Search

Patients with advanced cancer generate 4 million visits annually to emergency departments (EDs) and other dedicated, high-acuity oncology urgent care centers. Because of both the increasing complexity of systemic treatments overall and the higher rates of active therapy in the geriatric population, many patients experiencing acute decompensations are frail and acutely ill. This article comprehensively reviews the spectrum of oncologic emergencies and urgencies typically encountered in acute care settings. Presentation, underlying etiology, and up-to-date clinical pathways are discussed. Criteria for either a safe discharge to home or a transition of care to the inpatient oncology hospitalist team are emphasized. This review extends beyond familiar conditions such as febrile neutropenia, hypercalcemia, tumor lysis syndrome, malignant spinal cord compression, mechanical bowel obstruction, and breakthrough pain crises to include a broader spectrum of topics encompassing the syndrome of inappropriate antidiuretic hormone secretion, venous thromboembolism and malignant effusions, as well as chemotherapy-induced mucositis, cardiomyopathy, nausea, vomiting, and diarrhea. Emergent and urgent complications associated with targeted therapeutics, including small molecules, naked and drug-conjugated monoclonal antibodies, as well as immune checkpoint inhibitors and chimeric antigen receptor T-cells, are summarized. Finally, strategies for facilitating same-day direct admission to hospice from the ED are discussed. This article not only can serve as a point-of-care reference for the ED physician but also can assist outpatient oncologists as well as inpatient hospitalists in coordinating care around the ED visit.

Background COVID-19 has disproportionately affected older adults. Frailty has been associated with impaired vaccine response in other vaccine types, but the impact of frailty on mRNA vaccine response is undefined. Methods Observational study of adults aged 55 and older from 1 U.S. health care system between January 22, 2021 and September 16, 2021 with self-reported Moderna or Pfizer COVID-19 mRNA vaccine and an electronic frailty index (eFI) score from their medical record (n = 1 677). Participants’ frailty status was compared with positive antibody detection (seroconversion) following full vaccination and subsequent loss of positive antibody detection (seroreversion) using logistic regression models. Results Of 1 677 older adults with median (interquartile range) age, 67 (62 and 72) years, and frailty status (nonfrail: 879 [52%], prefrail: 678 [40%], and frail: 120 [7.2%]), seroconversion was not detected in 23 (1.4%) over 60 days following full vaccination. Frail individuals were less likely to seroconvert than nonfrail individuals, adjusted odds ratio (OR) 3.75, 95% confidence interval (CI; 1.04, 13.5). Seroreversion was detected in 50/1 631 individuals (3.1%) over 6 months of median follow-up antibody testing. Frail individuals were more likely to serorevert than nonfrail individuals, adjusted OR 3.02, 95% CI (1.17, 7.33). Conclusion Overall antibody response to COVID-19 mRNA vaccination was high across age and frailty categories. While antibody detection is an incomplete descriptor of vaccine response, the high sensitivity of this antibody combined with health-system data reinforce our conclusions that frailty is an independent predictor of impaired antibody response to the COVID-19 mRNA vaccines. Frailty should be considered in vaccine studies and prevention strategies.

The aim of this research was to explore factors affecting the well-being and resilience of healthcare workers (HCWs) during COVID-19.Qualitative content analysis of survey responses to a single, open-ended question.The study took place in June and July 2020 in the Mid-Atlantic United States. Qualitative data from 452 HCWs were analysed with deductive content analysis, using a National Academy of Medicine model of factors affecting clinician well-being and resilience. The study is reported according to the Standards for Reporting Qualitative Research and the Consolidated Criteria for Reporting Qualitative Research.The findings reflect each of the seven domains of the National Academy of Medicine model, demonstrating the diverse factors that have impacted the well-being and resilience of HCWs during the COVID-19 pandemic. The results of the study show that factors within the workplace have significantly impacted the well-being and resilience of HCWs during the pandemic, in particular, the practice environment and the rules and regulations implemented by healthcare organizations. At the same time, individual and even societal factors have also affected well-being during the pandemic, but not to the same degree as factors within the workplace.The research findings illustrate how multiple, diverse factors have influenced the well-being and resilience of HCWs during the pandemic. The study has practical relevance for healthcare leaders and important implications for future research.Health system leaders can address the well-being and resilience of healthcare workers by implementing solutions that address health system factors like the practice environment and the policies and procedures of the organization. Researchers should not only focus on individual factors associated with professional well-being but must also expand research and interventional studies to include the system and environmental factors that significantly affect clinicians.

Background Wearing a face mask is a primary public health method to reduce SARS-CoV-2 transmission. We assessed the association between self-reported mask use and risk of COVID-19 infection during three periods of the pandemic. Methods We performed a nested case-control analysis within the NC-CCRP of adults ≥18 years who completed daily syndromic surveillance surveys from April 2020 through February 2022, comparing self-reported cases to controls who never self-reported a positive test. We matched up to 10 controls to each case on calendar time of self-reported positive test and corresponding daily survey entry. Not wearing a mask was defined as responding “no” at least once in the ten days preceding the match date to “In the last 24 hours, have you worn a face mask or face covering every time you interacted with others (not in your household) within a distance of less than 6 feet?” Conditional logistic regression models of risk of COVID-19 infection were adjusted for demographics, vaccination status, and recent known exposure to COVID-19. We tested any days not wearing a mask during the Pre-Delta (July 1 2020-June 30, 2021), Delta (July 1– November 30, 2021), and Omicron (December 1, 2021 – February 28, 2022) periods. Results Among 3,901 cases and 27,813 date-matched controls, there was a significant interaction between mask use and time period (p< 0.001). Prior to July 2021, the odds of a reported SARS-CoV-2 infection was 66% higher (aOR=1.66, 95% CI=1.43 – 1.91) among participants reporting at least one day not wearing a mask compared to those who reported no days (1592 cases, 11717 controls). During the Delta-predominant period, the results were similar (aOR=1.53, 95% CI=1.23 – 1.89; 659 cases, 4649 controls). This association was attenuated during the Omicron-predominant period, where the odds of a reported SARS-CoV-2 infection was 16% higher (aOR=1.16, 95% CI=1.03 – 1.32; 1563 cases, 10960 controls). Conclusion While the effect of not wearing a mask remains significant, during the Omicron-predominant period we observed a decrease in the association between self-reported mask wearing and risk of SARS-CoV-2 infection. The increased transmissibility of Omicron, pandemic fatigue, and increasing population immunity are possible contributing factors. Disclosures Michael S. Runyon, MD, MPH, Abbott Laboratories: Grant/Research Support|Roche Diagnostics Operations, Inc: Grant/Research Support.

