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Introduction: Standard emergency medicine practice includes tetanus vaccine administration as part of wound care management for patients who are not fully immunized. Since there have been no available studies in the United States reaffirming the prevalence of Clostridium tetani (C tetani) since 1926, we sought to identify its prevalence in a major urban county in the US.Methods: We sampled soil, rusted metal, concrete, and dog feces to determine the prevalence of C tetani in a single metropolitan county in the United States. Soil samples and swabs were collected from four locations: the soil of a public park and an elementary school; dog feces from a single public dog park; and rusted surfaces (metal and concrete) in common student areas of a university campus. The presence of C tetani in each sample was determined using a quantitative polymerase chain reaction.Results: In total, 200 samples were collected, of which 37 (18.5%) tested positive for C tetani DNA. Among the 140 samples taken from the soil, just one (0.7%) tested positive for C tetani DNA. Of the 40 samples of rusted metal and concrete surfaces, 30 (75%) tested positive for C tetani, and six (30%) of the 20 samples from dog feces tested positive for C tetani.Conclusion: We found that C tetani is frequently present on rusted metal and concrete surfaces but rarely in soil samples. Minor wounds contaminated with soil may be considered low risk for tetanus. However, future studies should assess the burden of C tetani in other similar urban, suburban, and rural environments to help determine the threat of C tetani more exactly.

Background: Increasingly, patient satisfaction scores are being used to assess emergency physicians. We sought to determine whether the patient satisfaction scores collected by our hospital system are lower for patients who are treated in the emergency department (ED) on night shifts as compared to those treated on day shifts.Methods: We performed a cross-sectional analysis of patient satisfaction scores from three EDs in Florida. We obtained satisfaction data from NRC Health (the company that provides our surveys) using a random sample of 1,000 completed surveys from patients treated in 2022; we also performed manual chart review to obtain clinical data. The satisfaction surveys asked patients how likely they would be to recommend the facility (from 0–10). Patients who provided a score of 9 or 10 were considered “promoters.” For our primary analysis, we compared the percentage of promoters for the day shift encounters (7 AM to 7 PM) to the night shift encounters (7 PM to 7 AM). We also performed a multivariable logistic regression analysis using several demographic and clinical variables to further assess the association between night shift arrival and satisfaction scores.Results: Of the 1,000 surveys analyzed, 66.3% of patients arrived during the day shift, and 33.7%arrived during the night shift. Of those who arrived during the day shift, 525 (79.2%) were promoters compared to 228 (67.7%) of those who arrived during the night shift, a difference of 11.5% (95%confidence interval [CI] 5.7–17.4%), P < 0.001. On multivariable analysis, night shift arrival was associated with a lower chance of a patient being a promoter, with adjusted odds ratio 0.60 (95% CI 0.43–0.84), P = 0.003.Conclusion: Patients who presented to the ED during the night shift were less likely to be promoters than patients who arrived during the day shift. Assessments of patient satisfaction data should account for time of visit and other facility-related and operational characteristics.

Background: Increasingly, patient satisfaction scores are being used to assess emergency physicians. We sought to determine whether the patient satisfaction scores collected by our hospital system are lower for patients who are treated in the emergency department (ED) on night shifts as compared to those treated on day shifts. Methods: We performed a cross-sectional analysis of patient satisfaction scores from three EDs in Florida. We obtained satisfaction data from NRC Health (the company that provides our surveys) using a random sample of 1,000 completed surveys from patients treated in 2022; we also performed manual chart review to obtain clinical data. The satisfaction surveys asked patients how likely they would be to recommend the facility (from 0–10). Patients who provided a score of 9 or 10 were considered “promoters.” For our primary analysis, we compared the percentage of promoters for the day shift encounters (7 AM to 7 PM) to the night shift encounters (7 PM to 7 AM). We also performed a multivariable logistic regression analysis using several demographic and clinical variables to further assess the association between night shift arrival and satisfaction scores. Results: Of the 1,000 surveys analyzed, 66.3% of patients arrived during the day shift, and 33.7% arrived during the night shift. Of those who arrived during the day shift, 525 (79.2%) were promoters compared to 228 (67.7%) of those who arrived during the night shift, a difference of 11.5% (95% confidence interval [CI] 5.7–17.4%), P

