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BACKGROUND: This study examined the main and interactive effects of parental problem drinking and resilience on problem (externalizing and internalizing) behaviors among Korean adolescents. METHODS: Data were collected from 482 adolescents (mean age=14.4 years, 57% girls) from four middle schools in two urban areas in Korea. A revised version of Kim's measure (2003) and Hyun's Problems Behaviors Profiles (2000) were employed to measure resilience and internalizing and externalizing behaviors, respectively. RESULTS: Hierarchical multiple regression analyses showed that parental problem drinking was directly associated with externalizing and internalizing behaviors. Further, the effects of parental problem drinking on both outcomes were moderated by resilience, such that the negative effects of parental problem drinking decreased in magnitude as resilience increased. Simple slope analyses showed that (1) the effects of parental problem drinking on externalizing behaviors were significant only at low levels of resilience and (2) the effects of parental problem drinking on internalizing behaviors were significant at low and average levels of resilience. CONCLUSIONS: Resilience may confer some protection against the adverse effects of parental problem drinking among Korean adolescents, but these protective effects are small in magnitude. Results highlight the importance of further research on culture-specific dimensions of resilience among Korean Children of Alcoholics (COAs). [ABSTRACT FROM AUTHOR]

This study examines race/ethnicity and gender differences in drug use and abuse for substances other than alcohol among undergraduate college students. A probability-based sample of 4,580 undergraduate students at a Midwestern research university completed a cross-sectional Web-based questionnaire that included demographic information and several substance use measures. Male students were generally more likely to report drug use and abuse than female students. Hispanic and White students were more likely to report drug use and abuse than Asian and African American students prior to coming to college and during college. The findings of the present study reveal several important racial/ethnic differences in drug use and abuse that need to be considered when developing collegiate drug prevention and intervention efforts. [ABSTRACT FROM AUTHOR]

To assess the prevalence and motives for illicit use of prescription stimulants and alcohol and other drugs (AODs), associated with these motives, the authors distributed a self-administered Web survey TO a random sample of 9,161 undergraduate college students. Of the study participants, 8.1% reported lifetime and 5.4% reported past-year illicit use of prescription stimulants. The most prevalent motives given for illicit use of prescription stimulants were to (1) help with concentration, (2) increase alertness, and (3) provide a high. Although men were more likely than women were to report illicit use of prescription stimulants, the authors found no gender differences in motives. Regardless of motive, illicit use of prescription stimulants was associated with elevated rates of AOD use, and number of motives endorsed and AOD use were positively related. Students appear to be using these prescription drugs non-medically, mainly to enhance performance or get high. [ABSTRACT FROM AUTHOR]

Background: Trauma during pregnancy presents multifaceted risks to both the developing fetus and the expectant mother due to pregnancy-induced physiological adaptations that affect the response to traumatic injuries. The infrequent occurrence of cardiac arrest during pregnancy necessitates interventions such as perimortem cesarean section (PMCS), now termed resuscitative hysterotomy. While early resuscitative hysterotomy focused primarily on fetal survival, more recent literature reports substantial maternal benefits. Resuscitative hysterotomy can lead to the restoration of maternal pulse and blood pressure within minutes and has shown potential to improve maternal outcomes. RH has been demonstrated to aid in fetal and maternal survival in hemodynamic unstable pregnant patients before cardiovascular collapse. The linguistic change from PMCS to resuscitative hysterotomy is a shift towards maternal-centric approaches and survival., Objective: In this series, we evaluate the outcomes of resuscitative hysterotomy performed before or after cardiovascular collapse to maximize maternal survival while concurrently optimizing fetal outcomes., Methods: We performed a retrospective case series review of 4 consecutive pregnant trauma patients who underwent RH due to hemodynamic instability. In addition, we conducted a descriptive analysis of all pregnant patients from 2013 to May 2024 who presented due to a traumatic injury but did not require a RH., Results: The average age of patients undergoing RH was 26.5 ± 6.8 years. All patients were in the third trimester with a mean gestational age of 32.3 ± 0.5 weeks. Fifty percent (50 %) of patients were involved in motor vehicle accidents, one (25 %) pedestrian was hit by a vehicle, and one (25 %) had GSW to the head. The median time to RH was 14.5 min. The mean estimated blood loss (EBL) was 625 mL ±108.9 mL. The maternal survival rate was 50 %, with a fetal survival rate of 100 %. Three patients achieved hemodynamic stability; however, one of the patients progressed to death by neurological criteria. Therefore, we achieved 50 % of maternal survival. A resuscitative hysterotomy was performed due to early signs of maternal hemorrhagic shock and suggestive features of ongoing bleeding (persistent maternal tachycardia despite adequate analgesia and resuscitation, persistent maternal bradycardia, gradual decline of BP, and FHR abnormalities) in three patients. The remaining patient was found to have cardiac arrest at the scene with a brief return of spontaneous circulation and received resuscitative hysterotomy in the ED to restore cardiovascular function., Conclusion: RH in pregnant patients with traumatic injury and impending hemorrhagic shock or cardiovascular collapse may provide maternal survival benefits by supporting circulatory function and promoting resuscitation with no additional risks to fetal outcomes. Quick decision-making is crucial to the implementation of this life-saving procedure. Further research with a more significant number of patients is needed to validate the efficacy of RH in maximizing maternal survival. This case series adds to the evolving literature on RH, shedding light on practical aspects and maternal outcomes to inform ongoing discussions and strategies for maternal cardiopulmonary resuscitation., Competing Interests: Declaration of competing interest None., (Copyright © 2024. Published by Elsevier Ltd.)

Objectives: Regulatory requirements around protected faculty effort to support graduate medical education (GME) programs have changed. The amount of labor required to run a GME program is unknown. We sought to describe the work performed by program leadership and core faculty in emergency medicine (EM)., Methods: We performed a prospective survey study of core faculty in EM. Participants completed a demographic questionnaire followed by quarterly time surveys, covering activities in eight domains: evaluation, teaching and education, scholarly activity, service, interview/recruitment, clinical supervision, student responsibilities, and wellness and administration. We collected data from April 2022 to March 2023. We calculated descriptive statistics and used analyses of variance (ANOVA) to assess differences by faculty role and quarter., Results: A total of 596 physicians completed the demographic questionnaire and 347 (58.2%) completed at least one quarterly time survey including 142 (41%) females, 48 (14%) program directors (PDs), 84 (24%) assistant/associate program directors (APDs), and 215 (62%) general core faculty (GCF). The mean number of hours per week spent on nonclinical education work was 60 h for PDs, 47 h for APDs, and 44 h for GCF. ANOVA found significant differences in mean hours per week and faculty role in domains of evaluation ( p  < 0.001), service ( p  = 0.007), and interview/recruitment ( p  < 0.001). We detected differences in mean hours per week and quarter in domains of evaluation ( p  < 0.001), teaching and education ( p  < 0.001), interview and recruitment ( p  < 0.001), and clinical supervision ( p  < 0.001)., Conclusions: Running a residency program requires many hours of faculty work, which can vary based on faculty role and time of year. These results can inform decisions regarding faculty support., Competing Interests: J.J., F.E.G., T.M., M.W., and L.R.H. were members of the board of directors for the Council of Residency Directors in Emergency Medicine during the time of the study. T.M. is a member of the Residency Review Committee., (© 2024 Society for Academic Emergency Medicine.)

Purpose: To describe ED neuroimaging trends across the time-period spanning the early adoption of endovascular therapy for acute stroke (2013-2018)., Materials and Methods: We performed a retrospective, cross-sectional study of ED visits using the 2013-2018 National Emergency Department Sample, a 20% sample of ED encounters in the United States. Neuroimaging use was determined by Common Procedural Terminology (CPT) code for non-contrast head CT (NCCT), CT angiography head (CTA), CT perfusion (CTP), and MRI brain (MRI) in non-admitted ED patients. Data was analyzed according to sampling weights and imaging rates were calculated per 100,000 ED visits. Multivariate logistic regression analysis was performed to identify hospital-level factors associated with imaging utilization., Results: Study population comprised 571,935,906 weighted adult ED encounters. Image utilization increased between 2013 and 2018 for all modalities studied, although more pronounced in CTA (80.24/100,000 ED visits to 448.26/100,000 ED visits (p < 0.001)) and CTP (1.75/100,000 ED visits to 28.04/100,000 ED visits p < 0.001)). Regression analysis revealed that teaching hospitals were associated with higher odds of high CTA utilization (OR 1.88 for 2018, p < 0.05), while low-volume EDs and public hospitals showed the reverse (OR 0.39 in 2018, p < 0.05)., Conclusions: We identified substantial increases in overall neuroimaging use in a national sample of non-admitted emergency department encounters between 2013 and 2018 with variability in utilization according to both patient and hospital properties. Further investigation into the appropriateness of this imaging is required to ensure that access to acute stroke treatment is balanced against the timing and cost of over-imaging., (© 2024. The Author(s), under exclusive licence to American Society of Emergency Radiology (ASER).)