Background We characterize the evolution of symptoms in those with self-reported SARS-CoV-2 infections and the likelihood of seeking treatment or medical care during different waves of the pandemic. Methods The NC-CCRP is a longitudinal observational study of 37,820 participants who completed a daily symptom log from April 2020 through February 2022, during which there were 5,167 self-reported COVID-19 infections. Three variant periods were defined as pre-delta, delta, and omicron, based on the predominant variant in North Carolina. Quasi-Poisson and logistic regression models adjusted for demographics and vaccination were used to assess COVID-19 symptoms and their duration and seeking treatment or hospitalization. Results Cough was the most reported symptom in all waves and increased from 77% pre-delta to 85% during omicron (p=0.001). Sore throat was more common during self-reported infections during omicron (71%), compared with 62% during delta and 54% pre-delta (p< 0.001). The largest change in proportion reporting a symptom was loss of taste or smell which decreased from 55% during pre-delta to 17% during omicron (p< 0.001). Compared with the pre-delta period, delta (incidence risk reduction, IRR 0.86; 95% CI 0.79-0.93) and omicron (IRR 0.67; 95% CI 0.61-0.73) were associated with lower symptom duration. Participants infected during the delta wave were more likely to seek treatment compared with either pre-delta (odds ratio, OR 1.32 95% CI 1.06-1.64) or omicron (OR 1.42; 95% CI 1.21-1.67). Omicron period infections were associated with a lower likelihood of self-reported hospitalization compared with pre-delta (OR 0.26; 95% CI 0.10-0.59) or delta (OR 0.26; 95% CI 0.11-0.60). Vaccination was associated with a reduced likelihood of hospitalization (OR 0.35; 95% CI 0.18-0.70). Proportion and Duration of Symptoms by Variant Wave; Unadjusted by Vaccination Status. Conclusion Our study indicates evolution in symptom presentation and duration by variant period. The omicron wave was associated with shorter duration and lower severity of illness. Longitudinal tracking of symptomology and severity of a novel pathogen provide insights into the evolution of the pathogen in the community and is vital for public health and clinical response. Disclosures All Authors: No reported disclosures.

Background The COVID-19 Community Research Partnership (CCRP) is a large multicenter healthcare system-based study of the COVID-19 pandemic, including factors impacting risk of infection and hospitalization. The CCRP includes a subset of immunocompromised (IC) participants with varying vaccination status over time. Methods We conducted an observational cohort study of 2,515 IC and 41,941 non-IC CCRP participants who contributed electronic health record data and daily electronic surveys to self-report COVID-19 symptoms, test results, and vaccinations from April 2020 to March 2022. The IC population included those with stem cell transplant, HIV, cancer, autoimmune disease, or solid organ transplant. The latter 3 must have also had an active systemic therapy to meet the IC condition (e.g. chemotherapy, immune modulator, steroid). Logistic regression was used to investigate risk of COVID-19 and hospitalization among IC participants and according to vaccine status within viral variant time periods (pre-delta, delta, omicron). Results IC conditions included cancer (51%), autoimmune (41%), solid organ/stem cell transplant (9%), and HIV (7%). The IC group was older and had more comorbidities. 95% of vaccine recipients received an mRNA vaccine. More vaccine breakthrough infections occurred in the IC group than non-IC group (36.1% vs 29.5%, p< 0.001). IC participants were less likely to remain COVID-19 free over time if vaccinated but not boosted (Fig 1A). However, after receiving a booster there was no difference in COVID-19 cases between the groups (Fig 1B). IC participants were more likely to be hospitalized with COVID-19 (OR 2.85; 95% CI 1.69–4.76), but vaccination reduced risk for hospitalization (OR 0.26; 95% CI 0.08–0.8). Receipt of a booster dose reduced risk of COVID-19 among IC participants during the delta wave (IRR 0.52; 95% CI 0.28–0.94) but not during omicron. However, during omicron risk of hospitalization in the IC group was reduced by a booster dose (OR 0.13; 95% CI 0.02–0.72). Conclusion IC individuals were at increased risk for COVID-19 hospitalizations and breakthrough infections. After receiving a booster, IC participants were conferred the same level of protection from infection as their non-IC counterparts, highlighting the importance of boosters for these individuals. Disclosures All Authors: No reported disclosures.

