about ongoing levels of SARS-CoV-2 community transmission early in the pandemic, we aimed to develop a surveillance tool using readily available emergency department (ED) operations data extracted from the electronic health record (EHR). This involved optimizing the identification of acute respiratory infection (ARI)-related encounters and then comparing metrics for these encounters before and after the confirmation of SARS-CoV-2 community transmission. Methods We performed an observational study using operational EHR data from two Midwest EDs with a combined annual census of over 80,000. Data were collected three weeks before and after the first confirmed case of local SARS-CoV-2 community transmission. To optimize capture of ARI cases, we compared various metrics including chief complaint, discharge diagnoses, and ARI-related orders. Operational metrics for ARI cases, including volume, pathogen identification, and illness severity, were compared between the preand post-community transmission timeframes using chi-square tests of independence. Results Compared to our combined definition of ARI, chief complaint, discharge diagnoses, and isolation orders individually identified less than half of the cases. Respiratory pathogen testing was the top performing individual ARI definition but still only identified 72.2% of cases. From the pre to post periods, we observed significant increases in ED volumes due to ARI and ARI cases without identified pathogen. Conclusion Certain methods for identifying ARI cases in the ED may be inadequate and multiple criteria should be used to optimize capture. In the absence of widely available SARS-CoV-2 testing, operational metrics for ARI-related encounters, especially the proportion of cases involving negative pathogen testing, are useful indicators for active surveillance of potential COVID-19 related ED visits.

Objectives In the 2016 Peace Accord with the Fuerzas Armadas Revolucionarias de Colombia (FARC), Colombia promised to reincorporate 14,000 ex‐combatants into the healthcare system. However, FARC ex‐combatants have faced significant challenges in receiving healthcare, and little is known about physicians’ abilities to address this population's healthcare needs. Methods An electronic questionnaire sent to the Colombian Emergency Medicine professional society and teaching hospitals assessed physicians’ knowledge, attitudes, and experiences with the FARC ex‐combatant reincorporation process. Results Among 53 participants, most were male (60.4%), and ∼25% were affected by the FARC conflict (22.6%). Overall knowledge of FARC reincorporation was low, with nearly two‐thirds of participants (61.6%) scoring in the lowest category. Attitudes around ex‐combatants showed low bias. Few physicians received training about reincorporation (7.5%), but 83% indicated they would like such training. Twenty‐two participants (41.5%) had identified a patient as an ex‐combatant in the healthcare setting. Higher knowledge scores were significantly correlated with training about reincorporation (r = 0.354, n = 53, P = 0.015), and experience identifying patients as ex‐combatants (r = 0.356, n = 47, P = 0.014). Conclusion Findings suggested high interest in training and low knowledge of the reincorporation process. Most physicians had low bias, frequent experiences with ex‐combatants, and cared for these patients when they self‐identify. The emergency department (ED) serves as an entrance into healthcare for this population and a potential setting for interventions to improve care delivery, especially those related to mental healthcare. Future studies could evaluate effects of care delivery following training on ex‐combatant healthcare reintegration.

Author(s): Mathews, Kusum S.; Rodriguez, Sandra M.; Nelson, Judith E.; Richardson, Lynne D. | Abstract: Introduction: We conducted a cross-sectional study at the Icahn School of Medicine at Mount Sinai to elicit emergency physician (EP) perceptions regarding intensive care unit (ICU) triage decisions and ongoing management for boarding of ICU patients in the emergency department (ED). We assessed factors influencing the disposition decision for critically ill patients in the ED to characterize EPs’ perceptions about ongoing critical care delivery in the ED while awaiting ICU admission.Methods: Through content expert review and pilot testing, we iteratively developed a 25-item written survey targeted to EPs, eliciting current ICU triage structure, opinions on factors influencing ICU admission decisions, and views on caring for critically ill patients “boarding” in the ED for g4-6 hours.Results: We approached 732 EPs at a large, national emergency medicine conference, achieving 93.6% response and completion rate, with 54% academic and 46% community participants. One-fifth reported having formal ICU admission criteria, although only 36.6% reported adherence. Common factors influencing EPs’ ICU triage decisions were illness severity (91.1%), ICU interventions needed (87.6%), and diagnosis (68.2%), while ICU bed availability (13.5%) and presence of other critically ill patients in ED (10.2%) were less or not important. While 72.1% reported frequently caring for ICU boarders, respondents identified high patient volume (61.3%) and inadequate support staffing (48.6%) as the most common challenges in caring for boarding ICU patients.Conclusion: Patient factors (eg, diagnosis, illness severity) were seen as more important than system factors (eg, bed availability) in triaging ED patients to the ICU. Boarding ICU patients is a common challenge for more than two-thirds of EPs, exacerbated by ED volume and staffing constraints.

