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Abstract Healthcare systems face significant challenges in meeting the unique needs of older adults, particularly in the acute setting. Age‐friendly healthcare is a comprehensive approach using the 4Ms framework—what matters, medications, mentation, and mobility—to ensure that healthcare settings are responsive to the needs of older patients. The Age‐Friendly Emergency Department (AFED) is a crucial component of a holistic age‐friendly health system. Our objective is to provide an overview of the AFED model, its core principles, and the benefits to older adults and healthcare clinicians. The AFED optimizes the delivery of emergency care by integrating age‐specific considerations into various aspects of (1) ED physical infrastructure, (2) clinical care policies, and (3) care transitions. Physical infrastructure incorporates environmental modifications to enhance patient safety, including adequate lighting, nonslip flooring, and devices for sensory and ambulatory impairment. Clinical care policies address the physiological, cognitive, and psychosocial needs of older adults while preserving focus on emergency issues. Care transitions include communication and involving community partners and case management services. The AFED prioritizes collaboration between interdisciplinary team members (ED clinicians, geriatric specialists, nurses, physical/occupational therapists, and social workers). By adopting an age‐friendly approach, EDs have the potential to improve patient‐centered outcomes, reduce adverse events and hospitalizations, and enhance functional recovery. Moreover, healthcare clinicians benefit from the AFED model through increased satisfaction, multidisciplinary support, and enhanced training in geriatric care. Policymakers, healthcare administrators, and clinicians must collaborate to standardize guidelines, address barriers to AFEDs, and promote the adoption of age‐friendly practices in the ED.

Introduction: Older adults often have multiple comorbidities; therefore, they are at high risk for adverse events after discharge. The 4Ms framework—what matters, medications, mentation, mobility—has been used in acute and ambulatory care settings to identify risk factors for adverse events in older adults, although it has not been used in the emergency department (ED). We aimed to determine whether 1) use of the 4Ms worksheet would help emergency clinicians understand older adult patients’ goals of care and 2) use of the worksheet was feasible in the ED. Methods: We conducted a qualitative, descriptive study among patients aged ≥60 years and emergency clinicians from January–June 2022. Patients were asked to fill out a 4Ms worksheet; following this, semi-structured interviews were conducted with patients and clinicians separately. We analysed data to create codes, which were divided into categories and sub-categories. Results: A total of 20 older patients and 19 emergency clinicians were interviewed. We identified two categories based on our aims: understanding patient goals of care (sub-categories: clinician/ patient concordance; understanding underlying goals of care; underlying goals of care discrepancy) and use of 4Ms Worksheet (sub-categories: worksheet to discussion discrepancy; challenges using worksheet; challenge completing worksheet before discharge). Rates of concordance between patient and clinician on main concern/goal of care and underlying goals of care were 82.4% and 15.4%, respectively. Conclusion: We found that most patients and emergency clinicians agreed on the main goal of care, although clinicians often failed to elicit patients’ underlying goal(s) of care. Additionally, many patients preferred to have the interviewer fill out the worksheet for them. There was often discrepancy between what was written and what was discussed with the interviewer. More research is needed to determine the best way to integrate the 4Ms framework within emergency care.

Abstract Expectations are often dynamic: sports fans know that expectations are rapidly updated as games unfold. Yet expectations have traditionally been studied as static. Here we present behavioral and electrophysiological evidence of sub-second changes in expectations using slot machines as a case study. In Study 1, we demonstrate that EEG signal before the slot machine stops varies based on proximity to winning. Study 2 introduces a behavioral paradigm to measure dynamic expectations via betting, and shows that expectation trajectories vary as a function of winning proximity. Notably, these expectation trajectories parallel Study 1’s EEG activity. Studies 3 (EEG) and 4 (behavioral) replicate these findings in the loss domain. These four studies provide compelling evidence that dynamic sub-second updates in expectations can be behaviorally and electrophysiologically measured. Our research opens promising avenues for understanding the dynamic nature of reward expectations and their impact on cognitive processes.

Abstract Background We sought to identify what matters to older adults (60 years and older) presenting to the emergency department (ED) and the challenges or concerns they identify related to medication, mobility, and mentation to inform how the 4Ms framework could improve care of older adults in the ED setting. Methods A qualitative study was conducted using the 4Ms to identify what matters to older adults (≥60 years old) presenting to the ED and what challenges or concerns they identify related to medication, mobility, and mentation. We conducted semi‐structured interviews with a convenience sample of patients in a single ED. Interview guide responses and interviewer field notes were entered into REDCap. Interviews were reviewed by the research team (2 coders per interview) who inductively assigned codes. A codebook was created through an iterative process and was used to group codes into themes and sub‐themes within the 4Ms framework. Results A total of 20 ED patients participated in the interviews lasting 30–60 minutes. Codes identified for “what matters” included problem‐oriented expectation, coordination and continuity, staying engaged, being with family, and getting back home. Codes related to the other 4Ms (medication, mobility, and mentation) described challenges. Medication challenges included: non‐adherence, side effects, polypharmacy, and knowledge. Mobility challenges included physical activity and independence. Last, mentation challenges included memory concerns, depressed mood, and stress and worry. Conclusions Our study used the 4Ms to identify “what matters” to older adults presenting to the ED and the challenges they face regarding medication, mobility, and mentation. Understanding what matters to patients and the specific challenges they face can help shape and individualize a patient‐centered approach to care to facilitate the goals of care discussion and handoff to the next care team.

