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Introduction: Emergency departments (EDs) may be high-yield venues to address opioid deaths with education on both overdose prevention and appropriate actions in a witnessed overdose. In addition, the ED has the potential to equip patients with nasal naloxone kits as part of this effort. We evaluated the feasibility of an ED-based overdose prevention program and described the overdose risk knowledge, opioid use, overdoses, and overdose responses among participants who received overdose education and naloxone rescue kits (OEN) and participants who received overdose education only (OE). Methods: Program participants were surveyed by telephone after their ED visit about their substance use, overdose risk knowledge, history of witnessed and personal overdoses, and actions in a witnessed overdose including use of naloxone. Results: A total of 415 ED patients received OE or OEN between January 1, 2011 and February 28, 2012. Among those, 51 (12%) completed the survey; 37 (73%) of those received a naloxone kit, and 14 (27%) received OE only. Past 30-day opioid use was reported by 35% OEN and 36% OE, and an overdose was reported by 19% OEN and 29% OE. Among 53% (27/51) of participants who witnessed another individual experiencing an overdose, 95% OEN and 88% OE stayed with victim, 74% OEN and 38% OE called 911, 26% OEN and 25% OE performed rescue breathing, and 32% OEN (n=6) used a naloxone kit to reverse the overdose. We did not detect statistically significant differences between OEN and OE-only groups in opioid use, overdose or response to a witnessed overdose. Conclusion: This is the first study to demonstrate the feasibility of ED-based opioid overdose prevention education and naloxone distribution to trained laypersons, patients and their social network. The program reached a high-risk population that commonly witnessed overdoses and that called for help and used naloxone, when available, to rescue people. While the study was retrospective with a low response rate, it provides preliminary data for larger, prospective studies of ED-based overdose prevention programs. [West J Emerg Med. 2015;16(3):381–384.]

Introduction: Current recommendations for diagnostic imaging for moderately to severely ill patients with suspected coronavirus disease 2019 (COVID-19) include chest radiograph (CXR). Our primary objective was to determine whether lung ultrasound (LUS) B-lines, when excluding patients with alternative etiologies for B-lines, are more sensitive for the associated diagnosis of COVID-19 than CXR.Methods: This was a retrospective cohort study of all patients who presented to a single, academic emergency department in the United States between March 20 and April 6, 2020, and received LUS, CXR, and viral testing for COVID-19 as part of their diagnostic evaluation. The primary objective was to estimate the test characteristics of both LUS B-lines and CXR for the associated diagnosis of COVID-19. Our secondary objective was to evaluate the proportion of patients with COVID-19 that have secondary LUS findings of pleural abnormalities and subpleural consolidations.Results: We identified 43 patients who underwent both LUS and CXR and were tested for COVID-19. Of these, 27/43 (63%) tested positive. LUS was more sensitive (88.9%, 95% confidence interval (CI), 71.1-97.0) for the associated diagnosis of COVID-19 than CXR (51.9%, 95% CI, 34.0-69.3; p = 0.013). LUS and CXR specificity were 56.3% (95% CI, 33.2-76.9) and 75.0% (95% CI, 50.0-90.3), respectively (p = 0.453). Secondary LUS findings of patients with COVID-19 demonstrated 21/27 (77.8%) had pleural abnormalities and 10/27 (37%) had subpleural consolidations.Conclusion: Among patients who underwent LUS and CXR, LUS was found to have a higher sensitivity than CXR for the evaluation of COVID-19. This data could have important implications as an aid in the diagnostic evaluation of COVID-19, particularly where viral testing is not available or restricted. If generalizable, future directions would include defining how to incorporate LUS into clinical management and its role in screening lower-risk populations.