Introduction: Standard emergency medicine practice includes tetanus vaccine administration as part of wound care management for patients who are not fully immunized. Since there have been no available studies in the United States reaffirming the prevalence of Clostridium tetani (C tetani) since 1926, we sought to identify its prevalence in a major urban county in the US. Methods: We sampled soil, rusted metal, concrete, and dog feces to determine the prevalence of C tetani in a single metropolitan county in the United States. Soil samples and swabs were collected from four locations: the soil of a public park and an elementary school; dog feces from a single public dog park; and rusted surfaces (metal and concrete) in common student areas of a university campus. The presence of C tetani in each sample was determined using a quantitative polymerase chain reaction. Results: In total, 200 samples were collected, of which 37 (18.5%) tested positive for C tetani DNA. Among the 140 samples taken from the soil, just one (0.7%) tested positive for C tetani DNA. Of the 40 samples of rusted metal and concrete surfaces, 30 (75%) tested positive for C tetani, and six (30%) of the 20 samples from dog feces tested positive for C tetani. Conclusion: We found that C tetani is frequently present on rusted metal and concrete surfaces but rarely in soil samples. Minor wounds contaminated with soil may be considered low risk for tetanus. However, future studies should assess the burden of C tetani in other similar urban, suburban, and rural environments to help determine the threat of C tetani more exactly.

Abstract Past research indicates that people tend to react adversely to surveillance, but does it matter if advanced technologies such as artificial intelligence conduct surveillance rather than humans? Across four experiments (Study 1, N = 107; Study 2, N = 157; Study 3, N = 117; Study 4, N = 814), we examined how participants reacted to monitoring and evaluation by human or algorithmic surveillance when recalling instances of surveillance from their lives (Study 1), generating ideas (Studies 2 and 3), or imagining working in a call center (Study 4). Our results revealed that participants subjected to algorithmic (v. human) surveillance perceived they had less autonomy (Studies 1, 3, and 4), criticized the surveillance more (Studies 1-3), performed worse (Studies 2 and 3), and reported greater intentions to resist (Studies 1 and 4). Framing the purpose of the algorithmic surveillance as developmental, and thus informational, as opposed to evaluative, mitigated the perception of decreased autonomy and level of resistance (Study 4).

Innovation vouchers are a tool of innovation policy, which aims to initiate cooperation between different actors, particularly between the business and research entities. The paper compares the implementation of vouchers in the Czech Republic and Slovakia. Its objective is to compare the policy approaches to innovation vouchers in two countries in Central Europe which have a shared history, but which, at some point, went their own way. Vouchers in Czechia have a longer tradition and were first initiated at the regional level. In Slovakia, vouchers were only implemented at the national level and with a lower budget. The research confirmed the persistent differences in the innovation policies and the more proactive approach in Czechia. The paper's contribution also lies in the focus on transitive economies, which have received less research attention so far. Implications for the design of innovation policies in countries with emerging innovation systems are included.

Some experts have promoted the use of rapid testing for COVID-19. However, with the current technologies available, continuing to replace laboratory-based, real-time reverse transcription polymerase chain reaction tests with rapid (point-of-care) tests may lead to an increased number of false negative tests. Moreover, the more rapid dissemination of false negative results that can occur with the use of rapid tests for COVID-19 may lead to increased spread of the novel coronavirus if patients do not understand the concept of false negative tests. One means of combatting this would be to tell patients who have a “negative” rapid COVID-19 test that their test result was “indeterminate.”