Unlike commercial vessels, training ships have the unique purpose of providing students attempting to become ships’ officers with the onboard training education referred to in the International Convention on Standards of Training, Certification and Watchkeeping for Seafarers (STCW code). More than 100 people, including students, are usually aboard these internationally seagoing vessels. Despite training ships requiring strict safety management to prevent maritime accidents and protect lives, they are excluded from the application of key international rules and regulations concerning the safety of these ships due to an ambiguous legal status. Furthermore, there is no comprehensive safety management system at the central governmental level over training ships as they are operated by individual maritime institutions despite them being national property. Against these backgrounds, this research analyses current regulatory issues of training ships at the IMO level and the domestic level by referring to South Korean case. This research conducts a doctrinal legal study to understand the current legal status of training ships the application limits of the IMO regulatory instruments. The research concludes by referring to the necessity of the development of training ships Code to enhance he safety of training ships in the future.

Abstract Objectives Little is known about current practices in consulting physical therapy (PT) in the emergency department (ED) for older adults with falls, a practice that can reduce fall‐related ED revisits. This qualitative study aimed to understand perspectives of ED staff about ED PT consultation for older adults with falls and fall‐related complaints, specifically regarding perceived value and associated challenges and strategies. Methods We performed focus groups and key informant interviews with emergency physicians, advanced practice clinicians, nurses, physical therapists, occupational therapists, and technicians who perform ED geriatric screenings. We used rapid qualitative analysis to identify common themes related to decisions to consult PT from the ED, perceived value of PT, and common challenges and strategies in ED PT consultation. Results Twenty‐five participants in 4 focus groups and 3 interviews represented 22 distinct institutions with ED PT consultation available for older adults with falls. About two thirds of EDs represented relied on clinician gestalt to request PT consultation (n = 15, 68%), whereas one third used formal consultation pathways (n = 7, 32%). Participants valued physical therapists’ expertise, time, and facilitation of hospital throughput by developing safe discharge plans and contact with patients to improve outpatient follow‐up. Common challenges included limited ED PT staffing and space for PT evaluations; strategies to promote ED PT consultation included advocating for leadership buy‐in and using ED observation units to monitor patients and avoid admission until PT consultation was available. Conclusion ED PT consultation for older adults with falls may benefit patients, ED staff, and hospital throughput. Uncertainty remains over whether geriatric screening‐triggered consultation versus emergency clinician gestalt successfully identifies patients likeliest to benefit from ED PT evaluation. Leadership buy‐in, designated consultation space, and formalized consultation pathways are strategies to address current challenges in ED PT consultation.

Introduction: The Physician Orders for Life-Sustaining Treatment (POLST) form has been shown to lead to more goal-concordant care for these patients by providing detailed instructions regarding end-of-life interventions, made by the patient and/or medical decision maker. The aim of this study was to determine the level of awareness and understanding of the POLST form amongst providers at two ACGME-accredited emergency medicine residency programs. Methods: In this needs assessment study, we assessed awareness by sending a 13-item survey to all residents, faculty, and advanced practice providers in the two EDs in the United States. The content of the survey was developed by the study team using a modified Delphi process with content validity evaluated by a panel of emergency medicine and palliative care experts. We evaluated the association between the level of comfort and knowledge using the form and the level of training using the bivariate analysis. Results: Of the 205 questionnaires distributed, we received 63 responses (31%). Only 44% of responders reported using a POLST in the past year, and 40% did not feel comfortable interpreting and applying a POLST. Seventy percent of responders do not know where to locate this form. Furthermore, trainees reported a higher degree of familiarity and comfort with POLST forms when compared to staff physicians. Conclusion: A significant minority of ED providers do not know how to properly apply a POLST form. Our data suggests opportunities to educate ED personnel on locating and applying the POLST form.

Introduction: The coronavirus 2019 (COVID-19) pandemic caused significant disruptions in daily life. Given the role that social determinants of health play in the overall well-being of individuals and populations, we wanted to determine the effects of the COVID-19 pandemic on our patient population in the emergency department (ED). Methods: We adapted the Centers for Medicare and Medicaid Services social risk assessment to assess changes to participants’ social situations throughout the COVID-19 pandemic from January 2020–February 2021. The survey was administered within the ED to individuals selected by a convenience sample of patients who were stable enough to complete the form. Results: We received 200 (66%) responses from the 305 patients approached. Worsened food access was reported by 8.5% (17) of respondents, while 13.6% (27) reported worsened food concern since the onset of the COVID-19 pandemic. The odds of worsened food access were higher among non-Whites (adjusted odds ratio [aOR] 19.17, 95% confidence interval [CI] 3.33–110.53) and females (aOR 9.77, CI 1.51–63.44). Non-Whites had greater odds of worsened food concern (aOR 15.31, CI 3.94–59.54). Worsened financial difficulty was reported by 24% (48) of respondents. The odds of worsened financial difficulty were higher among females (aOR 2.87, 95% CI 1.08–7.65) and non-Whites (aOR 10.53, CI 2.75–40.35). Conclusion: The COVID-19 pandemic has worsened many of the social determinants of health found within communities. Moreover, vulnerable communities were found to be disproportionately affected as compared to their counterparts. Understanding the challenges faced by our patient populations can serve as a guide on how to assist them more comprehensively.