The aim of the study was to determine the impact of dual-task conditions on mobility after mild traumatic brain injury.Eleven adults with mild traumatic brain injury within 1 wk of injury and 10 age- and sex-matched healthy controls completed gait trials with a single-task condition and three separate dual-task conditions: counting by 1 (low), serial subtraction by 3 (medium), and alternating letters and numbers (high). Dual-task cost was calculated as dual-task cost = ([dual-task performance] - [single-task performance]) / [single-task performance] × 100%.Participants with mild traumatic brain injury ambulated slower than control subjects (P0.001). Significant differences in dual-task cost were noted for both group (P0.001) and dual-task condition (P = 0.005). Dual-task cost was greater for those with mild traumatic brain injury compared with controls with significant group differences for the low and high cognitive loads (P0.05). Only 1 of the 11 individuals with mild traumatic brain injury and 1 of the 10 controls demonstrated gait speed less than 80 cm/sec, which is predictive of community mobility, during any dual-task condition. Dual-task cost exceeded 11.9%, previously determined to be the minimal detectable change in healthy adults, for 9 of the 11 individuals with mild traumatic brain injury compared with 3 of the 10 controls.Dual-task cost may be a more sensitive measure for impairment during dual-task conditions than gait speed after mild traumatic brain injury.

Background: Obesity and T2D are risk factors for SARS-CoV-2 outcomes, but less is known about non-hospitalized cases. We hypothesized that those with obesity or T2D are more likely to have a positive Covid test, and among those with a positive test, to have symptoms. Methods: Among 31,117 North Carolina Covid Community Research Partnership participants with EHR data, we evaluated the association of self-reported and EHR obesity and T2D with a self-reported positive Covid test at any time. Among 2,418 participants with a positive test during the study, we evaluated the association of obesity and T2D with self-report of symptoms. Logistic regression models were adjusted for age, sex, race/ethnicity, socioeconomic status, and healthcare worker status. Results: We found a positive graded association between BMI category and positive Covid test, and a similar but weaker association with Covid symptoms among those with a positive test (Table) . T2D was associated with Covid infection but not symptoms. Conclusions: While the limitations of this health system convenience sample include generalizability and test seeking selection bias, the strong graded association of BMI and T2D with self-reported Covid infection suggests that obesity and T2D may play a role in risk for symptomatic SARS-CoV-2 beyond co-occurrence with socioeconomic risk factors. Disclosure M.Mongraw-chaffin: None. S.Edelstein: None. A.H.Tjaden: None. A.Seals: None. K.Miller: None. N.Ahmed: None. M.Espeland: None. M.A.Gibbs: None. D.Uschner: None. W.S.Weintraub: None. Funding The CARES Act of the U.S. Department of Health and Human Services (HHS) [Contract # NC DHHS GTS #49927].

Purpose To quantify the prevalence of opioid and benzodiazepine prescriptions for patients with rotator cuff disease across a large health care system and to describe evidence-based risk factors for opioid use within this population. Methods We conducted a retrospective cohort study at a major health care system of all patients with qualifying diagnostic codes. Emergency department, urgent care, and outpatient encounters between January and December 2016 for an acute rotator cuff tear, listed as the primary diagnosis, were included. Encounters with prescriptions for opioids or benzodiazepines were identified using the Prescription Reporting With Immediate Medication Utilization Mapping (PRIMUM) system. Descriptive statistics and the rate of controlled-substance prescribing were calculated for the population as a whole and among subgroups. Results We identified 9,376 encounters meeting the inclusion criteria. Of these encounters, 1,559 (16.6%) resulted in 1 or more prescriptions for an opioid or benzodiazepine that were issued during the visit. A total of 2,007 opioid and/or benzodiazepine prescriptions were issued for the 1,559 encounters (rate of 1.29 prescriptions per prescribing encounter). This represented 5,310 patients, of whom 1,096 (20.6%) received a prescription for an opioid or benzodiazepine during at least 1 of their encounters. Of patients who received a prescription, 20.9% had at least 1 risk factor for prescription misuse; 3.6% of patients had more than 1 risk factor. There were no demographic differences between patients with risk factors and patients without them. Conclusions The prescribing of opioids for the treatment of pain in patients with rotator cuff disease remains high across multiple locations and specialties within a large health care system. Using alternative pain management pathways as primary prevention for opioid misuse and abuse in high opioid-prescribing locations—and especially for patients identified as having a high risk of opioid misuse—is an important practice to continue in our shift away from opioid use as a health care system. Level of Evidence Level IV, case series.

Background Pelvic fractures represent a small percent of all skeletal injuries but are associated with significant morbidity and mortality secondary to hemodynamic instability from bleeding bone surfaces and disrupted pelvic vasculature. Stabilization of the pelvis prior to arrival at a treatment facility may mitigate the hemodynamic consequences of pelvic ring injuries and improve morbidity and mortality. Whether pelvic compression devices such as pelvic binders or sheets can be safely applied in the prehospital setting has not been well-studied. This study aims to evaluate the safety of applying a pelvic binder to at-risk patients in the field after scalable training and the feasibility of conducting a randomized trial evaluating this practice in the prehospital setting. Methods A pilot study (prospective randomized trial design) was conducted in the pre-hospital environment in an urban area surrounding a level-one trauma center. Pre-hospital emergency medical (EMS) personnel were trained to identify patients at high-risk for pelvic fracture and properly apply a commercial pelvic binder. Adult patients with a high-energy mechanism, suspected pelvic fracture, and “Priority 1” criteria were prospectively identified by paramedics and randomized to pelvic binder placement or usual care. Medical records were reviewed for safety outcomes. Secondary outcomes were parameters of efficacy including interventions needed to control hemorrhage (such as angioembolization and surgical control of bleeding) and mortality. Results Forty-three patients were randomized to treatment (binder: N=20; nonbinder: N=23). No complications of binder placement were identified. Eight patients (40%) had binders placed correctly at the level of the greater trochanter. Two binders (10%) were placed too proximally and 10 (50%) binders were not visualized on x-ray. Two binder group patients and three nonbinder group patients required angioembolization. None required surgical control of pelvic bleeding. Two nonbinder group patients and one binder group patient were readmitted within 30 days and one nonbinder group patient died within 30 days. Conclusion Identification of pelvic fractures in the field remains a challenge. However, a scalable training model for appropriate binder placement was successful without secondary injury to patients. The model for conducting prospective, randomized trials in the prehospital setting was successful.

