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STUDY OBJECTIVE: Public bikeshare programs are becoming increasingly common in the United States and around the world. These programs make bicycles accessible for hourly rental to the general public. We seek to describe the prevalence of helmet use among adult users of bikeshare programs and users of personal bicycles in 2 cities with recently introduced bikeshare programs (Boston, MA, and Washington, DC). METHODS: We performed a prospective observational study of adult bicyclists in Boston, MA, and Washington, DC. Trained observers collected data during various times of the day and days of the week. Observers recorded the sex of the bicycle operator, type of bicycle, and helmet use. All bicycles that passed a single stationary location in any direction for a period of between 30 and 90 minutes were recorded. RESULTS: There were 43 observation periods in 2 cities at 36 locations; 3,073 bicyclists were observed. There were 562 (18.3%; 95% confidence interval [CI] 16.4% to 20.3%) bicyclists riding shared bicycles. Overall, 54.5% of riders were unhelmeted (95% CI 52.7% to 56.3%), although helmet use varied significantly with sex, day of use, and type of bicycle. Bikeshare users were unhelmeted at a higher rate compared with users of personal bicycles (80.8% versus 48.6%; 95% CI 77.3% to 83.8% versus 46.7% to 50.6%). Logistic regression, controlling for type of bicycle, sex, day of week, and city, demonstrated that bikeshare users had higher odds of riding unhelmeted (odds ratio [OR] 4.4; 95% CI 3.5 to 5.5). Men had higher odds of riding unhelmeted (OR 1.6; 95% CI 1.4 to 1.9), as did weekend riders (OR 1.3; 95% CI 1.1 to 1.6). CONCLUSION: Use of bicycle helmets by users of public bikeshare programs is low. As these programs become more popular and prevalent, efforts to increase helmet use among users should increase. [ABSTRACT FROM AUTHOR]

Background: In an era of increasing health care costs, the need for hospitalization is being scrutinized. In particular, 1-day hospitalizations are thought to be especially costly and unnecessary, and, increasingly, emergency department observation units (EDOUs) are being used as alternatives., Objective: Our aim was to determine the differences in outcomes and diagnoses between 1-day inpatient and EDOU stays for syncope., Methods: We retrospectively reviewed a cohort of patients with syncope who were seen in an urban ED with 1-day admission to an inpatient ward, EDOU, or full hospitalization. Etiology of syncope was classified as benign (vasovagal, dehydration), serious (dysrhythmia, sepsis, stroke/intracranial bleed, hemorrhage, valvular, ischemia, pulmonary embolism), or unknown. Data were analyzed using Fisher's exact test and t-test., Results: One hundred and seventy-two of 351 patients were >1-day admissions, 152 (85%) were admitted for 1 day, and 27 (15%) were admitted to EDOU. The mean (standard deviation [SD]) age when admitted to the hospital was significantly higher at 72 (18.4) years for > 1-day admissions and 68.8 (19.6) years for 1-day admissions vs. 53.0 (18.9) years for EDOU patients (p < 0.01). For fully admitted patients, 36% had benign etiologies of syncope and 38% had serious causes of syncope; in 1-day admitted patients, 48% had benign etiologies and 14% had serious causes. Among EDOU patients, 44% had benign etiologies and none were serious. One-day patients were more likely to have unknown causes of syncope at discharge (36%; 95% confidence interval 0.28 to 0.43) when compared with admitted patients (26%; 95% CI 0.2 to 0.33); similarly, observation patients were more likely to be discharged without a diagnosis (56%; 95% CI 0.37 to 0.74; p ≤ 0.05)., Conclusions: EDOU patients were less likely than patients admitted to the hospital to be discharged with an etiology of their syncope. Future EDOU protocols can benefit from set admission criteria and standardized evaluation protocols to facilitate maximal use of EDOU for syncope., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Emergency department observation units (EDOU) are often used for patients with cellulitis to provide intravenous antibiotics followed by a transition to an oral regimen for discharge. Because institutional regulations typically limit EDOU stays to 24 hours, patients lacking a clinical response within this period will often be subsequently admitted to the hospital for further treatment., Objective: The aim of this study was to determine the rate of hospital admission and characteristics predictive of admission in patients with cellulitis who are initially placed in an ED observation unit., Methods: A retrospective cohort study of patients placed into EDOU with a diagnosis of skin infection was conducted. Age, sex, history of diabetes mellitus, immunosuppression, intravenous drug use, location of cellulitis, presence of abscess, laboratory infectious markers, vital signs, and outpatient antibiotic treatment were recorded. The primary outcome was a hospital admission due to failure to respond to treatment within the 24-hour observation time window. Significant variables on univariate analysis were used to create a multivariate analysis, which identified predictive characteristics., Results: Four hundred six patient charts were reviewed, with 377 meeting inclusion criteria; the inpatient admission rate from EDOU was 29.2%. Using logistic regression techniques, we created a model of independent predictors for need of admission after 24 hours: cellulitis of the hand (odds ratio [OR], 2.9; 95% confidence interval [CI], 1.8-4.9), measured temperature higher than 100.4°F (OR, 2.5; 95% CI, 1.1-5.5), and lactate greater than 2 (OR, 3.1; 95% CI, 1.3-7.3) were predictive