Abstract We have previously developed a bispectral electroencephalography (BSEEG) device, which was shown to be effective in detecting delirium and predicting patient outcomes. In this study we aimed to apply the BSEEG approach for a sepsis. This was a retrospective cohort study conducted at a single center. Sepsis-positive cases were identified based on retrospective chart review. EEG raw data and calculated BSEEG scores were obtained in the previous studies. The relationship between BSEEG scores and sepsis was analyzed, as well as the relationship among sepsis, BSEEG score, and mortality. Data were analyzed from 628 patients. The BSEEG score from the first encounter (1st BSEEG) showed a significant difference between patients with and without sepsis (p = 0.0062), although AUC was very small indicating that it is not suitable for detection purpose. Sepsis patients with high BSEEG scores showed the highest mortality, and non-sepsis patients with low BSEEG scores showed the lowest mortality. Mortality of non-sepsis patients with high BSEEG scores was as bad as that of sepsis patients with low BSEEG scores. Even adjusting for age, gender, comorbidity, and sepsis status, BSEEG remained a significant predictor of mortality (p = 0.008). These data are demonstrating its usefulness as a potential tool for identification of patients at high risk and management of sepsis.

Introduction: The application of structural competency and structural vulnerability to emergency medicine (EM) research has not been previously described despite EM researchers routinely engaging structurally vulnerable populations. The purpose of this study was to conduct a scoping review and consensus-building process to develop a structurally competent research approach and operational framework relevant to EM research. Methods: We conducted a scoping review focused on structural competency and structural vulnerability. Results of the review informed the development of a structural competency research framework that was presented throughout a multi-step consensus process culminating in the 2021 Society for Academic Emergency Medicine Consensus Conference. Feedback to the framework was incorporated throughout the conference. Results: The scoping review produced 291 articles with 123 articles relevant to EM research. All 123 articles underwent full-text review and data extraction following a standardized data extraction form. Most of the articles acknowledged or described structures that lead to inequities with a variety of methodological approaches used to operationalize structural competency and/or structural vulnerability. The framework developed aligned with components of the research process, drawing upon methodologies from studies included in the scoping review. Conclusion: The framework developed provides a starting point for EM researchers seeking to understand, acknowledge, and incorporate structural competency into EM research. By incorporating components of the framework, researchers may enhance their ability to address social, historical, political, and economic forces that lead to health inequities, reframing drivers of inequities away from individual factors and focusing on structural factors.

Abstract Background Prior data has demonstrated increased mortality in hospitalized patients with acute heart failure (AHF) and troponin elevation. No data has specifically examined the prognostic significance of troponin elevation in patients with AHF discharged after emergency department (ED) management. Objective Evaluate the relationship between troponin elevation and outcomes in patients with AHF who are treated and released from the ED. Methods This was a secondary analysis of the Get with the Guidelines to Reduce Disparities in AHF Patients Discharged from the ED (GUIDED‐HF) trial, a randomized, controlled trial of ED patients with AHF who were discharged. Patients with elevated conventional troponin not due to acute coronary syndrome (ACS) were included. Our primary outcome was a composite endpoint: time to 30‐day cardiovascular death and/or heart failure‐related events. Results Of the 491 subjects included in the GUIDED‐HF trial, 418 had troponin measured during the ED evaluation and 66 (16%) had troponin values above the 99th percentile. Median age was 63 years (interquartile range, 54‐70), 62% (n = 261) were male, 63% (n = 265) were Black, and 16% (n = 67) experienced our primary outcome. There were no differences in our primary outcome between those with and without troponin elevation (12/66, 18.1% vs 55/352, 15.6%; P = 0.60). This effect was maintained regardless of assignment to usual care or the intervention arm. In multivariable regression analysis, there was no association between our primary outcome and elevated troponin (hazard ratio, 1.00; 95% confidence interval, 0.49–2.01, P = 0.994) Conclusion If confirmed in a larger cohort, these findings may facilitate safe ED discharge for a group of patients with AHF without ACS when an elevated troponin is the primary reason for admission.

Event cameras are bio-inspired sensors that capture intensity changes of pixels individually, and generate asynchronous and independent “events”. Due to the fundamental difference from the conventional cameras, most research on event cameras builds a global event frame by grouping events according to their timestamps or their number to employ traditional computer vision algorithms. However, in order to take advantage of event cameras, it makes sense to generate asynchronous output on an event-by-event basis. In this paper, we propose an optical flow estimation algorithm with low latency and robustness to various scenes to utilize the advantage of the event camera by enhancing the existing optical flow algorithm. Furthermore, we estimate angular velocity with low latency using the proposed optical flow stream. For the validation of algorithms, we evaluate the accuracy and latency of optical flow with publicly available datasets. Moreover, we assess the performance of the proposed angular velocity estimation in comparison to the existing algorithms. Both validations suggest that our asynchronous optical flow shows comparable accuracy to the existing algorithms and the latency is reduced by half compared to the existing block matching algorithm on average. Also, our angular velocity estimation is superior to the existing algorithms in terms of accuracy and robustness while showing low latency within 15 ms consistently.