The modified Sgarbossa criteria have been established to aid in the diagnosis of ST-elevation myocardial infarction in patients with left bundle branch block. Thus far, the sensitivities and specificities of the Sgarbossa signs have only been evaluated retrospectively in cohorts of patients with and without occlusive myocardial infarctions. These statistical analyses were based on correlating ST abnormalities with serum markers of myocardial injury and/or results of emergent cardiac catheterization. We present a patient with acute cardiovascular emergency where electrocardiograms revealed intermittent left bundle branch block. In serial ECGs, highly dynamic ST abnormalities on the narrow QRS beats were associated with similarly dynamic ST changes in the left bundle branch block beats. Our findings provided direct and real-time confirmation of the usefulness of the Sgarbossa and the modified Sgarbossa criteria in the diagnosis of acute ST elevation in patients with left bundle branch block.

OBJECTIVES: To evaluate whether a nurse navigator-led, multicomponent Sepsis Transition And Recovery program improves 30-day mortality and readmission outcomes after sepsis hospitalization. DESIGN: Multisite pragmatic randomized clinical trial. SETTING: Three hospitals in North Carolina from January 2019 to March 2020. PATIENTS: Eligible patients hospitalized for suspected sepsis and deemed high-risk for mortality or readmission by validated internal risk models. INTERVENTIONS: Patients were randomized to receive usual care alone (i.e., routine transition support, outpatient care; n = 342) or additional Sepsis Transition And Recovery support (n = 349). The 30-day intervention involved a multicomponent transition service led by a nurse navigator through telephone and electronic health record communication to facilitate best practice postsepsis care strategies during and after hospitalization including: postdischarge medication review, evaluation for new impairments or symptoms, monitoring comorbidities, and palliative care approach when appropriate. Clinical oversight was provided by a Hospital Medicine Transition Services team. MEASUREMENTS AND MAIN RESULTS: The primary outcome was a composite of mortality or hospital readmission at 30 days. Logistic regression models were constructed to evaluate marginal and conditional odds ratios (adjusted for prognostic covariates: age, comorbidity, and organ dysfunction at enrollment). Among 691 randomized patients (mean age = 63.7 ± 15.1 yr; 52% female), a lower percentage of patients in the Sepsis Transition And Recovery group experienced the primary outcome compared with the usual care group (28.7% vs 33.3%; risk difference, 4.7%; odds ratio, 0.80; 95% Cl, 0.58–1.11; adjusted odds ratio, 0.80; 95% Cl, 0.64–0.98). There were 74 deaths (Sepsis Transition And Recovery: 33 [9.5%] vs usual care: 41 [12.0%]) and 155 rehospitalizations (Sepsis Transition And Recovery: 71 [20.3%] vs usual care: 84 [24.6%]). CONCLUSIONS: In a multisite randomized clinical trial of patients hospitalized with sepsis, patients provided with a 30-day program using a nurse navigator to provide best practices for postsepsis care experienced a lower proportion of either mortality or rehospitalization within 30 days after discharge. Further research is needed to understand the contextual factors associated with successful implementation.

Coronavirus Disease-2019 (COVID-19) vaccine acceptance is variable. We surveyed participants in the COVID-19 Community Research Partnership from 17 December 2020 to 13 January 2021 to assess vaccine receptiveness. Vaccine uptake was then monitored until 15 May 2021; 20,232 participants responded to the receptiveness survey with vaccination status accessed in 18,874 participants via daily follow-up surveys (participants not completing daily surveys ≥30 days to 15 May 2021, were excluded). In the initial survey, 4802 (23.8%) were vaccine hesitant. Hesitancy was most apparent in women (Adjusted RR 0.93, p < 0.001), Black Americans (Adjusted RR 1.39, 1.41, 1.31 to non-Hispanic Whites, Other, and Hispanic or Latino, respectively p < 0.001), healthcare workers (Adjusted RR 0.93, p < 0.001), suburbanites (ref. Urban Adjusted RR 0.85, 0.90 to urban and rural dwellers, respectively, p < 0.01), and those previously diagnosed with COVID-19 (RR 1.20, p < 0.01). Those p < 0.0001), 78% (Adjusted RR 0.83, p < 0.0001), and 52.7% (Adjusted RR 0.65, p < 0.0001), respectively. These findings suggest that initial intent did not correlate with vaccine uptake in our cohort.

Cocaine is one of the most widely used illicit drugs in the U.S. [1]. We present a case of fatal cardiac arrest following cocaine abuse. The patient’s electrocardiograms demonstrated malignant dysr...

OBJECTIVES Addiction and overdose related to prescription drugs continues to be a leading cause of morbidity and mortality in the United States. We aimed to characterize the prescribing of opioids and benzodiazepines to patients who had previously presented with an opioid or benzodiazepine overdose. METHODS This was a retrospective chart review of patients who were prescribed an opioid or benzodiazepine in a 1-month time-period in 2015 (May) and had a previous presentation for opioid or benzodiazepine overdose at a large healthcare system. RESULTS We identified 60,129 prescribing encounters for opioids and/or benzodiazepines, 543 of which involved a patient with a previous opioid or benzodiazepine overdose. There were 404 unique patients in this cohort, with 97 having more than 1 visit including a prescription opioid and/or benzodiazepine. A majority of prescriptions (54.1%) were to patients with an overdose within the 2 years of the documented prescribing encounter. Prescribing in the outpatient clinical setting represented half (49.9%) of encounters, whereas emergency department prescribing was responsible for nearly a third (31.5%). CONCLUSIONS In conclusion, prescribing of opioids and benzodiazepines occurs across multiple locations in a large health care system to patients with a previous overdose. Risk factors, such as previous overdose should be highlighted through clinical decision support tools in the medical record to help prescribers identify patients at higher risk and to mobilize resources for this patient population. Prescribers need further education on factors that place their patients at risk for opioid use disorder and on alternative therapies to opioids and benzodiazepines.

