State-by-state estimates of avoidable trauma mortality with early and liberal versus delayed or restricted administration of tranexamic acid.

OBJECTIVE: Early administration of tranexamic acid (TXA) has been shown to save lives in trauma patients, and some U.S. emergency medical systems (EMS) have begun providing this therapy prehospital. Treatment protocols vary from state to state: Some offer TXA broadly to major trauma patients, others reserve it for patients meeting vital sign criteria, and still others defer TXA entirely pending a hospital evaluation. The purpose of this study is to compare the avoidable mortality achievable under each of these strategies, and to report on the various approaches used by EMS. METHODS: We used the National Center for Health Statistics Underlying Cause of Death data to identify a TXA-naïve population of trauma patients who died from 2007 to 2012 due to hemorrhage. We estimated the proportion of deaths where the patient was hypotensive or tachycardic using the National Trauma Data Bank. We used avoidable mortality risk ratios from the landmark CRASH 2 study to calculate lives saved had TXA been given within one hour of injury based on a clinician's gestalt the patient was at risk for significant hemorrhage; had it been reserved only for hypotensive or tachycardic patients; or had it been given between hours one to three of injury, considered here as a surrogate for deferring the question to the receiving hospital. RESULTS: Had TXA been given within 1 hour of injury, an average of 3409 deaths per year could have been averted nationally. Had TXA been given between one and three hours after injury, 2236 deaths per year could have been averted. Had TXA only been given to either tachycardic or hypotensive trauma patients, 1371 deaths per year could have been averted. Had TXA only been given to hypotensive trauma patients, 616 deaths per year could have been averted. Similar trends are seen at the individual state level. A review of EMS practices found 15 statewide protocols that allow EMS providers to administer TXA for trauma. CONCLUSION: Providing early TXA to persons at risk of significant hemorrhage has the potential to prevent many deaths from trauma, yet most states do not offer it in statewide prehospital treatment protocols.

A prospective prostate cancer screening programme for men with pathogenic variants in mismatch repair genes (IMPACT): initial results from an international prospective study.

BACKGROUND: Lynch syndrome is a rare familial cancer syndrome caused by pathogenic variants in the mismatch repair genes MLH1, MSH2, MSH6, or PMS2, that cause predisposition to various cancers, predominantly colorectal and endometrial cancer. Data are emerging that pathogenic variants in mismatch repair genes increase the risk of early-onset aggressive prostate cancer. The IMPACT study is prospectively assessing prostate-specific antigen (PSA) screening in men with germline mismatch repair pathogenic variants. Here, we report the usefulness of PSA screening, prostate cancer incidence, and tumour characteristics after the first screening round in men with and without these germline pathogenic variants. METHODS: The IMPACT study is an international, prospective study. Men aged 40-69 years without a previous prostate cancer diagnosis and with a known germline pathogenic variant in the MLH1, MSH2, or MSH6 gene, and age-matched male controls who tested negative for a familial pathogenic variant in these genes were recruited from 34 genetic and urology clinics in eight countries, and underwent a baseline PSA screening. Men who had a PSA level higher than 3·0 ng/mL were offered a transrectal, ultrasound-guided, prostate biopsy and a histopathological analysis was done. All participants are undergoing a minimum of 5 years' annual screening. The primary endpoint was to determine the incidence, stage, and pathology of screening-detected prostate cancer in carriers of pathogenic variants compared with non-carrier controls. We used Fisher's exact test to compare the number of cases, cancer incidence, and positive predictive values of the PSA cutoff and biopsy between carriers and non-carriers and the differences between disease types (ie, cancer vs no cancer, clinically significant cancer vs no cancer). We assessed screening outcomes and tumour characteristics by pathogenic variant status. Here we present results from the first round of PSA screening in the IMPACT study. This study is registered with ClinicalTrials.gov, NCT00261456, and is now closed to accrual. FINDINGS: Between Sept 28, 2012, and March 1, 2020, 828 men were recruited (644 carriers of mismatch repair pathogenic variants [204 carriers of MLH1, 305 carriers of MSH2, and 135 carriers of MSH6] and 184 non-carrier controls [65 non-carriers of MLH1, 76 non-carriers of MSH2, and 43 non-carriers of MSH6]), and in order to boost the sample size for the non-carrier control groups, we randomly selected 134 non-carriers from the BRCA1 and BRCA2 cohort of the IMPACT study, who were included in all three non-carrier cohorts. Men were predominantly of European ancestry (899 [93%] of 953 with available data), with a mean age of 52·8 years (SD 8·3). Within the first screening round, 56 (6%) men had a PSA concentration of more than 3·0 ng/mL and 35 (4%) biopsies were done. The overall incidence of prostate cancer was 1·9% (18 of 962; 95% CI 1·1-2·9). The incidence among MSH2 carriers was 4·3% (13 of 305; 95% CI 2·3-7·2), MSH2 non-carrier controls was 0·5% (one of 210; 0·0-2·6), MSH6 carriers was 3·0% (four of 135; 0·8-7·4), and none were detected among the MLH1 carriers, MLH1 non-carrier controls, and MSH6 non-carrier controls. Prostate cancer incidence, using a PSA threshold of higher than 3·0 ng/mL, was higher in MSH2 carriers than in MSH2 non-carrier controls (4·3% vs 0·5%; p=0·011) and MSH6 carriers than MSH6 non-carrier controls (3·0% vs 0%; p=0·034). The overall positive predictive value of biopsy using a PSA threshold of 3·0 ng/mL was 51·4% (95% CI 34·0-68·6), and the overall positive predictive value of a PSA threshold of 3·0 ng/mL was 32·1% (20·3-46·0). INTERPRETATION: After the first screening round, carriers of MSH2 and MSH6 pathogenic variants had a higher incidence of prostate cancer compared with age-matched non-carrier controls. These findings support the use of targeted PSA screening in these men to identify those with clinically significant prostate cancer. Further annual screening rounds will need to confirm these findings. FUNDING: Cancer Research UK, The Ronald and Rita McAulay Foundation, the National Institute for Health Research support to Biomedical Research Centres (The Institute of Cancer Research and Royal Marsden NHS Foundation Trust; Oxford; Manchester and the Cambridge Clinical Research Centre), Mr and Mrs Jack Baker, the Cancer Council of Tasmania, Cancer Australia, Prostate Cancer Foundation of Australia, Cancer Council of Victoria, Cancer Council of South Australia, the Victorian Cancer Agency, Cancer Australia, Prostate Cancer Foundation of Australia, Asociación Española Contra el Cáncer (AECC), the Instituto de Salud Carlos III, Fondo Europeo de Desarrollo Regional (FEDER), the Institut Català de la Salut, Autonomous Government of Catalonia, Fundação para a Ciência e a Tecnologia, National Institutes of Health National Cancer Institute, Swedish Cancer Society, General Hospital in Malmö Foundation for Combating Cancer.