Background: Syncope, a common problem encountered in the emergency department (ED), has a multitude of causes ranging from benign to life-threatening. Hospitalization may be required, but the management can vary substantially depending on specific clinical characteristics. Models predicting admission and hospitalization length of stay (LoS) are lacking. The purpose of this study was to design an effective, exploratory model using machine learning (ML) technology to predict LoS for patients presenting with syncope. Methods: This was a retrospective analysis using over 4 million patients from the National Emergency Department Sample (NEDS) database presenting to the ED with syncope between 2016–2019. A multilayer perceptron neural network with one hidden layer was trained and validated on this data set. Results: Receiver Operator Characteristics (ROC) were determined for each of the five ANN models with varying cutoffs for LoS. A fair area under the curve (AUC of 0.78) to good (AUC of 0.88) prediction performance was achieved based on sequential analysis at different cutoff points, starting from the same day discharge and ending at the longest analyzed cutoff LoS ≤7 days versus >7 days, accordingly. The ML algorithm showed significant sensitivity and specificity in predicting short (≤48 h) versus long (>48 h) LoS, with an AUC of 0.81. Conclusions: Using variables available to triaging ED clinicians, ML shows promise in predicting hospital LoS with fair to good performance for patients presenting with syncope.

Aim The emergence and evolution of artificial intelligence (AI) has generated increasing interest in machine learning applications for health care. Specifically, researchers are grasping the potential of machine learning solutions to enhance the quality of care in emergency medicine. Methods We undertook a narrative review of published works on machine learning applications in emergency medicine and provide a synopsis of recent developments. Results This review describes fundamental concepts of machine learning and presents clinical applications for triage, risk stratification specific to disease, medical imaging, and emergency department operations. Additionally, we consider how machine learning models could contribute to the improvement of causal inference in medicine, and to conclude, we discuss barriers to safe implementation of AI. Conclusion We intend that this review serves as an introduction to AI and machine learning in emergency medicine.

Deficits in motivation and pleasure are common across many psychiatric disorders, and manifest as symptoms of amotivation and anhedonia, which are prominent features of both mood and psychotic disorders. Here we provide evidence for an association between neural value signals and symptoms of amotivation and anhedonia across adults with major depression, bipolar disorder, schizophrenia, or no psychiatric diagnosis. We found that value signals in the ventromedial prefrontal cortex (vmPFC) during intertemporal decision-making were dampened in individuals with greater motivational and hedonic deficits, after accounting for primary diagnosis. This relationship remained significant while controlling for diagnosis-specific symptoms of mood and psychosis, such as depression as well as positive and negative symptoms. Our results demonstrate that dysfunction in the vmPFC during value-based decision-making is specifically linked to motivational and hedonic impairments. These findings provide a quantitative neural target for the potential development of novel treatments for amotivation and anhedonia.

Introduction: Mental health and substance use disorder (MHSUD) patients in the emergency department (ED) have been facing increasing lengths of stay due to a shortage of inpatient beds. Previous research indicates mobile crisis outreach (MCO) reduces long ED stays for MHSUD patients. Our objective was to assess the impact of MCO contact on future ED utilization. Methods: We conducted a retrospective chart review of patients presenting to a large Midwest university ED with an MHSUD chief complaint from 2015–2018. We defined the exposure as those who had MCO contact and any MHSUD-related ED visit within 30 days of MCO contact. The MCO patients were 2:1 propensity score–matched by demographic data and comorbidities matched to patients with no MCO contact. Outcomes were all-cause and psychiatric-specific reasons for return to the ED within one year of the index ED visit. We report descriptive statistics and odds ratios (OR) to describe the difference between the two groups, and hazard ratios (HR) to estimate the risk of return ED visit. Results: The final sample included 106 MCO and 196 non-MCO patients. The MCO patients were more likely to be homeless (OR 14.8; 95% confidence interval [CI],1.87, 117), less likely to have adequate family or social support (OR 0.51; 95% CI, 0.31, 0.84), and less likely to have a hospital bed requested for them in the index visit by ED providers (OR 0.50; 95% CI, 0.29, 0.88). For those who returned to the ED, the median time for all-cause return to the ED was 28 days (interquartile range [IQR]: 6–93 days) for the MCO patients and 88 days (IQR: 20–164 days) for non-MCO patients. The risk of all-cause return to the ED was greater among MCO patients (67%) compared to non-MCO patients (49%) (adjusted HR: 1.66; 95% CI, 1.22, 2.27). Conclusion: The MCO patients had less family and social support; however, they were less likely to require hospitalization for each visit, likely due to MCO involvement. Patients with MCO contact presented to the ED more frequently than non-MCO patients, which implies a strong linkage between the ED and MCO in our community. An effective referral to community service from the ED and MCO and collaboration could be the next step to improve healthcare utilization.