Willingness to receive the newly developed Coronavirus Disease-2019 (COVID-19) vaccines is highly variable. To assess the receptiveness of a select sample of North Carolinians to COVID-19 vaccination, a brief survey was conducted among participants in the COVID-19 Community Research Partnership (CCRP) affiliated with five medical centers in North Carolina. A total of 20,232 CCRP participants completed a multiple choice, mini survey electronically between December 17, 2020 and January 13, 2021. Of the 20,232 survey respondents, 15,422 (76.2%) were receptive to vaccination. Vaccine receptiveness increased incrementally with age with those >70 years being the most willing to be vaccinated compared to all other age groups. Respondents with no previous COVID-19 diagnosis were more likely to accept the vaccine compared to those that have a previous COVID-19 diagnosis (76.6% vs 60.9%). Comparative analysis of gender, race/ethnicity, and residence locale revealed that women, African Americans, and suburban participants were less willing to get a COVID-19 vaccine. There was no difference in vaccine intent based on healthcare worker status. Of those unwilling to get the vaccine, 82% indicated that the reason was uncertainty about the safety and efficacy of the vaccine.

Opioids are frequently used for acute pain management of musculoskeletal injuries, which can lead to misuse and abuse. This study aimed to identify the opioid prescribing rate for ankle fractures treated nonoperatively in the ambulatory and emergency department setting across a single healthcare system and to identify patients considered at high risk for abuse, misuse, or diversion of prescription opioids that received an opioid. A retrospective cohort study was performed at a large healthcare system. The case list included nonoperatively treated emergency department, urgent care and outpatient clinic visits for ankle fracture and was merged with the Prescription Reporting With Immediate Medication Mapping (PRIMUM) database to identify encounters with prescription for opioids. Descriptive statistics characterize patient demographics, treatment location and prescriber type. Rates of prescribing among subgroups were calculated. There were 1,324 patient encounters identified, of which, 630 (47.6%) received a prescription opioid. The majority of patients were 18-64 years old (60.3%). Patients within this age range were more likely to receive an opioid prescription compared to other age groups (p < .0001). Patients treated in the emergency department were significantly more likely to receive an opioid medication (68.3%) compared to patients treated at urgent care (33.7%) or in the ambulatory setting (16.4%) (p < .0001). Utilizing the PRIMUM tool, 14.2% of prescriptions were provided to patients with at least one risk factor. Despite the recent emphasis on opioid stewardship, 14.2% of patients with risk factors for misuse, abuse, or diversion received opioid analgesics in this study, identifying an area of improvement for prescribers.

Introduction The COVID-19 Community Research Partnership is a population-based longitudinal syndromic and sero-surveillance study. The study includes over 17,000 participants from six healthcare systems in North Carolina who submitted over 49,000 serology results. The purpose of this study is to use these serology data to estimate the cumulative proportion of the North Carolina population that has either been infected with SARS-CoV-2 or developed a measurable humoral response to vaccination. Methods Adult community residents were invited to participate in the study between April 2020 and February 2021. Demographic information was collected and daily symptom screen was completed using a secure, HIPAA-compliant, online portal. A portion of participants were mailed kits containing a lateral flow assay to be used in-home to test for presence of anti-SARS-CoV-2 IgM or IgG antibodies. The cumulative proportion of participants who tested positive at least once during the study was estimated. A standard Cox proportional hazards model was constructed to illustrate the probability of seroconversion over time up to December 20, 2020 (before vaccines available). A separate analysis was performed to describe the influence of vaccines through February 15, 2021. Results 17,688 participants contributed at least one serology result. 68.7% of the population were female, and 72.2% were between 18 and 59 years of age. The average number of serology results submitted per participant was 3.0 (±1.9). By December 20, 2020, the overall probability of seropositivity in the CCRP population was 32.6%. By February 15, 2021 the probability among healthcare workers and non-healthcare workers was 83% and 49%, respectively. An inflection upward in the probability of seropositivity was demonstrated around the end of December, suggesting an influence of vaccinations, especially for healthcare workers. Among healthcare workers, those in the oldest age category (60+ years) were 38% less likely to have seroconverted by February 15, 2021. Conclusions Results of this study suggest more North Carolina residents may have been infected with SARS-CoV-2 than the number of documented cases as determined by positive RNA or antigen tests. The influence of vaccinations on seropositivity among North Carolina residents is also demonstrated. Additional research is needed to fully characterize the impact of seropositivity on immunity and the ultimate course of the pandemic.