Introduction: Human trafficking (HT) is a public health issue that adversely affects patients' well-being. Despite the prevalence of trafficked persons in health care settings, a lack of educational modules exists for use in clinical contexts. We developed a 50-minute train-the-trainer module on HT., Methods: After piloting the workshop for faculty, fellows, and residents ( n = 19) at the Society for Academic Emergency Medicine (SAEM) national conference, we implemented it in medical students' curricula during their emergency medicine clerkship at the University of Iowa ( n = 162). We evaluated the worskhop by (a) a retrospective pre-post survey of self-reported ability to (1) define HT, (2) recognize high-risk signs, (3) manage situations with trafficked persons, and (4) teach others about HT, and (b) a 3-month follow-up survey to assess longitudinal behavior change., Results: In both contexts, results demonstrated improvement across all learning outcomes (pre-post differences of 1.5, 1.3, 1.9, and 1.7 on a 4-point Likert-type scale for each learning objective above, respectively, at the SAEM conference and 1.2, 1.0, 1.3, and 1.3 at the University of Iowa; p < .001 for all). In the 3-month follow-up, we observed statistically significant changes in self-reported consideration of and teaching about HT during clinical encounters among learners who had previously never done either ( p < .001 and p = .006, respectively)., Discussion: This train-the-trainer module is a brief and effective clinical tool for bedside teaching about HT, especially among people who have never previously considered HT in a clinical context., (© 2024 Young et al.)

Background and objective Studies assessing the incidence of venous thromboembolic (VTE) events in the setting of massive balanced transfusions and/or tranexamic acid (TXA) infusion have yielded varied outcomes. In light of this, we conducted this study to examine the incidence of VTEs in trauma patients requiring blood products, and to identify the risk factors for VTE and mortality in this population. Methods We performed a retrospective analysis of trauma patients admitted to our level 1 trauma center from January 2013 to September 2023. Clinical characteristics were compared between patients who developed VTE and those who did not. A regression analysis of potential variables associated with the development of VTEs and mortality was performed. Results Among 1305 patients (mean age: 42.4 ± 18.8 years) receiving blood products within the initial 24 hours, 4.3% (56 patients) developed a VTE. Patients with VTE experienced prolonged ICU and hospital stays and ventilation duration (p<0.001). They were also noted to have delayed initiation of VTE prophylaxis (104.2 vs. 50.3 hours, p<.001). Prolonged ventilation >7 days was the sole significant factor associated with VTE in multivariate regression analysis [odds ratio (OR): 6.2, p=0.004]. Early TXA administration (within four hours) showed a higher association with VTE than TXA within 24 hours (OR: 2.1, p=0.07 vs. OR 1.6, p=0.22). Massive transfusion was found to increase VTE risk (OR: 2.65, p<0.001). Severe head and neck (OR: 6.0, p=0.002) and chest (OR: 3.8, p=0.01) injuries were key predictors of mortality, while TXA was not significantly associated with mortality in the multivariate model. Conclusions Our study revealed an elevated risk of VTE in patients requiring massive transfusion protocol (MTP, ≥6 units). Early TXA administration was neither associated with increased VTE risk in MTP patients nor increased mortality risk. Strategies directed at reducing the risk of VTE in massively transfused patients while maintaining the survival benefits of balanced resuscitation and TXA need to be devised., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Halalmeh et al.)

Introduction: Medical drones have potential for improving the response times to out-of-hospital emergencies. However, widespread adoption is hindered by unanswered questions surrounding medical dispatch and bystander safety. This study evaluated the impact of novel drone-specific dispatch instructions (DSDI) on bystanders' ability to interact effectively with a medical drone and provide prompt, safe, and high-quality treatment in a simulated emergency scenario. We hypothesized DSDI would improve bystanders' performance and facilitate safer bystander-drone interactions., Methods: Twenty-four volunteers were randomized to receive either DSDI and standard Medical Priority Dispatch (MPD) instructions or MPD alone in a simulated out-of-hospital cardiac arrest (OHCA) or pediatric anaphylaxis., 3 Participants in the DSDI group received detailed instructions on locating and interacting with the drone and its enclosed medical kit. The simulations were video recorded. Participants completed a semi-structured interview and survey., Results: The addition of DSDI did not lead to statistically significant changes to the overall time to provide care in either the anaphylaxis or OHCA simulations. However, DSDI did have an impact on bystander safety. In the MPD only group, 50% (6/12) of participants ignored the audio and visual safety cues from the drone instead of waiting for it to be declared safe compared to no DSDI participants ignoring these safety cues., Conclusions: All participants successfully provided patient care. However, this study indicates that DSDI may be useful to ensure bystander safety and should be incorporated in the continued development of emergency medical drones., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Christine M. Brent reports financial support was provided by Toyota Motor Corporation. James M. Pribble reports financial support was provided by Toyota Motor Corporation. Laura R. Hopson reports financial support was provided by Toyota Motor Corporation. Emily J. Mathias reports financial support was provided by Toyota Motor Corporation. Nathaniel Hunt reports financial support was provided by Toyota Motor Corporation. Christine M. Brent reports a relationship with the Medical Control Authority of Michigan that includes: board membership. Co-author employed by Emergent Health Partners − E.E.D. Co-author employed by Emergent Health Partners − I.G.S. Co-author employed by Emergent Health Partners − N.K.M. Corresponding author employed as EMS Medical Director − C.M.B. Co-author employed as EMS Medical Director − N.H. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Author(s).)

Intro: Medical drones are an emerging technology which may facilitate rapid treatment in time-sensitive emergencies. However, drones rely on lay rescuers, whose interactions with multipurpose medical drones have not been studied, and the optimal drone design remains unclear., Methods: We conducted 24 simulations of adult out-of-hospital cardiac arrest (OHCA) and pediatric anaphylaxis with a prototype drone equipped with spoken and visual cues and a multipurpose medical kit. 24 layperson volunteers encountered one of the two scenarios and were supported through administering treatment by a simulated 911 dispatcher. Bystander-drone interactions were evaluated via a convergent parallel mixed methods approach using surveys, video event review, and semi-structured interviews., Results: 83% (20/24) of participants voiced comfort interacting with the drone. 96% (23/24) were interested in future interaction. Participants appreciated the drone's spoken instructions but found visual cues confusing. Participants retrieved the medical kit from the drone in a mean of 5 seconds (range 2-14) of drone contact; 79% (19/24) found this step easy or very easy. The medical kit's layered design caused difficulty in retrieving appropriate equipment. Participants expressed a wide range of reactions to the unique drone design., Conclusions: Laypeople can effectively and comfortably interact with a medical drone with a novel design. Feedback on design elements will result in further refinements and valuable insights for other drone designers. A multipurpose medical kit created more challenges and indicates the need for further refinement to facilitate use of the equipment., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: ‘Dr. Brent, Dr. Hopson, Dr. Pribble, Dr. Mathias and Dr. Hunt report funding support from Toyota Motors North America Research and Development for this study. Ms. Davidson, Ms. Majhail and Ms. Scott report employment, during one or more phases of the study, with Huron Valley Ambulance of Emergent Health Partners, a licensed transporting advanced life support agency (ALS) that serves as a regional provider of BLS/ALS medical transport and 9–1-1 dispatched emergency response in southern Michigan. Dr. Brent and Dr. Hunt report a leadership role as co-deputy medical director for the Washtenaw/Livingston Medical Control Authority, a regional EMS oversight body. All other authors report no relevant interests.’., (© 2024 The Authors.)

Introduction: Exposure to community violence (ECV) continues to be a major public health problem among urban adolescents in the United States. We sought to identify subgroups of adolescents' ECV and examine how after-school activities are related to exposure subgroups across two samples., Methods: In Study 1 there were 1432 adolescents (Cohort 9 n = 717, M age  = 11, and Cohort 12 n = 715, M age  = 14; 52% boys) from the Project on Human Development in Chicago Neighborhoods (1994-2002). Study 2 had a more recent sample of 537 adolescents (M age  = 16 years; 54% girls) from the After-School Activity Study (ASAS; 2015-2017) in Chicago and Detroit., Results: Exploratory latent class analyses yielded a three-class solution for Study 1: a "No ECV" class (44%); a "Low ECV" class (36%); and a "High Exposure" class (14%). In Study 2, a four-class solution was the best fit with a "No ECV" class (33%), a "Moderate Witness/Low Victim" class (36%), a "High Witness/Moderate Victim" class (19%), and a "High ECV" class (11%). Home-based activities appeared to be protective against high ECV for adolescents in Study 2. School-based activities were associated with higher ECV across both samples, but community-based activities were only associated with greater violence exposure in Study 1. Adolescents' unstructured socializing in both studies was associated with higher odds of ECV., Conclusions: Results indicate that subgroups of adolescents can be identified based on ECV and highlight the complexity of after-school activities as risk and protective factors in both past and more recent contexts., (© 2023 Foundation for Professionals in Services to Adolescents.)