Across many studies, ventromedial prefrontal cortex (vmPFC) activity has been found to correlate with subjective value during value-based decision-making. Recently, however, vmPFC has also been shown to reflect a hexagonal gridlike code during navigation through physical and conceptual space, and such gridlike codes have been proposed to enable value-based choices between novel options. Here, we first show that, in theory, a hexagonal gridlike code can in some cases mimic vmPFC activity previously attributed to subjective value, raising the possibility that the subjective value correlates previously observed in vmPFC may have actually been a misconstrued gridlike signal. We then compare the two accounts empirically, using fMRI data from a large number of subjects performing an intertemporal choice task. We find clear and unambiguous evidence that subjective value is a better description of vmPFC activity in this task than a hexagonal gridlike code. In fact, we find no significant evidence at all for a hexagonal gridlike code in vmPFC activity during intertemporal choice. This result limits the generality of gridlike modulation as description of vmPFC activity. We suggest that vmPFC may flexibly switch representational schemes so as to encode the most relevant information for the current task.

Abstract Background Over the past 2 decades, emergency ultrasound has become essential to patient care, and is a mandated competency for emergency medicine residency graduation. However, the best evidence regarding emergency ultrasound education in residency training is not known. We performed a scoping review to determine the (1) characteristics and (2) outcomes of published structured training methods, (3) the quality of publications, and (4) the implications for research and training. Methods We searched broadly on multiple electronic databases and screened studies from the United States and Canada describing structured emergency ultrasound training methods for emergency medicine residents. We evaluated methodological quality with the Medical Education Research Study Quality Instrument (MERSQI), and qualitatively summarized study and intervention characteristics. Results A total of 109 studies were selected from 6712 identified publications. Publications mainly reported 1 group pretest–posttest interventions (38%) conducted at a single institution (83%), training in image acquisition (82%) and interpretation (94%) domains with assessment of knowledge (44%) and skill (77%) outcomes, and training in cardiac (18%) or vascular access (15%) applications. Innovative strategies, such as gamification, cadaver models, and hand motion assessment are described. The MERSQI scores of 48 articles ranged from 0 to 15.5 (median, 11.5; interquartile range, 9.6–13.0) out of 18. Low scores reflected the absence of reported valid assessment tools (73%) and higher level outcomes (90%). Conclusions Although innovative strategies are illustrated, the overall quality of research could be improved. The use of standardized planning and assessment tools, intentionally mapped to targeted domains and outcomes, might provide valuable formative and summative information to optimize emergency ultrasound research and training.

Abstract Nonhuman primate models are valuable in biomedical research. However, reference data for clinical pathology parameters in cynomolgus and rhesus monkeys are limited. In the present study, we established hematologic and biochemical reference intervals for healthy cynomolgus and rhesus monkeys anesthetized with ketamine hydrochloride. A total of 142 cynomolgus monkeys (28 males and 114 females) and 42 rhesus monkeys (22 males and 20 females) were selected and analyzed in order to examine reference intervals of 20 hematological and 16 biochemical parameters. The effects of sex were also investigated. Reference intervals for hematological and biochemical parameters were separately established by species (cynomolgus and rhesus) and sex (male and female). No sex-related differences were determined in erythrocyte-related parameters for cynomolgus and rhesus monkey housed in indoor laboratory conditions. Alkaline phosphatase and gamma glutamyltransferase were significantly lower in females than males in both cynomolgus and rhesus monkeys aged 48–96 months. The reference values for hematological and biochemical parameters established herein might provide valuable information for researchers using cynomolgus and rhesus monkeys in experimental conditions for biomedical studies.

Over recent decades, the demand for smarter and more intelligent manufacturing systems has increased in order to meet the growing requirements of customers. Manufacturing systems are termed as smart manufacturing systems (SMSs); these systems are capable of fully integrated autonomous operation. Specifically, the concept of autonomous systems and functions has been adopted for next generation manufacturing systems (NGMSs). Among these NGMSs, the fractal manufacturing system (FrMS) exhibits several characteristics that are similar to those of SMSs. Therefore, in this paper, a smart, self-reconfigurable manufacturing system (SSrMS) based on the FrMS is proposed. The proposed SSrMS architecture was designed for realizing self-reconfiguration functions based on the FrMS concept. SSrMS exhibits a fractal structure, which enables the distribution of control features; this also constitutes the fundamental basis of autonomous operation and reconfiguration between each fractal. SSrMS architecture includes the use of big data, digital facilities, and simulations. Furthermore, we introduce three reconfiguration methods to conduct system reconfiguration, which are a goal decision model, a negotiation model, and a sustainability assessment method. The goal decision model was developed to determine a goal of each fractal to achieve the system’s goal. In other words, each fractal can decide a goal to achieve the system’s goal, such as maximizing productivity or profit, or minimizing cost, and others. The negotiation model was adopted to perform partial process optimization by reassigning tasks and resources between the fractals, based on the goal of coping with the changes in the system’s condition. The sustainability assessment method was designed to simultaneously evaluate sustainability with respect to the system’s goals. The proposed architecture of SSrMS with goal decision model, negotiation model, and sustainability assessment method has the features of self-optimization, self-organization, and self-reconfiguration in order to achieve fully autonomous operations for the manufacturing system. The proposed architecture including three methods are expected to provide a fundamental study of the autonomous operations. The main findings of in this study is the development of a new architecture for fully autonomous operations of the smart manufacturing system with reconfiguration methods of goal-oriented manufacturing processes.