IntroductionThe COVID-19 Community Research Partnership is a population-based longitudinal syndromic and sero-surveillance study. The study includes over 17,000 participants from six healthcare systems in North Carolina who submitted over 49,000 serology results. The purpose of this study is to use these serology data to estimate the cumulative proportion of the North Carolina population that has either been infected with SARS-CoV-2 or developed a measurable humoral response to vaccination.MethodsAdult community residents were invited to participate in the study between April 2020 and February 2021. Demographic information was collected and daily symptom screen was completed using a secure, HIPPA-compliant, online portal. A portion of participants were mailed kits containing a lateral flow assay to be used in-home to test for presence of anti-SARS-CoV-2 IgM or IgG antibodies. The cumulative proportion of participants who tested positive at least once during the study was calculated. A standard Cox proportional hazards model was constructed to illustrate the probability of seroconversion over time up to December 20, 2020 (before vaccines available). A separate analysis was performed to describe the influence of vaccines during an extended period through February 15, 2021.Results17,688 participants contributed at least one serology result. Approximately two-thirds of the population were female and almost three-quarters were between 30 and 64 years of age. The average number of serology test results submitted per participant was 3.0 (±1.9). At December 20, 2020, the overall probability of seropositivity in the CCRP population was 32.6%. At February 15, 2021 the probability among healthcare workers and non-healthcare workers was 83% and 49%, respectively. An inflection upward in the probability of seropositivity was demonstrated around the end of December, suggesting an influence of vaccinations, especially for healthcare workers. Among healthcare workers, those in the oldest age category (60+ years) were 38% less likely to have seroconverted by February 15, 2021.ConclusionsResults of this study suggest more North Carolina residents may have been infected with SARS-CoV-2 than the number of documented cases as determined by positive RNA or antigen tests. The influence of vaccinations on seropositivity among North Carolina residents is also demonstrated. Additional research is needed to fully characterize the impact of seropositivity on immunity and the ultimate course of the pandemic.

Background Estimating population prevalence and incidence of prior SARS-CoV-2 infection is essential to formulate public health recommendations concerning the COVID-19 pandemic. However, interpreting estimates based on sero-surveillance requires an understanding of the duration of elevated antibodies following SARS-CoV-2 infection, especially in the large number of people with pauci-symptomatic or asymptomatic disease. Methods We examined > 30,000 serology assays for SARS-CoV-2 specific IgG and IgM assays acquired longitudinally in 11,468 adults between April and November 2020 in the COVID-19 Community Research Partnership. Results Among participants with serologic evidence for infection but few or no symptoms or clinical disease, roughly 50% sero-reverted in 30 days of their initial positive test. Sero-reversion occurred more quickly for IgM than IgG and for antibodies targeting nucleocapsid protein compared with spike proteins, but was not associated with age, sex, race/ethnicity, or healthcare worker status. Conclusions The short duration of antibody response suggests that the true population prevalence of prior SARS-CoV-2 infection may be significantly higher than presumed based on earlier sero-surveillance studies. The impact of the large number of minimally symptomatic COVID-19 cases with only a brief antibody response on population immunity remains to be determined.

Background It is vital for frontline emergency physicians to immediately recognize the signs and symptoms of measles to initiate appropriate therapy and prevent spread to the health care team and other patients. Objective This review serves as a clinically practical updated reference for when the differential diagnosis includes measles. Discussion Measles is a highly contagious illness that classically presents with a rash, fever, cough, coryza, and conjunctivitis. Cases in the United States since 2000 have been attributed mainly to travelers who are infected abroad and then spread the illness to small, susceptible populations within the United States. Complications from measles are relatively common and can be associated with significant morbidity and mortality. Clinical suspicion should be confirmed with laboratory testing, which is most commonly a serum immunoglobulin M. The management of measles is mainly supportive. Patients that require more aggressive management include those who are pregnant, immunocompromised, or unvaccinated. Treatment may consist of the measles vaccine, intravenous immunoglobulin, vitamin A, and even ribavirin. Additionally, special precautions are required by hospital workers to help prevent the spread of the virus, which include N-95 masks and patient isolation in an airborne infection isolation room. Conclusion Emergency physicians must be readily able to identify, contain patients with suspected measles, and determine who will need further medical management for this potentially life-threatening illness. As this public health crisis evolves, novel ways of screening for and reporting cases of measles is needed.

Background Traumatic tension pneumocephalus is a rare complication after craniofacial fractures that can cause devastating neurologic deficits if not managed promptly and effectively. Case Report A 38-year-old man with no past medical history presented to the Emergency Department (ED) after a motor vehicle crash. He was noted to have an open frontal scalp laceration. Computed tomography (CT) revealed a right frontal subdural hematoma and right medial frontal contusion. There was also a frontal bone fracture extending through the frontal sinus with mild underlying pneumocephalus. He was monitored for cerebrospinal fluid (CSF) leak and was subsequently discharged on postinjury day 9. He re-presented to the ED 14 days post injury with lethargy, confusion, headache, and swelling around his scalp laceration. A CT scan was obtained that revealed a large-volume intraparenchymal pneumocephalus (pneumocerebri) with mass effect and midline shift. The patient was started on 100% oxygen and admitted to the intensive care unit. He was taken to the operating room for evacuation of the pneumocerebri, repair of dural defect, placement of a vascularized pericranial graft, and placement of a lumbar drain. His lumbar drain was removed on postoperative day 3 and he was discharged home neurologically intact on postoperative day 6. At 1 month follow-up he had no evidence of CSF leak and was neurologically intact. Why Should an Emergency Physician Be Aware of This? This case is presented to increase awareness among emergency physicians that traumatic tension pneumocephalus, and in this case, pneumocerebri, is a rare life-threatening neurosurgical emergency in patients with severe craniofacial fractures after blunt or penetrating head trauma. Early temporizing measures in the ED, such as 100% oxygen via nonrebreather face mask, and urgent neurosurgical consultation are indicated to prevent neurologic deterioration.

The evaluation and treatment of wide QRS-complex tachycardia remains a challenge, and mismanagement is quite common. Diagnostic aids such as wide-complex tachycardia algorithms perform poorly in the real-life setting. The purpose of this review is to offer a simple clinical-electrocardiographic approach for the initial evaluation and management of the adult patient with stable wide-complex tachycardia that does not require recollection of complex guidelines or algorithms.