Background and Objectives: Spouses with concordant (i.e., similar) drinking behaviors often report better quality marriages and are married longer compared with those who report discordant drinking behaviors. Less is known regarding whether concordant or discordant patterns have implications for health, as couples grow older. The present study examined whether drinking patterns among older couples are associated with mortality over time., Research Design and Methods: The Health and Retirement Study (HRS) is a nationally representative sample of individuals and their partners (married/cohabiting) over age 50 in the United States, in which participants completed surveys every 2 years. Participants included 4,656 married/cohabiting different-sex couples (9,312 individuals) who completed at least 3 waves of the HRS from 1996 to 2016. Participants reported whether they drank alcohol at all in the last 3 months, and if so, the average amount they drank per week. Mortality data were from 2016., Results: Analyses revealed concordant drinking spouses (both indicated they drank in the last 3 months) survived longer than discordant drinking spouses (1 partner drinks and the other does not) and concordant nondrinking spouses. Analysis of average drinks per week showed a quadratic association with mortality such that light drinking predicted better survival rates among individuals and their partners compared with abstaining and heavy drinking. Further, similar levels of drinking in terms of the amount of drinking were associated with greater survival, particularly among wives., Discussion and Implications: This study moves the field forward by showing that survival varies as a function of one's own and one's partner's drinking., (© The Author(s) 2023. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Most cases of pediatric epistaxis are spontaneous and self-resolve. However, a subset of children may experience significant bleeding and require procedural or medical intervention., Objective: We aim to identify risk factors associated with moderate and severe epistaxis in the emergency department (ED) and explore management outcomes., Methods: We retrospectively reviewed all patients under 22 years old with epistaxis who presented to our ED between 2013 and 2022. Epistaxis severity was defined as mild (required nasal compression or intranasal medications), moderate (required cautery or packing), or severe (required factor replacement, transfusion, hospital admission, or surgery). We performed univariable and multinomial regression analyses, with risk factors and outcomes analyzed according to severity., Results: Of 858 visits, 41 (5%) patients had moderate and 67 (8%) had severe epistaxis. Patients with moderate epistaxis were older than those with mild and severe epistaxis (median 15.6 vs. 8.3 vs. 10.7 years, p < 0.001). In regression analysis, moderate epistaxis was associated with older age, prior ED visit within 72 h, and antiplatelet medication use (p < 0.01). Severe epistaxis was associated with bleeding disorders, nasal procedures within 30 days, and anticoagulation medication use (p ≤ 0.001). Bleeding over 30 min prior to arrival was associated with both moderate and severe epistaxis (p < 0.05). Of the 67 patients with severe epistaxis, 10 (15%) required factor replacement, 28 (42%) required transfusion, 52 (77%) required hospital admission, and 5 (7%) underwent surgery., Conclusion: Epistaxis severity is associated with certain risk factors. However, most cases of pediatric epistaxis are mild and do not require intervention or ED evaluation., Competing Interests: Declaration of competing interest The authors report no conflict of interest., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Euglycemic diabetic ketoacidosis (DKA) (glucose <250 milligrams per deciliter (mg/dL) has increased in recognition since introduction of sodium-glucose co-transporter 2 (SGLT2) inhibitors but remains challenging to diagnose and manage without the hyperglycemia that is otherwise central to diagnosing DKA, and with increased risk for hypoglycemia with insulin use. Our objective was to compare key resource utilization and safety outcomes between patients with euglycemic and hyperglycemic DKA from the same period., Methods: This is a retrospective review of adult emergency department patients in DKA at an academic medical center. Patients were included if they were >18 years old, met criteria for DKA on initial laboratories (pH ≤7.30, serum bicarbonate ≤18 millimoles per liter [mmol/L], anion gap ≥10), and were managed via a standardized DKA order set. Patients were divided into euglycemic (<250 milligrams per deciliter [mg/dL]) vs hyperglycemic (≥250 mg/dL) cohorts by presenting glucose. We extracted and analyzed patient demographics, resource utilization, and safety outcomes. Etiologies of euglycemia were obtained by manual chart review. For comparisons between groups we used independent-group t -tests for continuous variables and chi-squared tests for binary variables, with alpha 0.05., Results: We identified 629 patients with DKA: 44 euglycemic and 585 hyperglycemic. Euglycemic patients had milder DKA on presentation (higher pH and bicarbonate, lower anion gap; P  < 0.05) and lower initial glucose (195 vs 561 mg/dL, P  < 0.001) and potassium (4.3 vs 5.3 mmol/L, P  < 0.001). Etiologies of euglycemia were insulin use prior to arrival (57%), poor oral intake with baseline insulin use (29%), and SGLT2 inhibitor use (14%). Mean time on insulin infusion was shorter for those with euglycemic DKA: 13.5 vs 19.4 hours, P  = 0.003. Mean times to first bicarbonate >18 mmol/L and first long-acting insulin were similar. Incidence of hypoglycemia (<70 mg/dL) while on insulin infusion was significantly higher for those with euglycemic DKA (18.2 vs 4.8%, P  = 0.02); incidence of hypokalemia (<3.3 mmol/L) was 27.3 vs 19.1% ( P  = 0.23)., Conclusion: Compared to hyperglycemic DKA patients managed in the same protocolized fashion, euglycemic DKA patients were on insulin infusions 5.9 hours less, yet experienced hypoglycemia over three times more frequently. Future work can investigate treatment strategies for euglycemic DKA to minimize adverse events, especially iatrogenic hypoglycemia., Competing Interests: Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.

Aim: To evaluate coagulofibrinolytic abnormalities and the effects of ART-123 (recombinant human thrombomodulin alpha) in a porcine model of cardiac arrest and prolonged cardiopulmonary resuscitation (CA/CPR)., Methods: Fifteen pigs ( n  = 5 per group) underwent 8 minutes of no-flow CA followed by 50 minutes of mechanical CPR, while 2 pigs underwent sham arrest. CA/CPR animals were randomized to receive saline or 1 mg/kg ART-123 pre-arrest (5 minutes prior to ventricular fibrillation) or post-arrest (2 minutes after initiation of CPR). Arterial and venous blood samples were drawn at multiple time points for blood gas analysis and measurement of plasma and whole blood markers of coagulation and fibrinolysis., Results: In saline-treated CA/CPR, but not sham animals, robust and persistent activation of coagulation and fibrinolysis was observed throughout resuscitation. After 50 minutes of CPR, plasma tests and thromboelastography indicated a mix of hypercoagulability and consumptive coagulopathy. ART-123 had a robust anticoagulant effect, reducing both thrombin-antithrombin (TAT) complexes and d-dimer ( p  < 0.05 for each). The duration of anticoagulant effect varied depending on the timing of ART-123 administration. Similarly, ART-123 when given prior to cardiac arrest was found to have pro-fibrinolytic effects, increasing free tissue plasminogen activator (tPA, p  = 0.02) and decreasing free plasminogen activator inhibitor-1 (PAI-1, p  = 0.04)., Conclusion: A porcine model of prolonged CA/CPR reproduces many of the coagulofibrinolytic abnormalities observed in human cardiac arrest patients. ART-123 demonstrates a combination of anticoagulant and profibrinolytic effects, depending on the timing of its administration relative to cardiac arrest., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: BZ and CFG received study drug (ART123) and research funding from Asahi Kasei Pharma (AKP) Corporation. AKP was not involved in experimental design, data analysis, or manuscript preparation. BMM, CCM, DL, NG, JAC, CHH, MHT, and RWN have no conflicts of interest to report., (© 2023 The Authors.)

Objectives: Emergency department (ED) boarding, or remaining in the ED after admission before transfer to an inpatient bed, is prevalent. Boarding patients may decompensate before inpatient transfer, necessitating escalation to the intensive care unit (ICU). We evaluated the impact of an ED-ICU on decompensating boarding ED patients., Methods: This is a retrospective single-center observational study. We identified decompensated boarding ED patients necessitating critical care before departure from the ED from October 2012 to December 2021. An automated query and manual chart review extracted data. Three cohorts were defined: pre-ED-ICU implementation (Group 1), post-ED-ICU implementation with ED-ICU care (Group 2), and post-ED-ICU implementation with inpatient ICU admission without ED-ICU care (Group 3). Primary outcome was ICU length of stay (LOS). Secondary outcomes included hospital LOS, in-hospital mortality, and ICU admissions with ICU LOS <24 hours. Between-groups comparisons used multiple regression analysis for continuous variables, χ 2 tests and multivariable logistic regression analysis for binary variables, and follow-up contrasts for statistically significant omnibus tests., Results: A total of 1123 visits met inclusion criteria: 225 in Group 1, 780 in Group 2, and 118 in Group 3. Mean ICU LOS was shorter for Group 2 than Group 1 or 3 (47.4 vs 92.3 vs 103.9 hours, P  < 0.001). Mean hospital LOS was shorter for Group 2 than Group 1 or 3 (185.1 vs 246.8 vs 257.3 hours, P  < 0.01). In-hospital mortality was similar between groups. The proportion of ICU LOS <24 hours was lower for Group 2 than Group 1 or 3 (16.5 vs 27.1 vs 32.2%, P  < 0.01)., Conclusion: For decompensating boarding ED patients, ED-ICU care was associated with decreased ICU and hospital LOS, similar mortality, and fewer short-stay ICU admissions, suggesting ED-ICU care is associated with downstream resource preservation., (© 2023 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

Purpose: To compare key resource utilization and safety outcomes of adult emergency department (ED) patients in diabetic ketoacidosis (DKA) managed via the Two-Bag or traditional One-Bag method., Materials and Methods: This is a retrospective review at an academic medical center ED. Patients were included if >18 years, met diagnostic criteria for DKA (pH ≤ 7.30, bicarbonate ≤ 18 mmol/L, anion gap ≥ 10), and were managed via a standardized order set (either Two-Bag or One-Bag Method). Comparisons used independent-groups t -tests for continuous variables and χ 2 tests for binary variables., Results: We identified 634 patients with DKA managed via the Two-Bag method, and 107 managed via the One-Bag method. Cohorts were similar in demographics and presenting laboratories. The Two-Bag Method was associated with 8.1 h shorter to first bicarbonate >18 mmol/L (11.9 vs 20.0, P  < .001), and 24 fewer IV fluid bags (5.3 vs 29.7, P  < .001). Incidence of hypokalemia (potassium <3.0 mmol/L) was 53% lower in the Two-Bag cohort (6.6 vs 14.0%, P  = .03); incidence of hypoglycemia (glucose <70 mg/dL) was 5.8 versus 10.3%, P  = .16., Conclusions: For adult ED patients in DKA, the Two-Bag Method was associated with faster resolution of acidosis, fewer IV fluid bags charged, lower incidence of hypokalemia, and trend toward lower incidence of hypoglycemia compared to the One-Bag Method.