Grapevines are susceptible to a wide range of fungal diseases that result in significant annual economic losses in the global wine industry. The present study uses a non-targeted mass spectrometry approach to explore metabolic profiles of healthy and infected Austrian Grüner Veltliner grapes and wine. The samples were analysed by liquid chromatography coupled to time-of-flight mass spectrometry and ion mobility-mass spectrometry combined with multivariate statistical data analysis. Clear differences between healthy and infected samples were observed using multivariate analysis, allowing sample classification according to infection. In total, 111 grape and wine markers were identified as a result of infection, of which 68 were identified with confidence levels 1 or 2. The statistical analysis results outlined metabolites such as (-)-epicatechin, (+)-catechin, astilbin, quercetin 3-O-glucuronide, gluconic acid, alpha-lipoic acid, caftaric acid, galactaric acid, fumaric acid, 1,2-benzenedicarboxylic acid, indole-3-lactic acid, dipeptides and tripeptides, to be discriminant in detection of grapes and wine infection.

Many public officials are calling for increased testing for the 2019 novel coronavirus disease (COVID-19), and some governments have taken extraordinary measures to increase the availability of testing. However, little has been published about the sensitivity and specificity of the reverse transcriptase-polymerase chain reaction (RT-PCR) nasopharyngeal swabs that are commonly used for testing. This narrative review evaluates the literature regarding the accuracy of these tests, and makes recommendations based on this literature. In brief, a negative RT-PCR nasopharyngeal swab test is insufficient to rule out COVID-19. Thus, over-reliance on the results of the test may be dangerous, and the push for widespread testing may be overstated.

Alteplase is the only Food and Drug Administration-approved intravenous (IV) thrombolytic medication for acute ischemic stroke. However, multiple recent studies comparing tenecteplase and alteplase suggest that tenecteplase is at least as efficacious as alteplase with regards to neurologic improvement. When given at 0.25 milligrams per kilogram (mg/kg), tenecteplase may have less bleeding complications than alteplase as well. This narrative review evaluates the literature and addresses the practical issues with regards to the use of tenecteplase versus alteplase for acute ischemic stroke, and it recommends that physicians consider tenecteplase rather than alteplase for thrombolysis of acute ischemic stroke.

Introduction: Computed tomography pulmonary angiography (CTPA) is the test of choice for diagnosis of pulmonary embolism (PE) in the emergency department (ED), but this test may be indeterminate for technical reasons such as inadequate contrast filling of the pulmonary arteries.  Many hospitals have requirements for intravenous (IV) catheter size or location for CTPAs to reduce the chances of inadequate filling, but there is a lack of clinical data to support these requirements. The objective of this study was to determine if a certain size or location of IV catheter used for contrast for CTPA is associated with an increased chance of an indeterminate CTPA. Methods: This was a retrospective chart review of patients who underwent CTPA in the emergency department.  A CTPA was considered indeterminate if the radiology report indicated it was inadequate to exclude a pulmonary embolism.  The reason for the study being indeterminate, and the size and location of the IV catheter were abstracted. The rate of inadequate contrast filling of the pulmonary vasculature was calculated and compared for various IV catheter sizes and locations.  In particular, 20-gauge or larger IV catheters in the antecubital fossa or forearm were compared to all other sizes and locations. Results: A total of 19.3% of the 1500 CTPA reports reviewed met our criteria as indeterminate, and 51.6% of those were due to inadequate filling.  Patients with a 20-gauge IV catheter or larger placed in the antecubital fossa or forearm had inadequate filling 9.2% of the time compared to 13.2% for patients who had smaller IVs or IVs in other locations (difference:  4.0% [95% CI -1.7% to 9.7%]).  There were also no statistically significant differences in the rates of inadequate filling when data were further stratified by IV catheter location and size. Conclusion: We did not detect any statistically significant differences in the rate of inadequate contrast filling based on IV catheter locations or sizes.  While small differences not detected in this study may exist, it seems prudent to proceed with CTPA in patients with difficult IV access who need emergent imaging even if they have a small or distally located IV.