Introduction The National Emergency X-Radiography Utilization Study (NEXUS) clinical decision rule is extremely sensitive for clearance of cervical spine (C-spine) injury in blunt trauma patients with distracting injuries. Objectives We sought to determine whether the NEXUS criteria would maintain sensitivity for blunt trauma patients when femur fractures were not considered a distracting injury and an absolute indication for diagnostic imaging. Methods We retrospectively analyzed blunt trauma patients with at least 1 femur fracture who presented to our emergency department as trauma activations from 2009 to 2011 and underwent C-spine injury evaluation. Presence of C-spine injury requiring surgical intervention was evaluated. Results Of 566 trauma patients included, 77 (13.6%) were younger than 18 years. Cervical spine injury was diagnosed in 53 (9.4%) of 566. A total of 241 patients (42.6%) had positive NEXUS findings in addition to distracting injury; 51 (21.2%) of these had C-spine injuries. Of 325 patients (57.4%) with femur fractures who were otherwise NEXUS negative, only 2 (0.6%) had C-spine injuries (95% confidence interval [CI], 0.2%-2.2%); both were stable and required no operative intervention. Use of NEXUS criteria, excluding femur fracture as an indication for imaging, detected all significant injuries with a sensitivity for any C-spine injury of 96.2% (95% CI, 85.9%-99.3%) and negative predictive value of 99.4% (95% CI, 97.6%-99.9%). Conclusions In our patient population, all significant C-spine injuries were identified by NEXUS criteria without considering the femur fracture a distracting injury and indication for computed tomographic imaging. Reconsidering femur fracture in this context may decrease radiation exposure and health care expenditure with little risk of missed diagnoses.

Background Spontaneous celiac artery dissection is a rare visceral artery dissection that typically presents with acute abdominal or flank pain. Case report We describe a case of a 54-year old previously healthy male who presented to the Emergency Department with subacute back pain and was found to have a spontaneous celiac artery dissection. Why should an emergency physician be aware of this? Emergency medicine physicians frequently consider acute aortic dissection in patients presenting to the Emergency Department with acute chest, back, and/or upper abdominal pain. Less commonly thought of are variations of arterial dissection, including those involving the celiac artery. Given readily available diagnostic imaging modalities and therapeutic interventions, it remains important to consider visceral arterial dissection, and to recognize the varied clinical manifestations of this rare clinical entity.

Severe hyperkalemia is a hazardous condition that warrants urgent intervention. In critically ill patients, the electrocardiogram (ECG) can be the most immediately available diagnostic tool in identifying patients with potentially lethal hyperkalemia. Peaking of the T waves, the most widely appreciated ECG sign, is actually rarely a manifestation of life-threatening hyperkalemia. In this review, we provide several clinical-electrocardiographic manifestations that can help identify those patients with hyperkalemia who require prompt intervention.

BACKGROUND: The ABCs of trauma resuscitation begin with the airway evaluation, and effective airway management is imperative in the care of a patient with critical injury. The Eastern Association for the Surgery of Trauma Practice Management Guidelines committee aimed to update the guidelines for emergency tracheal intubation (ETI) published in 2002. These guidelines were made to assist clinicians with decisions regarding airway management for patients immediately following traumatic injury. The goals of the work group were to develop evidencebased guidelines to (1) characterize patients in need of ETI and (2) delineate the most appropriate procedure for patients undergoing ETI. METHODS: A search of the National Library of Medicine and the National Institutes of Health MEDLINE database was performed using PubMed (www.pubmed.gov). RESULTS: The search retrieved English-language articles published from 2000 to 2012 involving patients who had sustained blunt trauma, penetrating trauma, or heat-related injury and had developed respiratory system insufficiency or required ETI in the immediate period after injury (first 2 hours after injury). Sixty-nine articles were used to construct this set of practice management guidelines. CONCLUSION: The data supported the formation of six Level 1 recommendations, four Level 2 recommendations, and two Level 3 recommendations. In summary, the decision to intubate a patient following traumatic injury is based on multiple factors, including the need for oxygenation and ventilation, the extent and mechanism of injury, predicted operative need, or progression of disease. Rapid sequence intubation with direct laryngoscopy continues to be the recommended method for ETI, although the use of airway adjuncts such as blind insertion supraglottic devices and video laryngoscopy may be useful in facilitating successful ETI and may be preferred in certain patient populations. There is no pharmacologic induction agent of choice for ETI; however, succinylcholine is the neuromuscular blockade agent recommended for rapid sequence intubation. (J Trauma Acute Care Surg. 2012;73: S333YS340. Copyright * 2012 by Lippincott Williams & Wilkins)

Trauma remains a leading cause of mortality in the USA.1 In 2016, the American College of Emergency Physicians (ACEP) and the American College of Surgeons Committee on Trauma were major stakeholders in the National Academy of Science, Engineering and Medicine report that suggested there are up to 30 000 preventable deaths from trauma annually in the USA, many from uncontrolled hemorrhage.2 As the front-line provider, the emergency physician (EP) must receive extensive training in the care of traumatically injured patients. Several procedural interventions, including the performance of an emergency department resuscitative thoracotomy (EDRT), ultrasound, and arterial catheter insertion, are therefore included as part of the model of clinical practice for emergency medicine (EM).3 Resuscitative endovascular balloon occlusion of the aorta (REBOA)4 has emerged as a potential technique for controlling previously lethal truncal hemorrhage in the extremis trauma patient. Advances in ultrasound and catheter technology have simplified placement, decreasing the need for postplacement vascular access site repair. Programs to educate providers in the use of REBOA have emerged, but have been designed exclusively for surgeons with limited ability for EP participation. We strongly think that with appropriate training, EPs can develop the …

Relationships between physicochemical drug properties and toxicity were inferred from a data set consisting of animal in vivo toleration (IVT) studies on 245 preclinical Pfizer compounds; an increased likelihood of toxic events was found for less polar, more lipophilic compounds. This trend held across a wide range of types of toxicity and across a broad swath of chemical space.