Prior to 2020, pain management in the Washtenaw/Livingston County Medical Control Authority (W/L MCA) Emergency Medical Service (EMS) system in Southeast Michigan was limited to morphine, fentanyl, ketorolac, and acetaminophen. Based on the increasing evidence describing its safety and efficacy, ketamine was added to local protocols for pain management. This study aimed to evaluate differences in pain management and adverse effects of ketamine and opioid administration. Data from pediatric patients who received ketamine or an opioid in the W/L MCA EMS system from October 2019 to March 2021 were analyzed. The primary outcome was the difference in pain score, and the secondary outcome was adverse effects observed after analgesic administration. The decrease in pain scores was greater among ketamine patients (mean: 5.2) compared to opioid patients (mean: 2.9), p  < 0.001. The prevalence of adverse effects was higher among patients in the ketamine group (28.6%) compared to patients in the opioid group (2.4%, p  < 0.001). Of 14 patients who received ketamine, one 17-year-old male experienced mild anxiety (7.1%), two teenage females experienced mild dissociation (14.3%), and one 20-year-old female experienced mild nausea (7.1%). Overall, ketamine is a safe and effective option compared to opioids for pediatric patients experiencing moderate to severe prehospital pain.

Background: American Heart Association Advanced Cardiac Life Support (ACLS) guidelines support the use of either amiodarone or lidocaine for cardiac arrest caused by ventricular tachycardia or ventricular fibrillation (VT/VF) based on studies of out-of-hospital cardiac arrest. Studies comparing amiodarone and lidocaine in adult populations with in-hospital VT/VF arrest are lacking., Research Question: Does treatment with amiodarone vs lidocaine therapy have differential associations with outcomes among adult patients with in-hospital cardiac arrest from VT/VF?, Study Design and Methods: This retrospective cohort study of adult patients receiving amiodarone or lidocaine for VT/VF in-hospital cardiac arrest refractory to CPR and defibrillation between January 1, 2000, and December 31, 2014, was conducted within American Heart Association Get With the Guidelines-Resuscitation (GWTG-R) participating hospitals. The primary outcome was return of spontaneous circulation (ROSC). Secondary outcomes were 24 h survival, survival to hospital discharge, and favorable neurologic outcome., Results: Among 14,630 patients with in-hospital VT/VF arrest, 68.7% (n = 10,058) were treated with amiodarone and 31.3% (n = 4,572) with lidocaine. When all covariates were statistically controlled, compared with amiodarone, lidocaine was associated with statistically significantly higher odds of the following: (1) ROSC (adjusted OR [AOR], 1.15, P = .01; average marginal effect [AME], 2.3; 95% CI, 0.5 to 4.2); (2) 24 h survival (AOR, 1.16; P = 004; AME, 3.0; 95% CI, 0.9 to 5.1); (3) survival to discharge (AOR, 1.19; P < .001; AME, 3.3; 95% CI, 1.5 to 5.2); and (4) favorable neurologic outcome at hospital discharge (AOR, 1.18; P < .001; AME, 3.1; 95% CI, 1.3 to 4.9). Results using propensity score methods were similar to those from multivariable logistic regression analyses., Interpretation: Compared with amiodarone, lidocaine therapy among adult patients with in-hospital cardiac arrest from VT/VF was associated with statistically significantly higher rates of ROSC, 24 h survival, survival to hospital discharge, and favorable neurologic outcome., (Copyright © 2022 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Importance: Most patients presenting to US emergency departments (EDs) with acute pulmonary embolism (PE) are hospitalized, despite evidence from multiple society-based guidelines recommending consideration of outpatient treatment for those with low risk stratification scores. One barrier to outpatient treatment may be clinician concern regarding findings on PE-protocol computed tomography (CTPE), which are perceived as high risk but not incorporated into commonly used risk stratification tools., Objective: To evaluate the association of concerning CTPE findings with outcomes and treatment of patients in the ED with acute, low-risk PE., Design, Setting, and Participants: This cohort study used a registry of all acute PEs diagnosed in the adult ED of an academic medical center from October 10, 2016, to December 31, 2019. Acute PE cases were divided into high- and low-risk groups based on PE Severity Index (PESI) class alone or using a combination of PESI class and biomarker results. The low-risk group was further divided based on the presence of concerning CTPE findings: (1) bilateral central embolus, (2) right ventricle-to-left ventricle ratio greater than 1.0, (3) right ventricle enlargement, (4) septal abnormality, or (5) pulmonary infarction. Data analysis was conducted from June to October 2022., Main Outcomes and Measures: The primary outcome was all-cause mortality at 7 and 30 days. Secondary outcomes included hospitalization, length of stay, need for intensive care, use of echocardiography and/or bedside ultrasonography, and activation of the PE response team (PERT) ., Results: Of 817 patients (median [IQR] age, 58 [47-71] years; 417 (51.0%) female patients; 129 [15.8%] Black and 645 [78.9%] White patients) with acute PEs, 331 (40.5%) were low risk and 486 (59.5%) were high risk by PESI score. Clinical outcomes were similar for all low-risk patients, with no 30-day deaths in the low-risk group with concerning CTPE findings (0 of 151 patients) vs 4 of 180 (2.2%) in the low-risk group without concerning CTPE findings and 88 (18.1%) in the high-risk group (P < .001). Low-risk patients with concerning CTPE findings were less frequently discharged from the ED than those without concerning CTPE findings (3 [2.0%] vs 14 [7.8%]; P = .01) and had more frequent echocardiography (87 [57.6%] vs 49 [27.2%]; P < .001) and PERT activation for consideration of advanced therapies (34 [22.5%] vs 11 [6.1%]; P < .001)., Conclusions and Relevance: In this single-center study, CTPE findings widely believed to confer high risk were associated with increased hospitalization and resource utilization in patients with low-risk PE but not short-term adverse clinical outcomes.

This mixed-methods survey study aims to describe the effects of the COVID-19 pandemic on the mental health of a sample of 571 children and adolescent seeking psychiatric emergency care. The study was conducted from July to October 2020 at a large Midwestern academic center. Among the respondents, there were significant increases in mental health symptoms attributed to the COVID-19 pandemic, including anxiety (71% of respondents), depression (66%), suicidal thoughts or behaviors (45%), and aggression (31%). There were significant differences in reported increases in symptoms by age and gender. In addition, 38% of participants reported that the pandemic led to a change or closure of their health care treatment, including mental health providers, with 22% reporting that reduced treatment access led to their emergency visit. Further research is indicated to assess other, more diverse populations, as well as the longer-term mental health impacts of the pandemic.

Objectives: Hypothermic infants are at risk for serious bacterial and herpes simplex virus infections, but there are no evidence-based guidelines for managing these patients. We sought to characterize variations and trends in care for these infants in the emergency department (ED)., Methods: We conducted a retrospective cross-sectional study of infants under 90 days old presenting to 32 pediatric EDs from 2009 through 2019 with an International Classification of Diseases diagnosis code for hypothermia. We characterized variation in diagnostic testing, antimicrobial treatment, and disposition of children in three age groups (≤30 days, 31-60 days, and 61-90 days old) and analyzed care trends., Results: Of 7828 ED encounters meeting inclusion criteria, most (81%) were ≤ 30 days of age. Infants in the 0-30 days old age group, compared to 61-90 days old age group, had a higher proportion of blood (75% vs. 68%), urine (72% vs. 64%), and cerebrospinal fluid (CSF; 35% vs. 22%) cultures obtained (p < 0.01) and greater antimicrobial use (81% vs. 68%; p < 0.01) in the ED. From 2009 to 2019, C-reactive protein (CRP), and procalcitonin usage steadily increased, from 25% to 40% and 0% to 30% respectively, while antibiotic use (83% to 77%), CSF testing (53% to 44%), and chest radiography (47% to 34%) decreased. Considerable interhospital variation was noted in testing and treatment, including CSF testing (14-70%), inflammatory markers (CRP and procalcitonin; 8-88%), and antibiotics (56-92%)., Conclusion: Substantial hospital-level variation exists for managing hypothermic infants in the ED. Long-term trends are notable for changing practice over time, particularly with increased use of inflammatory markers. Prospective studies are needed to risk stratify and optimize care for this population., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Importance: Value in health care is quality per unit cost (V = Q/C), and an emergency department-based intensive care unit (ED-ICU) model has been associated with improved quality. To assess the value of this care delivery model, it is essential to determine the incremental direct cost of care., Objective: To determine the association of an ED-ICU with inflation-adjusted change in mean direct cost of care, net revenue, and direct margin per ED patient encounter., Design, Setting, and Participants: This retrospective economic analysis evaluated the cost of care delivery to patients in the ED before and after deployment of the Joyce and Don Massey Family Foundation Emergency Critical Care Center, an ED-ICU, on February 16, 2015, at a large academic medical center in the US with approximately 75 000 adult ED visits per year. The pre-ED-ICU cohort was defined as all documented ED visits by patients 18 years or older with a complete financial record from September 8, 2012, through June 30, 2014 (660 days); the post-ED-ICU cohort, all visits from July 1, 2015, through April 21, 2017 (660 days). Fiscal year 2015 was excluded from analysis to phase in the new care model. Statistical analysis was performed March 1 through December 30, 2021., Exposures: Implementation of an ED-ICU., Main Outcomes and Measures: Inflation-adjusted direct cost of care, net revenue, and direct margin per patient encounter in the ED., Results: A total of 234 884 ED visits during the study period were analyzed, with 115 052 patients (54.7% women) in the pre-ED-ICU cohort and 119 832 patients (54.5% women) in the post-ED-ICU cohort. The post-ED-ICU cohort was older (mean [SD] age, 49.1 [19.9] vs 47.8 [19.6] years; P < .001), required more intensive respiratory support (2.2% vs 1.1%; P < .001) and more vasopressor use (0.5% vs 0.2%; P < .001), and had a higher overall case mix index (mean [SD], 1.7 [2.0] vs 1.5 [1.7]; P < .001). Implementation of the ED-ICU was associated with similar inflation-adjusted total direct cost per ED encounter (pre-ED-ICU, mean [SD], $4875 [$15 175]; post-ED-ICU, $4877 [$17 400]; P = .98). Inflation-adjusted net revenue per encounter increased by 7.0% (95% CI, 3.4%-10.6%; P < .001), and inflation-adjusted direct margin per encounter increased by 46.6% (95% CI, 32.1%-61.2%; P < .001)., Conclusions and Relevance: Implementation of an ED-ICU was associated with no significant change in inflation-adjusted total direct cost per ED encounter. Holding delivery costs constant while improving quality demonstrates improved value via the ED-ICU model of care.