Missing Early Education and Care During the Pandemic: The Socio-Emotional Impact of the COVID-19 Crisis on Young Children.

Worldwide, millions of children have missed out on early childhood education and care (ECEC) due to the closure of their settings during the COVID-19 pandemic. However, little is known about the socio-emotional impact of these closures on young children. This paper draws upon a study of 506 parents of children aged 1-10 years in Ireland who completed the online Play and Learning in the Early Years (PLEY) Survey during lockdown in May and June 2020. Parents responded to a series of questions about their child's play, learning and development during lockdown, and described the impact of the restrictions on their children's lives. The study was approved by the institutional ethics committee. Findings indicate that most children missed their friends, playing with other children, and the routine and structure of ECEC and school settings. Parents described the negative impact of the closure of these settings on their children's social and emotional well-being, which they suggested, resulted in tantrums, anxiety, clinginess, boredom, and under-stimulation. However, some parents did report positive aspects of lockdown for their children and the family, including more time to play with siblings and a break from the usual routine. While the findings of the PLEY study indicate that children's socio-emotional development was severely disrupted during lockdown, with a variety of negative impacts, this experience was not universal. Moreover, the findings suggest that families missed the nurturing environment provided by ECEC programs that supported their children's socio-emotional development, as well as the structure and routine afforded by their children's participation in early childhood programs.

Psychosocial effects of whole-body MRI screening in adult high-risk pathogenic TP53 mutation carriers: a case-controlled study (SIGNIFY).

BACKGROUND: Germline TP53 gene pathogenic variants (pv) cause a very high lifetime risk of developing cancer, almost 100% for women and 75% for men. In the UK, annual MRI breast screening is recommended for female TP53 pv carriers. The SIGNIFY study (Magnetic Resonance Imaging screening in Li Fraumeni syndrome: An exploratory whole body MRI) study reported outcomes of whole-body MRI (WB-MRI) in a cohort of 44 TP53 pv carriers and 44 matched population controls. The results supported the use of a baseline WB-MRI screen in all adult TP53 pv carriers. Here we report the acceptability of WB-MRI screening and effects on psychosocial functioning and health-related quality of life in the short and medium terms. METHODS: Psychosocial and other assessments were carried out at study enrolment, immediately before MRI, before and after MRI results, and at 12, 26 and 52 weeks' follow-up. RESULTS: WB-MRI was found to be acceptable with high levels of satisfaction and low levels of psychological morbidity throughout. Although their mean levels of cancer worry were not high, carriers had significantly more cancer worry at most time-points than controls. They also reported significantly more clinically significant intrusive and avoidant thoughts about cancer than controls at all time-points. There were no clinically significant adverse psychosocial outcomes in either carriers with a history of cancer or in those requiring further investigations. CONCLUSION: WB-MRI screening can be implemented in TP53 pv carriers without adverse psychosocial outcomes in the short and medium terms. A previous cancer diagnosis may predict a better psychosocial outcome. Some carriers seriously underestimate their risk of cancer. Carriers of pv should have access to a clinician to help them develop adaptive strategies to cope with cancer-related concerns and respond to clinically significant depression and/or anxiety.