Aim Angioedema is a nonpitting edema that can lead to death secondary to airway obstruction. Previously, a staging system based on localization of the angioedema was proposed for risk stratification of likelihood of need for admission or airway intervention. This study aims to evaluate a staging system based on angioedema localization as a method of predicting need for admission or airway intervention. Methods This was a retrospective chart review of angioedema cases that presented to an academic emergency department (ED) from August 1, 2006, to January 31, 2018. Data were collected on location of swelling, treatment setting, and medical and procedural interventions. Cases were categorized by modified Ishoo criteria, defined as follows: 1, lips, face, periorbital, extremities, total body/diffuse swelling; 2, soft palate, posterior pharynx; 3, tongue; 4, larynx. Predictive probability of disposition by stage was then compared. Results A total of 320 patients were included in this study (median age, 44 years; 54.4% female). Stage 4 was more likely to require intensive care unit care without (probability 17%) and with (67%) airway intervention compared with stage 1 without (2.5%) and with (0.1%) airway intervention. Conversely, stage 1 was more likely to be treated in ED and discharged (85%) compared with stage 4 (0%). Stage 4 was also more likely to require airway intervention (67%) compared with other stages (1, 0.1%; 2, 8.6%; 3, 16%). Conclusion Higher‐stage patients were more likely to require higher levels of care and airway intervention. Thus, the staging system appears to be a valid method of predicting risk among ED angioedema patients.

Introduction Delirium is a dangerous syndrome of acute brain dysfunction that is common in the emergency department (ED), especially among the geriatric population. Most systematic reviews of interventions for delirium prevention and treatment have focused on inpatient settings. Best practices of effective delirium care in ED settings have not been established. The primary objective of this study is to identify pharmacologic and non-pharmacologic interventions as applied by physicians, nursing staff, pharmacists and other ED personnel to prevent incident delirium and to shorten the severity and duration of prevalent delirium in a geriatric population within the ED.Methods and analysis Searches using subject headings and keywords will be conducted from database inception through June 2020 in MEDLINE, EMBASE, Web of Science, PsychINFO, CINAHL, ProQuest Dissertations and Theses Global and Cochrane CENTRAL as well as grey literature. Database searches will not be limited by date or language. Two reviewers will identify studies describing any interventions for delirium prevention and/or treatment in the ED. Disagreements will be settled by a third reviewer. Pooled data analysis will be performed where possible using Review Manager. Risk ratios and weighted difference of means will be used for incidence of delirium and other binary outcomes related to delirium, delirium severity or duration of symptoms, along with 95% CIs. Heterogeneity will be measured by calculating I2, and a forest plot will be created. If significant heterogeneity is identified, metaregression is planned using OpenMeta to identify possible sources of heterogeneity.Ethics and dissemination This is a systematic review of previously conducted research; accordingly, it does not constitute human subjects research needing ethics review. This review will be prepared as a manuscript and submitted for publication to a peer-reviewed journal, and the results will be presented at conferences.PROSPERO trial registration number CRD42020169654.

Effective learning requires using errors in a task-dependent manner, for example adjusting to errors that result from unpredicted environmental changes but ignoring errors that result from environmental stochasticity. Where and how the brain represents errors in a task-dependent manner and uses them to guide behavior are not well understood. We imaged the brains of human participants performing a predictive-inference task with two conditions that had different sources of errors. Their performance was sensitive to this difference, including more choice switches after fundamental changes versus stochastic fluctuations in reward contingencies. Using multi-voxel pattern classification, we identified task-dependent representations of error magnitude and past errors in posterior parietal cortex. These representations were distinct from representations of the resulting behavioral adjustments in dorsomedial frontal, anterior cingulate, and orbitofrontal cortex. The results provide new insights into how the human brain represents errors in a task-dependent manner and guides subsequent adaptive behavior.

What are the key ingredients that make some persuasive messages resonate with audiences and elicit action, while others fail? Billions of dollars per year are put towards changing human behavior, but it is difficult to know which messages will be the most persuasive in the field. By combining novel neuroimaging techniques and large-scale online data, we examine the role of key health communication variables relevant to motivating action at scale. We exposed a sample of smokers to anti-smoking web-banner messages from a real-world campaign while measuring message-evoked brain response patterns via fMRI, and we also obtained subjective evaluations of each banner. Neural indices were derived based on: (i) message-evoked activity in specific brain regions; and (ii) spatially distributed response patterns, both selected based on prior research and theoretical considerations. Next, we connected the neural and subjective data with an independent, objective outcome of message success, which is the per-banner click-through rate in the real-world campaign. Results show that messages evoking brain responses more similar to signatures of negative emotion and vividness had lower online click-through-rates. This strategy helps to connect and integrate the rapidly growing body of knowledge about brain function with formative research and outcome evaluation of health campaigns, and could ultimately further disease prevention efforts.