Objectives: Spouses often have concordant drinking behaviors and important influences on one another's cardiovascular health. However, little is known about the implications of dyadic drinking patterns for blood pressure, and the marital factors that confer risk or resilience. This article examined links between alcohol use and blood pressure within individuals and opposite-sex couples over time, and whether those links vary by negative marital quality among older adults., Methods: Participants were from the nationally representative longitudinal Health and Retirement Study that included 4,619 respondents in 2,682 opposite-sex couples who participated in at least 2 of the waves from 2006 to 2016. Participants reported the number of drinks they typically consume per week, negative marital quality, and had their blood pressure measured via a cuff., Results: Analyses revealed that greater drinking was associated with increased systolic blood pressure among both husbands and wives. Furthermore, husbands who drank more had higher blood pressure when wives drank more alcohol, whereas there was no association between husbands' drinking and blood pressure when wives drank less alcohol. Interactions with negative marital quality showed that drinking concordance may be associated with increased blood pressure over time in more negative marriages., Discussion: Findings indicated that spousal drinking concordance, although often associated with positive marital quality, may have negative long-term health effects., (© The Author(s) 2022. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background and objective Although hospitalization is required for only a minority of those infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the high rates of morbidity and mortality among these patients have led researchers to focus on the predictors of admission and adverse outcomes in the inpatient population. However, there is scarce data on the clinical trajectory of individuals symptomatic enough to present for emergency care, but not sick enough to be admitted. In light of this, we aimed to examine the symptomatology, emergency department (ED) revisits, and hospitalization of coronavirus disease 2019 (COVID-19) outpatients after discharge from the ED. Methods Adult patients with COVID-19 infection were prospectively enrolled after discharge from the ED between May and December 2020. Patients were followed up longitudinally for 14 days via phone interviews designed to provide support and information and to track symptomatology, ED revisits, and hospitalization. Results A volunteer, medical student-run program enrolled 199 COVID-19 patients discharged from the ED during the first nine months of the pandemic. Of the 176 patients (88.4%) who completed the 14-day protocol, 29 (16.5%) had a second ED visit and 17 (9.6%) were admitted, 16 (9%) for worsening COVID-19 symptoms. Age, male sex, comorbid illnesses, and self-reported dyspnea, diarrhea, chills, and fever were associated with hospital admission for patients with a subsequent ED visit. For those who did not require admission, symptoms generally improved following ED discharge. Age >65 years and a history of cardiovascular disease (CVD) were associated with a longer duration of cough, but generally, patient characteristics and comorbidities did not significantly affect the overall number or duration of symptoms. Conclusions Nearly one in five patients discharged from the ED with COVID-19 infection had a second ED evaluation during a 14-day follow-up period, despite regular phone interactions aimed at providing support and information. More than half of them required admission for worsening COVID-19 symptoms. Established risk factors for severe disease and self-reported persistence of certain symptoms were associated with hospital admission, while those who did not require hospitalization had a steady improvement in symptoms over the 14-day period., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Bayly et al.)

Background: Wraparound referrals are a cornerstone of hospital-based violence intervention programs, which have proven to be an effective public health approach for mitigating violence and recidivism. We hypothesized that replacing a manual referral process with an electronic referral application would increase the number of generated referrals and improve compliance with follow-up visits., Study Design: The population for this single center quantitative study was a convenience sample of firearm-injured patients. Data from 74 patients were collected using the electronic health record, the electronic referral application, and the trauma registry before and after the intervention., Results: Post-implementation of the electronic referral application showed an increased number of generated referrals, increased emergency department and inpatient utilization of trauma recovery center services, and an increase in second follow-up visit compliance., Conclusion: This study demonstrated an increase in the number of referrals and greater likelihood of completion of post-injury follow-up visits after implementing the electronic referral system., (© Copyright 2022 Springer Publishing Company, LLC.)

While ample research examines community violence as a serious public health problem that disproportionately affects minority adolescents, less attention focuses on adolescents' experiences of gender-based harassment in poor, urban neighborhoods. Using data from 416 urban, low-income Latino/a adolescents (53% female; M age  = 15.5), this study examined (a) the relations between community violence exposure (CVE), gender-based harassment, and posttraumatic stress disorder (PTSD) symptoms and (b) the role of parent-child cohesion as a moderator of the relations between CVE/harassment and PTSD symptoms. Whereas both CVE and gender-based harassment were associated with greater PTSD symptoms, the effect of gender-based harassment on PTSD symptoms was far greater than the effect of community violence. Additionally, the association between gender-based harassment and PTSD symptoms was exacerbated when parent-child cohesion was high, compared to when cohesion was low or average. Finally, Latino/a adolescents exposed to high levels of both CVE and gender-based harassment had worse PTSD symptoms compared to those exposed primarily to gender-based harassment, who in turn had worse PTSD symptoms than those exposed primarily to community violence. Findings highlight the importance of including adolescents' experiences with gender-based harassment when studying community violence., (© 2021 Society for Community Research and Action.)

Objective: Emergency department (ED) boarding of patients who are critically ill is associated with poor outcomes. ED-based intensive care units (ED-ICUs) may mitigate the risks of ED boarding. We sought to analyze the impact of ED length of stay (LOS) before transfer to an ED-ICU on patient outcomes., Methods: We retrospectively analyzed adult ED patients managed in the ED-ICU at a US medical center. Bivariate and multivariable linear regressions tested ED LOS as a predictor of inpatient ICU and hospital LOS, and separate bivariate and multivariable logistic regressions tested ED LOS as a predictor of inpatient ICU admission, 48-hour mortality, and hospital mortality. Multivariable analyses' covariates were age, sex, Charlson Comorbidity Index (CCI), Emergency Severity Index, and eSimplified Acute Physiology Score (eSAPS3)., Results: We included 5859 ED visits with subsequent care in the ED-ICU. Median age, CCI, eSAPS3, ED LOS, and ED-ICU LOS were 62 years (interquartile range [IQR], 48-73 years), 5 (IQR, 2-8), 46 (IQR, 36-56), 3.6 hours (IQR, 2.5-5.3 hours), and 8.5 hours (IQR, 5.3-13.4 hours), respectively, and 46.3% were women. Bivariate analyses showed negative associations of ED LOS with hospital LOS (β = -3.4; 95% confidence interval [CI], -5.9 to -1.0), inpatient ICU admission (odds ratio [OR], 0.86, 95% CI, 0.84-0.88), 48-hour mortality (OR, 0.89; 95% CI, 0.82-0.98), and hospital mortality (OR, 0.89; 95% CI, 0.85-0.92), but no association with inpatient ICU LOS. Multivariable analyses showed a negative association of ED LOS with inpatient ICU admission (OR, 0.91; 95% CI, 0.88-0.93), but no associations with other outcomes., Conclusions: We observed no significant associations between ED LOS before ED-ICU transfer and worsened outcomes, suggesting an ED-ICU may mitigate the risks of ED boarding of patients who are critically ill., Competing Interests: The authors declare no conflict of interest., (© 2022 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