of failure of ED observation., Conclusions: Patients with cellulitis placed into ED observation status were more likely to fail an observation trial if they had an objective fever in the ED, an elevated lactate, or a cellulitis that involved the hand., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objectives: The objective of this study is to determine whether creatine kinase-MB (CK-MB) index (CK-MBi) is useful in the evaluation of acute myocardial infarction (AMI) in patients with indeterminate troponin (Tn) in the emergency department (ED)., Methods: A retrospective cohort study was conducted of patients at an urban academic ED with over 55 000 annual visits who underwent Tn T (Roche, Indianapolis, IN) and CK-MB testing. One year of ED patients who had Tn testing were identified, and their corresponding CK-MBi was examined to find patients with indeterminate Tn (0.01-0.09) and positive CK-MBi (>6.0). Subsequent cardiac enzymes and hospital course were reviewed to identify patients diagnosed with AMI. A 95% confidence interval around point estimates were used in data analysis., Results: Over 1 year, 11 718 initial Tn were identified. Indeterminate Tn was seen in 2512 cases. Of these, 28 had positive CK-MBi. Of the 28, 5 were judged by treating physicians to be having AMI and underwent cardiac catheterization. Of the 5 patients, 4 had subsequent positive Tns on serial enzyme testing. One of the patients thought to be having AMI had no coronary artery disease on catheterization. The rate of true positive CK-MBi with indeterminate Tn was 0.16% (95% confidence interval, 0.04%-0.41%)., Conclusion: Initial results identify rare cases of AMI where CK-MBi is positive in the setting of indeterminate Tn. However, most patients with indeterminate Tn and positive CK-MBi were not judged to be having AMI. In most cases, CK-MBi is not positive with indeterminate Tn and when positive more commonly confuses the picture. This suggests CK-MBi could be eliminated in patients with indeterminate Tns., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to determine whether current troponin assay alone can be used for initial screening for acute myocardial infarction (AMI) and whether creatine kinase-MB (CK-MB) can safely be eliminated from this evaluation in the emergency department (ED)., Methods: A retrospective cohort study of patients who had cardiac troponin T (Roche, Basel, Switzerland) and CK-MB ordered at an urban academic level 1 trauma center with more than 55,000 annual visits. Patients with troponin testing in the ED were identified over a period of 12 months, and corresponding CK-MB indexes were examined identifying patients with negative troponins (<0.01) and positive CK-MB indexes (>6.0). In these patients, further cardiac markers, hospital course, and 30-day mortality were then evaluated. A 99% confidence interval around point estimate was used in data analysis., Results: During the study period, there were 11,092 separate ED patient encounters where a patient had at least one troponin resulted. Most (97.9%) of the samples had an associated CK-MB ordered. There were 7545 initial negative troponins representing 68% of all initial samples. Seven of these had an associated positive MB index. When subsequent troponins were evaluated, an additional 4910 negative troponins were identified, with 4 patients having a positive MB. None of these 11 patients were judged to have ruled in for AMI by the treating physicians. The rate of true-positive CK-MB index with negative troponin was 0% (99% confidence interval, 0-0.04%)., Conclusion: Our results suggest that CK-MB is not necessary in the initial screening for AMI and may safely be omitted in patients with negative troponins., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: The D-dimer assay has been shown to be an appropriate test to rule out pulmonary embolism (PE) in low-risk patients in the emergency department (ED). Multiple assays now are approved to measure D-dimer levels. Studies have shown a newer assay, Tina-quant, to have similar diagnostic accuracy to the VIDAS assay., Objectives: The objective was to determine effects of transitioning from the VIDAS assay to the Tina-quant D-dimer assay on the need for computed tomography angiogram (CTA) and ED length of stay (LOS) in patients being evaluated for PE in the ED., Methods: A retrospective cohort study was conducted of patients who had D-dimer levels ordered at an urban, academic, Level I trauma center with over 55,000 annual ED visits. The results of D-dimer levels in the ED were recorded over a period of 6 months prior to and 6 months after the transition to the new D-dimer assay. The numbers of positive and negative D-dimers and need for subsequent CTAs were recorded for comparison. LOS was also recorded to determine time saved. Medians were calculated and compared using Wilcoxon rank sum., Results: During the initial period, 875 D-dimers were ordered, with a positive rate of 41.5%. During the period after the introduction of the Tina-quant assay, 859 tests were ordered, with 25.5% having positive results. An absolute decrease of 16% in the number of necessary CTAs (p < 0.003) was seen after the transition to the Tina-quant assay. LOS data showed a mean LOS of 481 minutes in the ED for patients who underwent testing with the Tina-quant assay compared to 526 minutes with the VIDAS assay, saving an average of 45 minutes per patient (p < 0.003). The positive rate on performed imaging studies for D-dimer of > 500 rose from 13 of 308 (4.2%) to 17 of 187 (9.1%)., Conclusions: Switching D-dimer assays reduced both LOS and number of imaging studies in our patient population., (© 2011 by the Society for Academic Emergency Medicine.)