Background: High mammographic density is one of the strongest breast cancer risk factors; however, determinants of high mammographic density are understudied in Black women. We assessed growth and development factors across the lifecourse in relation to mammographic density. Methods: Within the Black Women's Health Study, we used Cumulus software to assess percent mammographic density from digital screening mammograms for 5,905 women ages 40 to 74 years. We fit linear regression models to quantify the association of lifecourse characteristics including birthweight, childhood somatotype, age at menarche, body mass index (BMI) at age 18 years, height, BMI at mammography, and adulthood waist-to-hip ratio with density overall and by age. We also performed a path analysis to assess the total and mediating effects of the growth and development factors on density. Results: BMI at age 18 years, height, BMI at mammography, and waist-to-hip ratio were significantly and inversely associated with density. On path analysis, total effects of childhood somatotype (standardized ß = -0.05, P < 0.001), BMI at age 18 years (standardized ß = -0.13, P < 0.001), BMI at mammography (standardized ß = -0.22, P < 0.001), and waist-to-hip ratio (standardized ß = -0.04, P < 0.001) were associated with density. Conclusions: Several factors across the lifecourse--greater childhood somatotype, BMI at age 18 years, height, BMI at mammography, and waist-to-hip ratio--were associated with lower mammographic density in this cohort of Black women. [ABSTRACT FROM AUTHOR]

Introduction: Supporting an “ultrasound-first” approach to evaluating renal colic in the emergency department (ED) remains important for improving patient care and decreasing healthcare costs. Our primary objective was to compare emergency physician (EP) ultrasound to computed tomography (CT) detection of hydronephrosis severity in patients with suspected renal colic. We calculated test characteristics of hydronephrosis on EP-performed ultrasound for detecting ureteral stones or ureteral stone size >5mm. We then analyzed the association of hydronephrosis on EP-performed ultrasound, stone size >5mm, and proximal stone location with 30-day events.Methods: This was a prospective observational study of ED patients with suspected renal colic undergoing CT. Subjects had an EP-performed ultrasound evaluating for the severity of hydronephrosis. A chart review and follow-up phone call was performed.Results: We enrolled 302 subjects who had an EP-performed ultrasound. CT and EP ultrasound results were comparable in detecting severity of hydronephrosis (x2=51.7, p5mm less likely (NPV 89%; LR-0.39). Larger stone size > 5mm was associated with 30-day events (OR 2.30, p=0.03).Conclusion: Using an ultrasound-first approach to detect hydronephrosis may help physicians identify patients with renal colic. The lack of hydronephrosis on ultrasound makes the presence of a larger ureteral stone less likely. Stone size >5mm may be a useful predictor of 30-day events.

BackgroundThe electrocardiographic PR interval increases with aging, differs by race, and is associated with atrial fibrillation (AF), pacemaker implantation, and all-cause mortality. We sought to determine the associations between PR interval and heart failure, AF, and mortality in a biracial cohort of older adults.Methods and resultsThe Health, Aging, and Body Composition (Health ABC) Study is a prospective, biracial cohort. We used multivariable Cox proportional hazards models to examine PR interval (hazard ratios expressed per SD increase) and 10-year risks of heart failure, AF, and all-cause mortality. Multivariable models included demographic, anthropometric, and clinical variables in addition to established cardiovascular risk factors. We examined 2722 Health ABC participants (aged 74±3 years, 51.9% women, and 41% black). We did not identify significant effect modification by race for the outcomes studied. After multivariable adjustment, every SD increase (29 ms) in PR interval was associated with a 13% greater 10-year risk of heart failure (95% confidence interval, 1.02-1.25) and a 13% increased risk of incident AF (95% confidence interval, 1.04-1.23). PR interval >200 ms was associated with a 46% increased risk of incident heart failure (95% confidence interval, 1.11-1.93). PR interval was not associated with increased all-cause mortality.ConclusionsWe identified significant relationships of PR interval to heart failure and AF in older adults. Our findings extend prior investigations by examining PR interval and associations with adverse outcomes in a biracial cohort of older men and women.