Background: Lung protective ventilation (LPV) is a key component in the management of acute respiratory distress syndrome and other acute respiratory pathology. Initiation of LPV in the emergency department (ED) is associated with improved patient-centered and system outcomes, but adherence to LPV among ED patients is low. The impact of an ED-based ICU (ED-ICU) on LPV adherence is not known., Methods: This single-center, retrospective, cohort study analyzed rates of adherence to a multifaceted LPV strategy pre- and post-implementation of an ED-ICU. LPV strategy components included low tidal volume ventilation, avoidance of severe hyperoxia and high plateau pressures, and positive end-expiratory pressure settings in alignment with best-evidence recommendations. The primary outcome was adherence to the LPV strategy at time of ED departure., Results and Conclusions: A total of 561 ED visits were included in the analysis, of which 60.0% received some portion of their emergency care in the ED-ICU. Adherence to the LPV strategy was statistically significantly higher in the ED-ICU cohort compared with the pre-ED-ICU cohort (65.8% vs 41.4%; p < 0.001) and non-ED-ICU cohort (65.8% vs 43.1%; p < 0.001). Among the ED-ICU cohort, 92.8% of patients received low tidal volume ventilation. Care in the ED-ICU was also associated with shorter ICU and hospital length of stay. These findings suggest improved patient and resource utilization outcomes for mechanically ventilated ED patients receiving care in an ED-ICU., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Background: Exception from informed consent (EFIC) enables the enrollment of research subjects with emergent conditions to clinical trials without prior consent. EFIC study approval requires community consultation and public disclosure. We hypothesized that the integration of social media with targeted emails and in-person outreach is an effective community consultation strategy., Methods: We utilized social media with targeted emails and in-person outreach for the community consultation of the ACCESS cardiac arrest trial. Study advertisements were disseminated using Facebook and Instagram, and targeted emails were sent to emergency medicine, prehospital, and cardiology providers. We also interviewed at-risk individuals with cardiac conditions, their caretakers, and patient advocacy groups. Participants were asked to complete a survey about their opinions about the study., Results: We collected 559 surveys over an 8-week period, and 70.5% of the surveys were obtained using social media. The median (IQR) age of survey respondents was 44 (33-57) years; 89.9% were White and 60.1% were women. A total of 91.3% believed ACCESS was an important study. Compared to the in-person group, more from social media (81.8% vs. 63.3%, p < 0.05) and targeted email (77.4% vs. 63.3%, p < 0.05) groups said they would include their loved ones in the study. More from the in-person group believed that their opinion would be considered seriously compared to the social media (75.9% vs. 62.6%, p < 0.05) and targeted email (75.9% vs. 54.5%, p < 0.05) groups. The incorporation of social media and targeted emails for community consultation reduced the cost per survey by fourfold compared to an in-person-only strategy., Conclusions: The integration of social media with targeted emails and in-person outreach was a feasible and cost-saving approach for EFIC community consultation. Future work is necessary to determine the perception and best utilization of social media for community consultation., (© 2021 Society for Academic Emergency Medicine.)

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.

Objective: The objective of this study was to evaluate feasibility of supplementing emergency department (ED) concussion discharge instructions for adolescents and parents with a newly created educational comic and a publicly available comic-based video at an outpatient sports neurology clinic., Methods: We created a gender-neutral, 2-page comic to augment text-only ED concussion discharge instructions. A sample of patients evaluated at a sports neurology clinic and their parents/guardians participated. Patients and their parents were randomized to view either the comic only or both the comic and publicly available comic-based video. Patients and parents completed preintervention and postintervention surveys to assess likeability and concussion knowledge including concussion definition, symptoms, return-to-ED criteria, and resuming normal activity. Data were analyzed using descriptive and comparative statistics., Results: A total of 57 patients (47.4% female; mean age, 15 years) and 37 guardians were enrolled. Most (73%) concussions were sports related, with the majority having sought care within 24 hours in an ED (80%). Over half (51%) had experienced 2 or more prior concussions. Overall, 31 adolescents and 20 guardians viewed both comic and video, whereas 26 adolescents and 17 guardians viewed the comic only. Both comic and video were favorably reviewed, but a higher proportion of respondents rated the video more positively than the comic for likability (P < 0.01), comprehensibility (P < 0.05), and increasing understanding (P < 0.05). Patients' knowledge of some concussion symptoms emphasized in the comic increased after reading (emotional changes, P = 0.02; vomiting, P = 0.04)., Conclusions: Patients showed increased concussion knowledge using the favorably endorsed comic-based discharge instructions. Using comic-based supplemental discharge tools may optimize concussion education for adolescents., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Upper gastrointestinal bleeding (UGIB) is associated with substantial morbidity, mortality, and intensive care unit (ICU) utilization. Initial risk stratification and disposition from the Emergency Department (ED) can prove challenging due to limited data points during a short period of observation. An ED-based ICU (ED-ICU) may allow more rapid delivery of ICU-level care, though its impact on patients with UGIB is unknown., Methods: A retrospective observational study was conducted at a tertiary U.S. academic medical center. An ED-ICU (the Emergency Critical Care Center [EC3]) opened in February 2015. Patients presenting to the ED with UGIB undergoing esophagogastroduodenoscopy within 72 h were identified and analyzed. The Pre- and Post-EC3 cohorts included patients from 9/2/2012-2/15/2015 and 2/16/2015-6/30/2019., Results: We identified 3788 ED visits; 1033 Pre-EC3 and 2755 Post-EC3. Of Pre-EC3 visits, 200 were critically ill and admitted to ICU [Cohort A]. Of Post-EC3 visits, 682 were critically ill and managed in EC3 [Cohort B], whereas 61 were critically ill and admitted directly to ICU without care in EC3 [Cohort C]. The mean interval from ED presentation to ICU level care was shorter in Cohort B than A or C (3.8 vs 6.3 vs 7.7 h, p < 0.05). More patients in Cohort B received ICU level care within six hours of ED arrival (85.3 vs 52.0 vs 57.4%, p < 0.05). Mean hospital length of stay (LOS) was shorter in Cohort B than A or C (6.2 vs 7.3 vs 10.0 days, p < 0.05). In the Post-EC3 cohort, fewer patients were admitted to an ICU (9.3 vs 19.4%, p < 0.001). The rate of floor admission with transfer to ICU within 24 h was similar. No differences in absolute or risk-adjusted mortality were observed., Conclusion: For critically ill ED patients with UGIB, implementation of an ED-ICU was associated with reductions in rate of ICU admission and hospital LOS, with no differences in safety outcomes., Competing Interests: Declaration of Competing Interest The authors individually and collectively have no conflicts of interest to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Although community violence and the deleterious behavioral and psychological consequences that are associated with exposure to community violence persist as serious public health concerns, identifying malleable factors that increase or decrease adolescents' risk of exposure to community violence remains a significant gap in our knowledge base. This longitudinal study addresses this research gap by investigating adolescents' endorsement of familismo values and participation in three types of after-school activities, specifically home-, school-, and community-based activities, as potential precursors to adolescents' risk for experiencing community violence. The sample consists of 416 Latino high school students (53% female) with a mean age of 15.5 years (SD = 1.0) and with 85% qualifying for free and reduced school lunch. Cross-sectional results demonstrated that adolescents' endorsement of the Latino cultural value of familismo was associated with lower rates of personal victimization. The frequency of non-structured community-based activities and part-time work were concurrently associated with higher rates of witnessing community violence and being personally victimized by violence. Only the frequency of non-structured community-based activities was related to witnessing more community violence and greater victimization one year later while controlling for prior exposure to violence. These findings underscore the importance of providing structured, well supervised after-school activities for low-income youth in high-risk neighborhoods., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background Vascular access is a critical component of emergency department (ED) care. Ultrasound guided placement of peripheral intravenous (USIV) catheters is increasingly common. However, USIV are thought to suffer from reduced durability and higher complication rates. Extended dwell catheters (EDC) are long peripheral IVs placed under combined ultrasound and wire guidance. The goal of this study is to compare dwell times and complication rates of EDC to standard peripheral USIV. Methods We performed a retrospective cohort study at a tertiary care adult ED comparing IV placements during a 17-month period (8/1/2018-12/31/2019), stratified by standard USIV versus EDC. The primary outcome was catheter dwell time and secondary outcomes included need for inpatient vascular access team (VAST) consultation, peripherally inserted central catheter (PICC) insertions, and radiocontrast extravasations. Multivariable Cox regression time-to-event analyses were used to evaluate dwell times, adjusting for age, gender, BMI and end-stage renal disease. Results 359 EDC and 4190 standard USIV were included for analysis. Most USIV (95.6%) and EDC (98.3%) were placed by ED technicians trained in ultrasound vascular access. EDC median dwell time (5.9 days [95%CI: 5.1-6.7]) exceeded standard USIV (3.8 days [95% CI: 3.6-4.0]). Patients with EDC placed in the ED required less VAST consultation (0.84 vs 0.99 charges/encounter), had similar rates of PICC line use (8.0% vs 8.4% of encounters) and had no radiocontrast extravasation events. Multivariable Cox regression demonstrated survival benefit (longer dwell time) favoring EDC (HR 0.70 [95%CI 0.60-0.81]). Conclusion Use of EDC results in longer dwell time and reduces subsequent use of vascular access resources, while maintaining low complication rates. EDC demonstrate superior durability which may justify their selection over standard USIV in some patients., Competing Interests: Declaration of Competing Interest JT reports that has received payment from Teleflex Inc. as a clinical educator., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Emergency physicians (EPs) perform critical actions while operating with diagnostic uncertainty. Point-of-care ultrasound (POCUS) is useful in evaluation of dyspneic patients. In prior studies, POCUS is often performed by ultrasound (US) teams without patient care responsibilities., Objectives: This study evaluates the effectiveness of POCUS in narrowing diagnostic uncertainty in dyspneic patients when performed by treating EPs vs. separate US teams., Methods: This multicenter, prospective noninferiority cohort study investigated the effect of a POCUS performing team in patient encounters for dyspnea. Before-and-after surveys assessing medical decision-making were administered to attending physicians. Primary outcome was change in most likely diagnosis after POCUS. This was assessed for noninferiority between encounters where the primary or US team performed POCUS. Secondary outcomes included change in differential diagnosis, confidence in diagnosis, interventions considered, and image quality., Results: There were 156 patient encounters analyzed. In the primary team group, most likely diagnosis changed in 40% (95% confidence interval 28-52%) of encounters vs. 32% (95% confidence interval 22-41%) in the US team group. This was noninferior using an a priori specified margin of 20% (p < .0001). Post-POCUS differential decreased by a mean 1.8 diagnoses and was equivalent within a margin of 0.5 diagnoses between performing teams (p = 0.034). Other outcomes were similar between groups., Conclusion: POCUS performed by primary teams was noninferior to POCUS performed by US teams for changing the most likely diagnosis, and equivalent when considering mean reduction in number of diagnoses. POCUS performed by treating EPs reduces cognitive burden in dyspneic patients., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Pertussis is a serious public health concern and accurate diagnosis is imperative. Comprehensive, multiplex respiratory pathogen polymerase chain reaction (PCR) panels (RPPs) have recently become popular, but their utility in excluding pertussis infection has not been fully explored., Objectives: To determine RPP testing results for pertussis using frozen banked samples that previously tested positive on dedicated Bordetella pertussis PCR testing, and to describe positive test rates for other respiratory pathogens on these samples via RPP., Methods: Our microbiology laboratory retrieved banked nasopharyngeal samples from inpatient, ambulatory, and emergency department sources that were positive for pertussis using B. pertussis PCR testing from March 2015 to October 2017. RPP was performed on thawed, archived samples. Rate of pertussis identification on RPP was determined, and positive tests for other pathogens were tabulated., Results: A total of 3482 specimens were submitted for pertussis PCR testing during the study period. Of those, 138 (4%) were positive for B. pertussis, and 102 (74%) samples were banked and available for RPP testing. Fifty-seven of 102 (56%) of the banked samples had positive RPP testing for pertussis. Of the 45 samples negative for pertussis on RPP testing, 20 (44%) tested positive for other respiratory pathogens., Conclusion: Negative testing for B. pertussis and positive testing for other respiratory pathogens on RPP was common in samples that previously tested positive on dedicated B. pertussis PCR testing, both of which could lead to missed diagnoses of pertussis infection. Clinicians should consider using dedicated pertussis PCR testing if pertussis infection is suspected., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: Emergency department (ED) patients are frequently ventilated with excessively large tidal volumes for predicted body weight based on height, which has been linked to poorer patient outcomes. We hypothesized that supplying tape measures to respiratory therapists (RT) would improve measurement of actual patient height and adherence to a lung-protective ventilation strategy in an ED-intensive care unit (ICU) environment., Methods: On January 14, 2019, as part of a ventilator-associated pneumonia prevention bundle in our ED-based ICU, we began providing RTs with tape measures and created a best practice advisory reminding them to record patient height. We then retrospectively collected data on patient height and tidal volumes before and after the intervention., Results: We evaluated 51,404 tidal volume measurements in 1,826 patients over the 4 year study period; of these patients, 1,579 (86.5%) were pre-intervention and 247 (13.5%) were post-intervention. The intervention was associated with a odds of the patient's height being measured were 10 times higher post-intervention (25.1% vs 3.2%, P <0.05). After the bundle was initiated, we observed a significantly higher percentage of patients ventilated with mean tidal volumes less than 8 cubic centimeters per kilogram (93.9% vs 84.5% P < 0.05)., Conclusion: Patients in an ED-ICU environment were ventilated with a lung-protective strategy more frequently after an intervention reminding RTs to measure actual patient height and providing a tape measure to do so. A significantly higher percentage of patients had height measured rather than estimated after the intervention, allowing for more accurate determination of ideal body weight and calculation of lung-protective ventilation volumes. Measuring all mechanically ventilated patients' height with a tape measure is an example of a simple, low-cost, scalable intervention in line with guidelines developed to improve the quality of care delivered to critically ill ED patients.