Tony Zitek,1 Mani Hashemi,2 Sara Zagroba,2 Valori H Slane2 1Department of Emergency Medicine, Mount Sinai Medical Center, Miami Beach, FL, USA; 2Department of Emergency Medicine, Kendall Regional Medical Center, Miami, FL, USACorrespondence: Tony Zitek, Department of Emergency Medicine, Mount Sinai Medical Center, 4300 Alton Road, Miami Beach, FL, 33140, USA, Tel +1-305-674-2121 Ext 56632, Email Zitek10@gmail.comPurpose: Acute aortic dissection (AAD) is a highly fatal disorder if not promptly diagnosed. Some international studies have suggested that serum d-dimer levels may be used to exclude AAD, but data are limited. We sought to confirm that d-dimer levels are elevated in American patients with AAD. Additionally, we sought to estimate the test characteristics of the d-dimer for AAD.Patients and Methods: We performed a retrospective analysis of patients in the Hospital Corporation of America database who arrived at the hospital between 2015 and 2019. We queried the database to find patients who had a diagnosis of AAD or (nonspecific) chest pain, and who also had a d-dimer performed within 24 hours of arrival at the hospital. The median d-dimer was compared in those diagnosed with AAD versus chest pain. We estimated the test characteristics of d-dimer for AAD at the standard cutoff value of 500 ng/mL.Results: In total, 48,902 patients met the criteria for analysis, including 572 with AAD and 48,330 with chest pain. The median d-dimers were 2455 ng/mL and 385 ng/mL for the AAD and chest pain groups, respectively (p < 0.0001). Using a cutoff of 500 ng/mL, the sensitivity of the d-dimer was 91.1% and the specificity was 71.4%.Conclusion: Serum d-dimer values are higher in patients with AAD than in those with nonspecific chest pain. At the standard cutoff of 500 ng/mL, the serum d-dimer has a high sensitivity for AAD, but not high enough that d-dimer levels alone can be used in isolation to exclude AAD.Keywords: aorta, dissection, d-dimer, diagnosis

Abstract Objective Patient satisfaction is now an important metric in emergency medicine, but the means by which satisfaction is assessed is evolving. We sought to examine hospital ratings on Google and Yelp as compared to those on Medicare's Care Compare (CC) and to determine if certain hospital characteristics are associated with crowdsourced ratings. Methods We performed a cross‐sectional analysis of hospital ratings on Google and Yelp as compared to those on CC using data collected between July 8 and August 2, 2021. For each hospital, we recorded the CC ratings, Yelp ratings, Google ratings, and each hospital's characteristics. Using multivariable linear regression, we assessed for associations between hospital characteristics and crowdsourced ratings. We calculated Spearman's correlation coefficients for CC ratings versus crowdsourced ratings. Results Among 3000 analyzed hospitals, the median hospital ratings on Yelp and Google were 2.5 stars (interquartile ratio [IQR], 2–3) and 3 stars (IQR, 2.7–3.5), respectively. The median number of Yelp and Google reviews per hospital was 13 and 150, respectively. The correlation coefficients for Yelp and Google ratings with CC's overall star ratings were 0.19 and 0.20, respectively. For Yelp and Google ratings with CC's patient survey ratings, correlation coefficients were 0.26 and 0.22, respectively. On multivariable analysis, critical access hospitals had 0.22 (95% confidence interval [CI], 0.14–0.30) more Google stars and hospitals in the West had 0.12 (95% CI, 0.05–0.18) more Google stars than references standard hospitals. Conclusion Patients use Google more frequently than Yelp to review hospitals. Median UnS hospital ratings on Yelp and Google are 2.5 and 3 stars, respectively. Crowdsourced reviews weakly correlate with CC ratings. Critical access hospitals and hospitals in the West have higher crowdsourced ratings.