We aimed to assess the current scope of handoff education and practice among resident physicians in academic centers and to propose a standardized handoff algorithm for the transition of care from the emergency department (ED) to an inpatient setting. This was a cross-sectional survey targeted at the program directors, associate or assistant program directors, and faculty members of emergency medicine (EM) residency programs in the United States (U.S.). The web-based survey was distributed to potential subjects through a listserv. A panel of experts used a modified Delphi approach to develop a standardized algorithm for ED to inpatient handoff. 121 of 172 programs responded to the survey for an overall response rate of 70.3%. Our survey showed that most EM programs in the U.S. have some form of handoff training, and the majority of them occur either during orientation or in the clinical setting. The handoff structure from ED to inpatient is not well standardized, and in those places with a formalized handoff system, over 70% of residents do not uniformly follow it. Approximately half of responding programs felt that their current handoff system was safe and effective. About half of the programs did not formally assess the handoff proficiency of trainees. Handoffs most commonly take place over the phone, though respondents disagree about the ideal place for a handoff to occur, with nearly equivalent responses between programs favoring the bedside over the phone or faceto-face on a computer. Approximately two-thirds of responding programs reported that their residents were competent in performing ED to inpatient handoffs. Based on this survey and on the review of the literature, we developed a five-step algorithm for the transition of care from the ED to the inpatient setting. Our results identified the current trends of education and practice in transitions of care, from the ED to the inpatient setting in U.S. academic medical centers. An algorithm, which guides this process, is proposed to address the current gap in the standardized approach to ED to inpatient handoffs that were identified in the survey’s assessment of needs. [West J Emerg Med. 2017;18(1)86-92.]

Measurements of volatile organic compounds (VOCs) have been ongoing for decades to track growth rates and assist in curbing emissions of these compounds into the atmosphere. To accurately establish mole fraction trends and assess the role of these gas-phase compounds in atmospheric chemistry it is essential to have good calibration standards. A necessity and precursor to accurate VOC gas standards are the gas cylinders and the internal wall treatments that aid in maintaining the stability of the mixtures over long periods of time, measured in years. This paper will discuss the stability of VOC gas mixtures in different types of gas cylinders and internal wall treatments. Stability data will be given for 85 VOCs studied in gas mixtures by National Metrology Institutes and other agency laboratories. This evaluation of cylinder treatment materials is the outcome of an activity of the VOC Expert Group within the framework of the World Meteorological Organization (WMO) Global Atmospheric Watch (GAW) program.

Health informatics is a vital technology that holds great promise in the healthcare setting. We describe two prominent health informatics tools relevant to emergency care, as well as the historical background and the current state of informatics. We also identify recent research findings and practice changes. The recent advances in machine learning and natural language processing (NLP) are a prominent development in health informatics overall and relevant in emergency medicine (EM). A basic comprehension of machine-learning algorithms is the key to understand the recent usage of artificial intelligence in healthcare. We are using NLP more in clinical use for documentation. NLP has started to be used in research to identify clinically important diseases and conditions. Health informatics has the potential to benefit both healthcare providers and patients. We cover two powerful tools from health informatics for EM clinicians and researchers by describing the previous successes and challenges and conclude with their implications to emergency care.

Obtaining grant funding is a fundamental component to achieving a successful research career. A successful grant application needs to meet specific mechanistic expectations of reviewers and funders. This paper provides an overview of the importance of grant funding within medical education, followed by a stepwise discussion of strategies for creating a successful grant application for medical education-based proposals. The last section includes a list of available medical education research grants.

The development of wearable electronics has emphasized user-comfort, convenience, security, and improved medical functionality. Several previous research studies transformed various types of sensors into a wearable form to more closely monitor body signals and enable real-time, continuous sensing. In order to realize these wearable sensing platforms, it is essential to integrate wireless power supplies and data communication systems with the wearable sensors. This review article discusses recent progress in wireless technologies and various types of wearable sensors. Also, state-of-the-art research related to the application of wearable sensor systems with wireless functionality is discussed, including electronic skin, smart contact lenses, neural interfaces, and retinal prostheses. Current challenges and prospects of wireless sensor systems are discussed.

Introduction: This study investigated whether a 9.6% decrease in the use of head computed tomography (HCT) for patients presenting to the emergency department (ED) with a chief complaint of headache was followed by an increase in proportions of death or missed intracranial diagnosis during the 22.5-month period following each index ED visit. Methods: We reviewed the electronic medical records of all patients sampled during a quality improvement effort in which the aforementioned decrease in HCT use had been observed. We reviewed notes from the ED, neurology, neurosurgery, and primary care services, as well as all brain imaging results to determine if death occurred or if an intracranial condition was discovered in the 22.5 months after each index ED visit. An independent, blinded reviewer reviewed each case where an intracranial condition was diagnosed after ED discharge to determine whether the condition was reasonably likely to have been related to the index ED visit’s presentation, thereby representing a missed diagnosis. Results: Of the 582 separate index ED visits sampled, we observed a total of nine deaths and 10 missed intracranial diagnoses. There was no difference in the proportion of death (p = 0.337) or missed intracranial diagnosis (p = 0.312) observed after a 9.6% reduction in HCT use. Among patients who subsequently had visits for headache or brain imaging, we found that these patients were significantly more likely to have not had a HCT done during the index ED visit (59.2% vs. 49.6% (p = 0.031) and 37.1% vs. 26% (p = 0.006), respectively). Conclusion: Our study adds to the compelling evidence that there is opportunity to safely decrease CT imaging for ED patients. To determine the cost effectiveness of such reductions further research is needed to measure what patients and their healthcare providers do after discharge from the ED when unnecessary testing is withheld.