Purpose: Identification of tube thoracostomy insertion location is currently performed using a blind, landmark based approach at either the fifth intercostal space (ICS) or inframammary crease in the midaxillary line. A significant percentage of thoracostomies at this site result in complications. This pilot study aimed to assess whether bedside ultrasound could aid in identifying safer tube thoracostomy insertion sites in emergency department patients., Methods: Fifty emergency department patients were enrolled in this study. Right and left hemidiaphragms were evaluated with ultrasound at the fifth ICS. Observations were made on if the diaphragm was below, above, or crossed the fifth ICS during an entire respiratory cycle., Results: Eighty-one (95% confidence interval 72-82) of the diaphragms were below, 13 (95% confidence interval 8-21) of the diaphragms were at, and 6 (95% confidence interval 3-12) of the diaphragms were above the location marked using traditional landmark techniques. On the right and left hemidiaphragms, 20% (95% confidence interval 19.9%-20.1%) and 18% (95% confidence interval 17.9%-18.1%) of diaphragms were above or crossing the fifth ICS, respectively CONCLUSIONS: Ultrasound identified a significant number of potential chest tube insertion sites at the fifth ICS that would result in subdiaphragmatic insertion or diaphragmatic injury. Based on this data ultrasound can be used to identify safer insertion sites and reduce thoracostomy complications., (© 2020 Wiley Periodicals, Inc.)

Background: Many emergency department (ED) patients in diabetic ketoacidosis (DKA) are admitted to an inpatient intensive care unit (ICU), while ICU capacity is under increasing strain. The Emergency Critical Care Center (EC3), a hybrid ED-ICU setting, opened with the goal of providing rapid initiation of ICU care in the ED., Objective: We sought to evaluate the impact of an ED-ICU on disposition and safety outcomes for adult ED patients in DKA., Methods: This was a retrospective pre-post cohort of ED visits from 2012-2018 at a single academic medical center. Adult ED patients in DKA (pH < 7.30, HCO 3  < 18 mEq/L, anion gap > 14, and glucose > 250 mg/dL) immediately before (pre-EC3) and after (post-EC3) opening of an ED-ICU were identified. ED disposition and safety data were collected and analyzed., Results: We identified 631 patient encounters: 217 pre-EC3 and 414 post-EC3. Baseline demographics were similar between cohorts. Fewer patients in the post-EC3 cohort were admitted to an ICU (11.6% vs. 23.5%, p < 0.001, number needed to treat [NNT] = 8) or general floor bed (58.0% vs. 73.3%, p < 0.001, NNT = 6), and more were discharged from the ED (27.1% vs. 1.4%, p < 0.001, NNT = 4). Rates of hypokalemia (10.1% vs. 6.0%, p = 0.08) and admission to non-ICU with transfer to ICU within 24 h (0.5% vs. 0%, p = 0.30) did not differ., Conclusion: Management of patients with DKA in an ED-ICU was associated with decreased ICU and hospital utilization with similar safety outcomes. Managing rapidly reversible critical illnesses in an ED-ICU may help obviate increasing strain facing many health care systems., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Leukostasis is a life-threatening complication of acute hyperleukocytic leukemia, and is associated with substantial mortality. Management of leukostasis requires time-sensitive diagnostics and therapeutics, and leukapheresis remains a mainstay of treatment in select patients. Leukapheresis requires coordination of multi-disciplinary resources, which can prove challenging in the emergency department setting, and delays in treatment due to the complexity and coordination required are common. The objective of this study was to assess the effect of utilization of an emergency department-ICU and a multidisciplinary care pathway on outcomes of critically ill leukostasis patients presenting to the emergency department., Design: Retrospective cohort study., Setting: Single large academic medical center in the United States., Patients: Adult emergency department patients with signs and symptoms of leukostasis requiring emergent leukapheresis from 2012-2019., Interventions: Implementation of a hybrid emergency department-ICU setting (emergency critical care center) and a multidisciplinary care pathway with members from Emergency Medicine, Hematology, Blood Bank, and Clinical Pathology., Measurements and Main Results: A total of 70 patients were identified and included for analysis: 14 preemergency critical care center; 32 postemergency critical care center, premultidisciplinary care pathway; and 24 postemergency critical care center, postmultidisciplinary care pathway. A statistically significant reduction in the time from emergency department presentation to initiation of leukapheresis was observed from preemergency critical care center to postemergency critical care center, premultidisciplinary care pathway and postemergency critical care center, postmultidisciplinary care pathway (11.5 vs 7.9 vs 7.7 hr; p = 0.004). Statistically significant reductions in in-hospital mortality were observed from preemergency critical care center to postemergency critical care center, premultidisciplinary care pathway and postemergency critical care center, postmultidisciplinary care pathway (64.3% vs 21.9% vs 25.0%; p = 0.01). A trend toward decreased inpatient ICU utilization was observed, although was not statistically significant (35.7% vs 12.5% vs 25.0%; p = 0.14.)., Conclusions and Relevance: Implementation of a multidisciplinary care pathway via use of an emergency department-ICU for critically ill patients with leukostasis was associated with statistically significant reductions in time to leukapheresis and in-hospital mortality. These findings suggest an emergency department-ICU model may allow for maximal resource and care coordination at the point of contact with critically ill patients and improved clinical outcomes., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Objective: Interpersonal violence is a significant public health problem, with substance use a key risk factor. Intensive longitudinal methods (ILMs) provide data on daily patterns/relationships between substance use and violence, informing prevention. Prior daily research has not focused on these relationships among urban minority samples., Methods: Within an RCT comparing ILM assessment/schedule methods, 162-participants completed daily IVR (n = 81) or SMS (n = 81) assessments measuring 19 substance use and violence (partner/non-partner) behaviors daily for 90-days. GLMMs characterized between- and within-person predictors of daily violence., Results: Participants [48.7%-female; age = 24.4; 62.3%-African-American; 66.7%-public assistance] completed an average of 46.5 daily reports [SD = 26.7]. Across 90-days, alcohol was characterized by episodic weekend use (average = 10 days-of-use, 34.4% drinking-days involved binge-drinking), while marijuana use was continuous (average = 27 days-of-use; 1.7 times/day), with no weekend differences. Among 118-violent conflicts, 52.5% occurred on weekends; 57.6% were with non-partners/peers; 61.0% involved perpetration/57.6% victimization; and 52.5% involved severe violence. For violence conflicts, 27.1% were preceded by alcohol/22.9% preceded by drug use. Between-person predictors of daily violence included retaliatory attitudes (AOR = 3.2) and anxiety (AOR = 1.1). Within-person predictors included weekends (AOR = 1.6), binge drinking (AOR = 1.9), non-medical prescription opioid use (AOR = 3.5) and illicit drug use (AOR = 8.1)., Conclusion: Among a high-risk urban minority sample, we found that higher baseline retaliatory attitudes and anxiety, as well as same-day binge drinking, non-medical prescription opioid use, and illicit drug use were associated with daily violence, likely reflecting both pharmacological and socio-contextual factors. Addressing substance use and retaliatory violence with tailored prevention efforts may aid in decreasing negative interpersonal violence outcomes., (Copyright © 2019. Published by Elsevier Ltd.)