This article presents an evaluation of the Bridging the Digital Divide Program, an intervention in five inner-city Chicago Catholic schools during one school year conducted by a local university. The interventions included (a) instillation of technology and (b) professional technology skill development for in-service teachers. The analysis indicates that (a) in-service teachers who participated in the workshops did increase their understanding of specific technology, (b) in-service teachers who did not participate also increased their use of technology, (c) students increased their use of technology and skill development, and (d) professional development programs need to address issues for in-service teachers at all levels of skill development.

We tested the hypothesis that retardation of aging by caloric restriction is due in part to decreased levels of plasma glucose over the life span. Male C57BL/6 mice expressing a human GLUT4 minigene (transgenic [TG] mice) and their nontransgenic littermates (NTG mice) were maintained under specific pathogen-free conditions. Mice were fed ad libitum (A mice) or 40% less than ad libitum (R mice) from age 6 weeks. Over the life span there were three different levels of plasma glucose, with NTGA mice having the highest daily levels, TGR mice the lowest daily values, and TGA and NTGR mice having similar levels intermediate between these values. Despite differences in plasma glucose, the differences measured in longevity (50% and 10% survival), physiology and tissue pathology were associated with diet rather than with levels of plasma glucose. We conclude that decreased plasma glucose over the life span is not an important factor in the action of calorie restriction on aging processes.

Resuscitation after hemorrhage with crystalloid solutions can lead to marked acidosis and iatrogenically worsen the lethal triad. The effect of differing solutions on base deficit and lactate has been sparsely prospectively studied in humans. We sought to quantify the effect of normal saline (NS) and lactated Ringer's (LR) resuscitation in voluntary blood donors as a model for Class I hemorrhage.A prospective randomized control trial was conducted in conjunction with blood drives. Donors were randomized to receive no intravenous fluid (noIVF), 2-L NS, or 2-L LR after blood donation of 500 mL. Lactate and base deficit were measured before and after fluid administration using an iSTAT. The mean laboratory values were compared between groups first using a global test followed by pairwise testing between groups using the Wilcoxon rank-sum and Kruskal-Wallis tests. The Bonferroni correction was used and a statistical significance of p0.0167 was set.A total of 157 patients completed the study. The mean (SD) age was 39.2 (12.7), and 65.0% were female. Patients in each group lost equivalent amounts of total blood volume, and a similar amount was replaced in the crystalloid group (p0.0167). Donors had comparable increases in lactate and base deficit after donation regardless of the group (p0.0167). After resuscitation with 2-L crystalloid, the lactate level increased higher in the LR group than in the noIVF or the NS group (1.36 mmol/L vs. 1.00 mmol/L vs. 1.54 mmol/L, p0.0001). In addition, the resuscitation base deficit increased in the NS group more than in the noIVF or LR group (-0.65 vs. -3.06 vs. -0.34, p0.0001).This study is one of the first human studies to prospectively demonstrate quantifiable differences in base deficit and lactate by type of crystalloid resuscitation. LR resuscitation elevated lactate levels, and NS negatively affected the base deficit. These findings are critical to the interpretation of trauma patient resuscitation with crystalloid solutions.Therapeutic study, level II.

Although rapid bedside toxicological screening is reliable, it has not been validated in the emergency department (ED) setting. We assessed the accuracy of a 10-min bedside immunoassay, Triage Panel (TP), for 7 drugs of abuse and tricyclic antidepressants (TCA) in ED patients suspected of drug toxicity. This was a prospective observational study conducted at an urban teaching ED (100,000 visits/year) of patients suspected of drug toxicity during a 7-month period. The assay was compared for agreement with combined SYVA EMIT and TLC. GC/MS or HPLC was used for analyzing sensitivity and specificity in discordant findings. A total of 172 cases (ages 0.6-73 years) were screened with TP, and 100 (58%) were found to be positive for at least one drug. Sensitivity (proportion and 95% CI) was as follows: cocaine 30/31 (90.6-100%), phencyclidine no cases, THC 21/24 (80.1-94.3), opiates 14/14 (100), amphetamines 1/1 (NA), barbiturates 10/10 (100), benzodiazepines 20/21 (90.5-99.9), and TCA 13/13 (100). Specificity was above 98% for every drug except TCAs (which was 95%), partly due to interference from iminostilbene (a carbamazepine metabolite) in three cases. Agreement between TP and hospital laboratory was over 90% for every drug class. Both benzodiazepines and THC showed significant disagreement between the two testing modalities. In conclusion, in a series of ED patients suspected of drug toxicity, the TP was an accurate tool to rule out the presence of seven drugs of abuse and TCAs. Further testing will be required to verify the efficacy of the test in populations with a higher prevalence of phencyclidine and amphetamine abuse.

The authors report the results of a survey on technology access and use in both religious and nonsectarian schools in the state of Illinois. Four hundred surveys were sent to a cross section of private schools, with a response rate of 45%. The study demonstrates there were only minimal differences between sectarian and nonsectarian schools and that they both had adequate, up-to-date equipment. Most schools provided their students and faculty with access to computer/internet technology in dedicated labs, media centers, and classrooms. The study does show that while both religious and nonsectarian private schools have the tools to integrate technology into the curriculum, and principals who positively rate the use of computer technology, most principals report that a majority of their teachers do not make use of technology in ways that promote higher-order thinking.