Background: Recent reports have identified associations between patient race and ethnicity and use of physical restraint while receiving care in the emergency department (ED). However, no study has assessed this relationship in hospitals primarily treating patients of color and underserved populations. The primary objective of this study was to evaluate the association between race/ethnicity and the use of restraints in an ED population at a minority‐serving, safety‐net institution. Methods: For this cross‐sectional study, chart review identified all adult patients presenting to the Boston Medical Center ED between January 2018 and April 2021. Generalized estimating equation logistic regression modeling was conducted to evaluate associations between race and use of restraints. Results: Of 348,384 ED visits (22.9% White, 46.7% Black, 23.1% Hispanic), 1852 (0.5%) had an associated physical restraint order. Multivariable models showed significant interactions (p = 0.02) between race/ethnicity, behavioral health diagnosis, and sex on the primary outcome of physical restraint. Stratified analysis revealed that among patients with no behavioral health diagnoses, Black (odds ratio [OR] 0.50, 95% confidence interval [CI] 0.34–0.72, p = 0.0003) and Hispanic (OR 0.35, 95% CI 0.20–0.63, p = 0.0004) patients had lower odds of restraint than White patients. Among female patients with a mental health and/or substance use disorder diagnosis, Black (OR 1.95, 95% CI 1.49–2.54, p < 0.0001) and Hispanic (OR 2.13, 95% CI 1.49–3.03, p < 0.0001) patients had higher odds of restraint than White patients. Similar trends were observed for Black male patients (OR 1.60, 95% CI 1.34–1.91, p < 0.0001) but not for Hispanic male patients (OR 0.96, 95% CI 0.73–1.26, p = 0.77) with behavioral health diagnoses who had similar odds of restraint to White patients. Additional factors associated with physical restraint include younger age, public or lack of insurance, and ED visits during the pandemic. Conclusions: Racial disparities exist in restraint utilization at this minority‐serving safety‐net hospital; however, these disparities are modified by sex and by behavioral health diagnoses. The reasons for these disparities may be multifactorial and warrant further investigation. [ABSTRACT FROM AUTHOR]

Advances in breast imaging and other screening tests have prompted studies to evaluate and compare the consistency between experts' ratings of existing with new screening tests. In clinical settings, medical experts make subjective assessments of screening test results such as mammograms. Consistency between experts' ratings is evaluated by measures of inter-rater agreement or association. However, conventional measures, such as Cohen's and Fleiss' kappas, are unable to be applied or may perform poorly when studies consist of many experts, unbalanced data, or dependencies between experts' ratings exist. Here we assess the performance of existing approaches including recently developed summary measures for assessing the agreement between experts' binary and ordinal ratings when patients undergo two screening procedures. Methods to assess consistency between repeated measurements by the same experts are also described. We present applications to three large-scale clinical screening studies. Properties of these agreement measures are illustrated via simulation studies. Generally, a model-based approach provides several advantages over alternative methods including the ability to flexibly incorporate various measurement scales (i.e. binary or ordinal), large numbers of experts and patients, sparse data, and robustness to prevalence of underlying disease. [ABSTRACT FROM AUTHOR]

The diagnostic accuracy of a test or rater has a crucial impact on clinical decision making. The assessment of diagnostic accuracy for multiple tests or raters also merits much attention. A Bayesian hierarchical conditional independence latent class model for estimating sensitivities and specificities for a large group of tests or raters is proposed, which is applicable to both with-gold-standard and without-gold-standard situations. Through the hierarchical structure, not only are the sensitivities and specificities of individual tests estimated, but also the diagnostic performance of the whole group of tests. For a small group of tests or raters, the proposed model is further extended by introducing pairwise covariances between tests to improve the fitting and to allow for more modeling flexibility. Correlation residual analysis is applied to detect any significant covariance between multiple tests. Just Another Gibbs Sampler (JAGS) implementation is efficiently adopted for both models. Three real data sets from literature are analyzed to explicitly illustrate the proposed methods. [ABSTRACT FROM AUTHOR]