Introduction: Leading change effectively is critical to advancing medical education. Residency didactics often require change in order to meet stakeholder's needs. Kotter's change management model (KCMM) is an 8-step method for implementing change that can be applied to educational initiatives. This innovation improved an emergency medicine residency didactics curriculum through application of KCMM., Methods: An initiative to improve residency didactics curriculum was titled the "Didactics Revolution" and implemented according to KCMM: establish a sense of urgency, form a powerful guiding coalition, create a vision, communicate the vision, empower others to act on the vision, plan for and create short-term wins, consolidate improvements and produce still more change, and institutionalize new approaches. Data from the Annual Program Review was utilized to assess the impact of the KCMM strategy., Results: The percentage of residents who agreed or strongly agreed that lectures provide a valuable learning experience increased from 39.1% in the year prior to 88.0% in the year during the implementation (p < .001), and remained relatively high at 73.5% in the year following. The percentage of residents who agreed or strongly agreed that they felt well-prepared for the written boards increased from 60.9% in the year prior to 92.0% in the year during the implementation (p = .01) and remained high at 73.5% in the year following., Conclusion: Residency didactics can be improved through the use of KCMM, a change management model originally developed in the corporate context.

Importance: Increased patient acuity, decreased intensive care unit (ICU) bed availability, and a shortage of intensivist physicians have led to strained ICU capacity. The resulting increase in emergency department (ED) boarding time for patients requiring ICU-level care has been associated with worse outcomes., Objective: To determine the association of a novel ED-based ICU, the Emergency Critical Care Center (EC3), with 30-day mortality and inpatient ICU admission., Design, Setting, and Participants: This retrospective cohort study used electronic health records of all ED visits between September 1, 2012, and July 31, 2017, with a documented clinician encounter at a large academic medical center in the United States with approximately 75 000 adult ED visits per year. The pre-EC3 cohort included ED patients from September 2, 2012, to February 15, 2015, when the EC3 opened, and the post-EC3 cohort included ED patients from February 16, 2015, to July 31, 2017. Data analyses were conducted from March 2, 2018, to May 28, 2019., Exposures: Implementation of EC3, an ED-based ICU designed to provide rapid initiation of ICU-level care in the ED setting and seamless transition to inpatient ICUs., Main Outcomes and Measures: The main outcomes were 30-day mortality among ED patients and rate of ED to ICU admission., Results: A total of 349 310 visits from a consecutive sample of ED patients (mean [SD] age, 48.5 [19.7] years; 189 709 [54.3%] women) were examined; the pre-EC3 cohort included 168 877 visits and the post-EC3 cohort included 180 433 visits. Implementation of EC3 was associated with a statistically significant reduction in risk-adjusted 30-day mortality among all ED patients (pre-EC3, 2.13%; post-EC3, 1.83%; adjusted odds ratio, 0.85; 95% CI, 0.80-0.90; number needed to treat, 333 patient encounters; 95% CI, 256-476). The risk-adjusted rate of ED admission to ICU decreased with implementation of EC3 (pre-EC3, 3.2%; post-EC3, 2.7%; adjusted odds ratio, 0.80; 95% CI, 0.76-0.83; number needed to treat, 179 patient encounters; 95% CI, 149-217)., Conclusions and Relevance: Implementation of a novel ED-based ICU was associated with improved 30-day survival and reduced inpatient ICU admission. Additional research is warranted to further explore the value of this novel care delivery model in various health care systems.

Objectives: The Association of American Medical Colleges Standardized Video Interview (SVI) was recently added as a component of emergency medicine (EM) residency applications to provide additional information about interpersonal communication skills (ICS) and knowledge of professionalism (PROF) behaviors. Our objective was to ascertain the correlation between the SVI and residency interviewer assessments of PROF and ICS. Secondary objectives included examination of 1) inter- and intrainstitutional assessments of ICS and PROF, 2) correlation of SVI scores with rank order list (ROL) positions, and 3) the potential influence of gender on interview day assessments., Methods: We conducted an observational study using prospectively collected data from seven EM residency programs during 2017 and 2018 using a standardized instrument. Correlations between interview day PROF/ICS scores and the SVI were tested. A one-way analysis of variance was used to analyze the association of SVI and ROL position. Gender differences were assessed with independent-groups t-tests., Results: A total of 1,264 interview-day encounters from 773 unique applicants resulted in 4,854 interviews conducted by 151 interviewers. Both PROF and ICS demonstrated a small positive correlation with the SVI score (r = 0.16 and r = 0.17, respectively). ROL position was associated with SVI score (p  <  0.001), with mean SVI scores for top-, middle-, and bottom-third applicants being 20.9, 20.5, and 19.8, respectively. No group differences with gender were identified on assessments of PROF or ICS., Conclusions: Interview assessments of PROF and ICS have a small, positive correlation with SVI scores. These residency selection tools may be measuring related, but not redundant, applicant characteristics. We did not identify gender differences in interview assessments.

Background: Extracorporeal cardiopulmonaryresuscitation (ECPR) is emerging as a viable rescue strategy for refractory out-of-hospital cardiac arrest. In the U.S., limited training of emergency medicine providers is a barrier to widespread implementation., Aims: Test the hypothesis that emergency medicine physicians and nurses can acquire and retain the skills to rapidly and safely initiate ECPR using high-fidelity simulation., Study Design: Prospective interventional study., Setting: U.S. tertiary academic medical center., Subjects: Emergency medicine physicians and nurses with no prior ECPR/ECMO experience., Methods: Teams of three physicians and three nurses underwent a two-day ECPR training course including didactics, hands-on training, and simulation. Teams were videotaped initiating ECPR in a high-fidelity simulation scenario before and after simulation training. The primary outcome was the proportion of simulations in which full ECPR support was achieved within 30 min of patient arrival., Results: Five teams completed the entire study. Full ECPR support was achieved within 30 min of patient arrival in 11/15, 15/15, and 15/15 attempts at baseline (B), post-testing (PT) and 3-month post-testing (3-PT), respectively (p = 0.06). Intervals (mean ± sd) required to achieve full ECPR support at B, PT, and 3-PT were 25.8±5.3, 17.2±4.6, and 19.2±1.9 min respectively (p < 0.05 for B vs. PT and 3-PT)., Conclusion: High fidelity simulation training is effective in preparing emergency medicine physicians and nurses to rapidly and safely initiate ECPR in a simulated cardiac arrest scenario, and should be considered when implementing an ED-based ECPR program., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Driving under the influence of cannabis (DUIC) is a public health concern among those using medical cannabis. Understanding behaviors contributing to DUIC can inform prevention efforts. We evaluated three past 6-month DUIC behaviors among medical cannabis users with chronic pain., Methods: Adults (N = 790) seeking medical cannabis certification or recertification for moderate/severe pain were recruited from February 2014 through June 2015 at Michigan medical cannabis clinics. About half of participants were male (52%) and 81% were White; their Mean age was 45.8 years. Participants completed survey measures of DUIC (driving within 2 h of use, driving while "a little high," and driving while "very high") and background factors (demographics, alcohol use, etc.). Unadjusted and adjusted logistic regressions were used to examine correlates of DUIC., Results: For the past 6 months, DUIC within 2 h of use was reported by 56.4% of the sample, DUIC while a "little high" was reported by 50.5%, and "very high" was reported by 21.1%. Greater cannabis quantity consumed and binge drinking were generally associated with DUIC behaviors. Higher pain was associated with lower likelihood of DUIC. Findings vary somewhat across DUIC measures., Conclusions: The prevalence of DUIC is concerning, with more research needed on how to best measure DUIC. Prevention messaging for DUIC may be enhanced by addressing alcohol co-consumption., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective: More than a third of the U.S. population of older adults is obese. The present study tests the Dyadic Biopsychosocial Model of Marriage and Health, which hypothesizes that, among married couples, individual and partner chronic stress predicts increased waist circumference and these links are exacerbated in negative quality marriages., Method: Participants were from the nationally representative longitudinal Health and Retirement Study (HRS). A total of 2,042 married individuals (in 1,098 married couples) completed psychosocial and waist circumference assessments in 2006 and 2010. Analyses examined whether negative marital quality and chronic stress in Wave 1 (2006) were associated with changes in waist circumference over time., Results: Actor-partner interdependence models revealed that greater partner stress, rather than individuals' own reports of stress, was associated with increased waist circumference over time. Higher perceived negative marital quality among husbands and lower negative marital quality among wives exacerbated the positive link between partner stress and waist circumference., Discussion: Consistent with the Dyadic Biopsychosocial Model of Marriage and Health, partner stress has direct associations with waist circumference among couples and this link is moderated by negative marital quality. Thus, dyadic perceptions of stress and negative marital quality are important to consider for understanding marriage and obesity.