Author(s): Ramaekers, Rosa; Perry, Jeffrey; Leafloor, Cameron; Thiruganasambandamoorthy, Venkatesh | Abstract: Introduction: There are currently no robust tools available for risk stratification of emergency department (ED) patients with lower gastrointestinal bleed (LGIB). Our aim was to identify risk factors and develop a preliminary model to predict 30-day serious adverse events among ED LGIB patients.Methods: We conducted a health records review including adult ED patients with acute LGIB. We used a composite outcome of 30-day all-cause death, recurrent LGIB, need for intervention to control the bleeding, and severe adverse events resulting in intensive care unit admission. One researcher collected data for variables and a second researcher independently collected 10% of the variables for inter-observer reliability. We used backward multivariable logistic regression analysis and SELECTION=SCORE option to create a preliminary risk-stratification tool. We assessed the diagnostic accuracy of the final model.Results: Of 372 patients, 48 experienced an adverse outcome. We found that age ≥75 years, hemoglobin ≤100 g/L, international normalized ratio ≥2.0, ongoing bleed in the ED, and a medical history of colorectal polyps were statistically significant predictors in the multivariable regression analysis. The area under the curve (AUC) for the model was 0.83 (95% confidence interval, 0.77-0.89). We developed a scoring system based on the logistic regression model and found a sensitivity 0.96 (0.90-1.00) and specificity 0.53 (0.48-0.59) for a cut-off score of 1.Conclusion: This model showed good ability to differentiate patients with and without serious outcomes as evidenced by the high AUC and sensitivity. The results of this study could be used in the prospective derivation of a clinical decision tool.

Author(s): Walter, Lauren A.; Leader, Elizabeth; Galbraith, James W. | Abstract: Introduction: A vaccine targeting high-risk human papillomavirus (HPV) strains can effectively prevent HPV-associated cervical cancer risk. However, many girls and women do not receive the vaccine, more often those impacted by health disparities associated with race and/or socioeconomic status. This same disparate population has also been shown to be at higher risk for cervical cancer. Many of these women also rely on the emergency department (ED) as a safety net for their healthcare. This study sought to gather information pertaining to HPV and cervical cancer risk factors, awareness of HPV and the vaccine, as well as HPV vaccine uptake in female patients presenting to an ED.Methods: We obtained 81 surveys completed by female ED patients. Demographics included age, race, income, insurance status, primary care provider status, and known cervical-cancer risk factors. Subsequent survey questions explored respondents’ knowledge, familiarity, and attitudes regarding HPV, cervical cancer, and the HPV vaccine, including vaccination uptake rates. We analyzed data using descriptive statistics and Fisher’s exact test.Results: Approximately one in seven respondents (14.8%) had never previously heard of HPV and 32.1% were unaware of the existence of a HPV vaccine. Minority patients, including those who were Black and Hispanic patients, low income patients, and uninsured and publicly insured patients were less likely to be aware of HPV and the vaccine and likewise were less likely to be offered and receive the vaccine. More than 60% of all respondents (61.3%) had never previously been offered the vaccine, and only 24.7% of all respondents had completed the vaccine series.Conclusion: Female ED patients may represent an at-risk cohort with relatively low HPV awareness and low HPV vaccine uptake. The ED could represent a novel opportunity to access and engage high-risk HPV populations.

The prediction of the estrogen receptor (ER) and androgen receptor (AR) activity of a compound is quite important to avoid the environmental exposures of endocrine-disrupting chemicals. The Estrogen and Androgen Receptor Database (EARDB, http://eardb.schanglab.org.cn/) provides a unique collection of reported ERα, ERβ, or AR protein structures and known small molecule modulators. With the user-uploaded query molecules, molecular docking based on multi-conformations of a single target will be performed. Moreover, the 2D similarity search against known modulators is also provided. Molecules predicted with a low binding energy or high similarity to known ERα, ERβ, or AR modulators may be potential endocrine-disrupting chemicals or new modulators. The server provides a tool to predict the endocrine activity for compounds of interests, benefiting for the ER and AR drug design and endocrine-disrupting chemical identification.