Background: Alterations in serum biomarkers have been used to evaluate for pancreatitis in the emergency department (ED). Studies have shown lipase to be as sensitive and more specific than amylase in diagnosing pancreatitis and that amylase plus lipase does not improve accuracy over lipase alone., Objective: To determine effects of interventions to decrease ordering of amylase in the evaluation of pancreatitis., Methods: We conducted a pre- and post-cohort study. The number of amylase and lipase tests ordered in the ED was recorded prior to intervention to establish a baseline. We introduced an educational intervention to order lipase without amylase. A second intervention involved removing amylase from bedside order entry forms. We introduced a third intervention that included deleting amylase from trauma order forms, and decoupling amylase and lipase in the computer ordering system. We recorded the number of lipase and amylase tests in weekly aggregates for comparison to the baseline. Data analysis using students t-test, standard deviation and p values are reported., Results: Before interventions 93% of patients had both tests ordered. Educational interventions resulted in a decrease to 91% (p=0.06) of co-ordering. Further interventions decreased the percentage of patients evaluated with both tests to 14.3%. This translates into a decrease in patient charges of approximately $350,000 a year., Conclusion: Using simple structured interventions in the ED can reduce amylase ordering. Educational programming alone was not effective in significantly decreasing amylase ordering; however, education plus system-based interventions decreased amylase ordering.

An experimental protocol designed to assess fatigability in motor units has been applied to two hindlimb muscles of anesthetized adult rats to study the effects of whole-muscle fatigue on the isometric twitch. Both soleus and extensor digitorum longus exhibited a linear relationship between fatigability (i.e., force decline after a 360-s fatigue test) and the magnitude of the twitch force following the fatigue test. Twitch force after the fatigue test was potentiated (i.e., greater than the value before the fatigue test) in many muscles, despite the development of considerable fatigue. This coexistence of fatigue and twitch potentiation was observed in 7% (5/70) of soleus and 48% (31/64) of extensor digitorum longus muscles. The coexistence was exhibited only by the least fatigable muscles of the fast-contracting extensor digitorum longus. The extensor digitorum longus muscles that did not exhibit twitch potentiation probably experienced a higher proportion of muscle-fiber inactivation, such as due to failure of neuromuscular propagation, that was induced by the fatigue regimen.

1. An experimental protocol designed to assess fatigability in motor units (Burke, Levine, Tsairis & Zajac, 1973) has been applied to the whole muscles of anaesthetized adult rats, and the association between the electromyogram (EMG) and force was monitored over the course of the test. 2. Both test muscles (soleus and extensor digitorum longus) exhibited a wide range of fatigability, which was defined as the decline in isometric peak force at 6 min, such that the data could be separated into five levels of fatigability. Fatigue indices for each test muscle were distributed across three levels. 3. The EMG was quantified with four measures of amplitude, four of duration, and one interaction term (area). Correlation analyses indicated that the EMG was adequately represented by one measure of amplitude (absolute amplitude), one of duration (peak-to-peak duration) and area. The best single measure was area. 4. The EMG-force associations for soleus varied markedly among its three fatigability groups. In contrast, over the course of the test, all three extensor digitorum longus groups displayed qualitatively similar EMG-force associations. 5. Multiple regression analyses indicated that the EMG parameters were able to predict peak force better for extensor digitorum longus than for soleus. Furthermore, for both test muscle, the prediction was best for the most fatigable group. 6. The associations between EMG and force exhibited three patterns for the two test muscles and three levels of fatigability. These differences suggested variation in the mechanisms, related to both fibre-type composition and susceptibility to fatigue, that dictate the performance elicited by this particular stimulus regimen. The mechanisms seem to include both intracellular and transmission processes.