Introduction: Two common ways of providing anesthesia for shoulder dislocation reductions in the emergency department (ED) are intra-articular lidocaine (IAL) injections and procedural sedation (PS). We sought to compare PS with propofol or etomidate to IAL for shoulder dislocation reductions in the ED. Methods: This was an open-label, randomized controlled trial of patients aged 18–70 years with anterior shoulder dislocations who presented to a single ED. We randomized patients to either PS or IAL for their shoulder dislocation reduction. The primary outcome measure was ED length of stay (LOS). Secondarily, we assessed patient satisfaction and the number of attempts required for successful reduction. Results: We identified 60 patients who met the criteria for enrollment, and were able to enroll 43. We randomized 23 patients to IAL and 20 to PS. In the IAL group, the mean ED LOS was 133 min as compared to 124 min for the PS group (difference 9 min [95% confidence interval (CI)-22–41], P = 0.54). Patients in the IAL group required an average of 1.9 reduction attempts as compared to 1.2 in the PS group (difference of 0.7 [95% CI 0.2–1.2]). The mean patient satisfaction scores were similar at 9.7 and 9.8 for the IAL and PS groups, respectively. Conclusions: This study lacked a sufficient sample size to detect small differences but found no statistically significant difference in mean ED LOS or patient satisfaction for patients who received IAL as compared to PS. Patients in the PS group required fewer attempts for successful reduction.

Tony Zitek,1,2 Luke Weber,1 Dominique Pinzon,1 Nicole Warren1– 3 1Department of Emergency Medicine, Mount Sinai Medical Center, Miami Beach, FL, USA; 2Department of Emergency Medicine, Herbert Wertheim College of Medicine at Florida International University, Miami, FL, USA; 3Department of Medical Education, University of Miami School of Medicine, Miami, FL, USACorrespondence: Tony ZitekMount Sinai Medical Center, Department of Emergency Medicine, 4300 Alton Road, Miami Beach, FL, 33140, USA, Tel +1 305-674-2121 x56632, Email Zitek10@gmail.comAbstract: Immune thrombocytopenia (ITP) is characterized by a platelet count less than 100 × 10^9/L without anemia or leukopenia. Patients with ITP may be asymptomatic, or they may have mild bleeding like petechiae, purpura, or epistaxis. In rare cases, they may present to the emergency department (ED) with life-threatening bleeding as a result of their thrombocytopenia. The emergency physician should thus be prepared to diagnose ITP and treat the bleeding that can result from it. The diagnosis of ITP requires excluding secondary causes of thrombocytopenia, and in the ED, the bare minimum workup for ITP includes a complete blood count and a peripheral blood smear. The peripheral blood smear should show a small number of large platelets with normal morphology, and there should not be an increased number of schistocytes. Many patients with ITP require no emergent treatment. However, if a patient with suspected ITP presents to the ED with critical hemorrhage, the emergency physician should initiate treatment with a platelet transfusion, corticosteroids, and intravenous immune globulin (IVIG) as soon as possible. For less severe bleeding, platelet transfusions are not recommended, and the treatment consists of corticosteroids by themselves or in conjunction with IVIG.Keywords: ITP, symptoms, diagnosis, treatment