Multivoxel pattern analysis (MVPA) typically begins with the estimation of single trial activation levels, and several studies have examined how different procedures for estimating single trial activity affect the ultimate classification accuracy of MVPA. Here we show that the currently preferred estimation procedures impart spurious positive correlations between the means of different category activity estimates within the same scanner run. In other words, if the mean of the estimates for one type of trials is high (low) in a given scanner run, then the mean of the other type of trials is also high (low) for that same scanner run, and the run-level mean across all trials therefore shifts from run to run. Simulations show that these correlations occur whenever there is a need to deconvolve overlapping trial activities in the presence of noise. We show that subtracting each voxel's run-level mean across all trials from all the estimates within that run (i.e., run-level mean centering of estimates), by cancelling out these mean shifts, leads to robust and significant improvements in MVPA classification accuracy. These improvements are seen in both simulated and real data across a wide variety of situations. However, we also point out that there could be cases when mean activations are expected to shift across runs and that run-level mean centering could be detrimental in some of these cases (e.g., different proportion of trial types between different runs).

Introduction: Our goal was to describe the pattern and identify risk factors of early-return ED visits or inpatient admissions following an index mental health and substance abuse (MHSA)-related ED visit in the United States. Methods: We performed a retrospective cohort study using Optum Labs Data Warehouse, a nationally representative database containing administrative claims data on privately insured and Medicare Advantage enrollees. Authors identified patients presenting to an ED with a primary diagnosis of MHSA between 2005 and 2013 who were discharged home. Study inclusion required continuous insurance enrollment for the 12 months preceding and the 31 days following the index ED visit. During the study period we included only the first ED visit for each patient. Results: A total of 49,672 (14.2%) had a return visit to the ED or had a hospitalization within 30 days following discharge. Mean time to the next ED visit or inpatient admission was 11.7 days. An increased age (age 65+ vs. age

Abstract Introduction The emergency department (ED) observation unit has become a unique practice opportunity to liberate inpatient capacity in the United States. Substantial variations in clinical practice and level of comfort among ED providers existed in a large health care system. We aimed to study the effectiveness of an educational module targeted for emergency medicine providers. Methods We developed a 20-minute online module including pretest, learning module, and posttest. The format consisted of Likert-scale (1 = least comfortable, 5 = most comfortable), true-or-false, and multiple-choice questions. The learning module contained slides, script, and figures describing management strategy for commonly encountered conditions in the observation unit. The institutional review board granted exempted review. Pre- and posttest scores were evaluated with the Wilcoxon rank-sum test, and a p value of less than .05 was considered significant. Results Twenty-one participants completed the pretest, with a mean score of 63.8 (SD = 19.3), and 14 participants completed the posttest, with a mean score of 87.9 (SD = 9.7; p = .0001). Eight participants responded to a follow-up survey, a response rate of 57%. Responses demonstrated that levels of provider comfort in selection of observation (M = 4.3, SD = 1.5), choice of stress test for chest pain (M = 4.3, SD = 1.0), asthma management (M = 4.1, SD = 1.0), anaphylaxis care (M = 4.1, SD = 1.4), and documentation (M = 4.3, SD = 0.9) were high. Discussion An online learning module can be useful to enhance the knowledge of observation medicine among emergency medicine providers.

Ingestion of disk batteries may have serious complications such as esophageal burn, perforation, and tracheoesophageal fistula, particularly when the battery is caught in the esophagus. Proper placement of the tracheal tube is critical when tracheoesophageal fistula was occurred from esophageal impaction the battery. Endoscopy of upper gastrointestinal tract in infants and children is an important and effective tool for the diagnosis and treatment of foreign body ingestion. But upper gastrointestinal endoscopy in infant and children has very high risk of tracheal compression and airway compromise. We present a case of ventilatory compromise during insertion of the upper gastrointestinal endoscopy in 16-month-old child with tracheoesophageal fistula secondary to disk battery ingestion.

The goal of the present study was to examine whether intention type affects eye movement patterns in a change detection task In addition, we assessed whether the eye movement index could be used to identify human implicit intent. We attempted to generate three types of intent amongst the study participants, dividing them into one of three conditions; each condition received different information regarding an impending change to the visual stimuli. In the “navigational intent” condition, participants were asked to look for any interesting objects, and were not given any more information about the impending change. In the “low-specific intent” condition, participants were informed that a change would occur. In the “high-specific intent” condition, participants were told that a change would occur, and that an object would disappear. In addition to this main change detection task, participants also had to perform a primary task, in which they were required to name aloud the colors of objects in the pre-change scene. This allowed us to control for the visual searching process during the pre-change scene. The main results were as follows: firstly, the primary task successfully controlled for the visual search process during the pre-change scene, establishing that there were no differences in the patterns of eye movements across all three conditions despite differing intents. Secondly, we observed significantly different patterns of eye movement between the conditions in the post-change scene, suggesting that generating a specific intent for change detection yields a distinctive pattern of eye-movements. Finally, discriminant function analysis showed a reasonable classification rate for identifying a specific intent. Taken together, it was found that both participant intent and the specificity of information provided to the participants affect eye movements in a change detection task.