Abstract Background: Extended infusion cefepime (1 gram every 6 hours administered over 3 hours) achieves pharmacodynamic efficacy against bacteria with a MIC of ≤8 mg/L in Monte Carlo simulations. This regimen has not been evaluated in clinical practice. Objective: Compare clinical and economic outcomes for cefepime by intermittent infusion and by extended infusion in the acute-care setting. Design: Single-center, retrospective cohort study. Setting: Tertiary-care academic medical center. Patients: Hospitalized adults who received cefepime between August 2016 and July 2018 with a diagnosis of sepsis or pneumonia. Methods: Clinical and economic outcomes were compared for patients who received empiric cefepime via intermittent infusion (30-minute infusion of 2 g every 8 hours) or extended infusion (3-hour infusion of 1 g every 6 hours). Clinical outcomes analyses were carried out using appropriate statistical methods. Results: Overall, 111 patients received intermittent infusion and 93 patients received extended infusion. Approximately half of the included patients had a positive culture for a bacterial pathogen (intermittent infusion 45.9% vs extended infusion 47.3%). Median hospital length of stay (intermittent infusion 6 days vs extended infusion 6 days; P = .67) and 90-day readmission rates (intermittent infusion 61.3% vs extended infusion 67.7%; P = .34) did not differ between the groups. Mortality was infrequent in both groups (intermittent infusion 2.9% vs extended infusion 1.5%; P = .45). Cefepime cost per patient was lower with cefepime by extended infusion: average total daily cost $86.06 for intermittent infusion versus $43.39 for extended infusion. Conclusions: Cefepime via extended infusion (4 grams/day) did not differ in clinical outcomes compared to intermittent infusion (6 grams/day) but reduced drug expenditure. Prospective, multicenter, high-quality studies should be conducted to evaluate a mortality difference between these regimens.

Introduction: The peripheral internal jugular (IJ), also called the “easy IJ,” is an alternative to peripheral venous access reserved for patients with difficult intravenous (IV) access. The procedure involves placing a single-lumen catheter in the IJ vein under ultrasound (US) guidance. As this technique is relatively new, the details regarding the ease of the procedure, how exactly it should be performed, and the safety of the procedure are uncertain. Our primary objective was to determine the success rate for peripheral IJ placement. Secondarily, we evaluated the time needed to complete the procedure and assessed for complications.Methods: This was a prospective, single-center study of US-guided peripheral IJ placement using a 2.5-inch, 18-gauge catheter on a convenience sample of patients with at least two unsuccessful attempts at peripheral IV placement by nursing staff. Peripheral IJ lines were placed by emergency medicine (EM) attending physicians and EM residents who had completed at least five IJ central lines. All physicians who placed lines for the study watched a 15-minute lecture about peripheral IJ technique. A research assistant monitored each line to assess for complications until the patient was discharged. Results: We successfully placed a peripheral IJ in 34 of 35 enrolled patients (97.1%). The median number of attempts required for successful cannulation was one (interquartile range (IQR): 1 to 2). The median time to successful line placement was 3 minutes and 6 seconds (IQR: 59 seconds to 4 minutes and 14 seconds). Two lines failed after placement, and one of the 34 successfully placed peripheral IJ lines (2.9%) had a complication – a local hematoma. There were, however, no arterial punctures or pneumothoraces. Although only eight of 34 lines were placed using sterile attire, there were no line infections.  Conclusion: Our research adds to the growing body of evidence supporting US-guided peripheral internal jugular access as a safe and convenient procedure alternative for patients who have difficult IV access.

The paper deals with tuning the filtered PID controller applied to third order plants with delay. This model option is chosen as a representative case where the loop characteristic quasi-polynomial is of higher order than three. Applying the similarity theory for introducing dimensionless parameterization a comparative model of third order plant dynamics is obtained. Four dominant poles – from the infinite spectrum of the control loop – are assigned by means of tuning three controller gains and a filter time constant where a specific argument increment criterion proves their dominance. The pole prescription coordinates are parameterized via damping, root and natural frequency ratios optimized in the space of the introduced similarity numbers according to the IAE criterion with respect to robustness and filtering constraints. Particularly the natural frequency ratio is a new parameter introduced to tune robustly the PID together with its filter. For the constrained IAE optimization the response of disturbance rejection is used as a representative of control loop behavior. In the space of similarity numbers of the plant it is shown that a limited range of plants is suited to be controlled on the PID control principle and the boundaries of this range are outlined. Survey maps of optimum controller parameters are presented and a comparative study on benchmark application example is added.