Interim Results from the IMPACT Study: Evidence for Prostate-specific Antigen Screening in BRCA2 Mutation Carriers.

BACKGROUND: Mutations in BRCA2 cause a higher risk of early-onset aggressive prostate cancer (PrCa). The IMPACT study is evaluating targeted PrCa screening using prostate-specific-antigen (PSA) in men with germline BRCA1/2 mutations. OBJECTIVE: To report the utility of PSA screening, PrCa incidence, positive predictive value of PSA, biopsy, and tumour characteristics after 3 yr of screening, by BRCA status. DESIGN, SETTING, AND PARTICIPANTS: Men aged 40-69 yr with a germline pathogenic BRCA1/2 mutation and male controls testing negative for a familial BRCA1/2 mutation were recruited. Participants underwent PSA screening for 3 yr, and if PSA > 3.0 ng/ml, men were offered prostate biopsy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: PSA levels, PrCa incidence, and tumour characteristics were evaluated. Statistical analyses included Poisson regression offset by person-year follow-up, chi-square tests for proportion t tests for means, and Kruskal-Wallis for medians. RESULTS AND LIMITATIONS: A total of 3027 patients (2932 unique individuals) were recruited (919 BRCA1 carriers, 709 BRCA1 noncarriers, 902 BRCA2 carriers, and 497 BRCA2 noncarriers). After 3 yr of screening, 527 men had PSA > 3.0 ng/ml, 357 biopsies were performed, and 112 PrCa cases were diagnosed (31 BRCA1 carriers, 19 BRCA1 noncarriers, 47 BRCA2 carriers, and 15 BRCA2 noncarriers). Higher compliance with biopsy was observed in BRCA2 carriers compared with noncarriers (73% vs 60%). Cancer incidence rate per 1000 person years was higher in BRCA2 carriers than in noncarriers (19.4 vs 12.0; p = 0.03); BRCA2 carriers were diagnosed at a younger age (61 vs 64 yr; p = 0.04) and were more likely to have clinically significant disease than BRCA2 noncarriers (77% vs 40%; p = 0.01). No differences in age or tumour characteristics were detected between BRCA1 carriers and BRCA1 noncarriers. The 4 kallikrein marker model discriminated better (area under the curve [AUC] = 0.73) for clinically significant cancer at biopsy than PSA alone (AUC = 0.65). CONCLUSIONS: After 3 yr of screening, compared with noncarriers, BRCA2 mutation carriers were associated with a higher incidence of PrCa, younger age of diagnosis, and clinically significant tumours. Therefore, systematic PSA screening is indicated for men with a BRCA2 mutation. Further follow-up is required to assess the role of screening in BRCA1 mutation carriers. PATIENT SUMMARY: We demonstrate that after 3 yr of prostate-specific antigen (PSA) testing, we detect more serious prostate cancers in men with BRCA2 mutations than in those without these mutations. We recommend that male BRCA2 carriers are offered systematic PSA screening.

Psychosocial impact of undergoing prostate cancer screening for men with BRCA1 or BRCA2 mutations.

OBJECTIVES: To report the baseline results of a longitudinal psychosocial study that forms part of the IMPACT study, a multi-national investigation of targeted prostate cancer (PCa) screening among men with a known pathogenic germline mutation in the BRCA1 or BRCA2 genes. PARTICPANTS AND METHODS: Men enrolled in the IMPACT study were invited to complete a questionnaire at collaborating sites prior to each annual screening visit. The questionnaire included sociodemographic characteristics and the following measures: the Hospital Anxiety and Depression Scale (HADS), Impact of Event Scale (IES), 36-item short-form health survey (SF-36), Memorial Anxiety Scale for Prostate Cancer, Cancer Worry Scale-Revised, risk perception and knowledge. The results of the baseline questionnaire are presented. RESULTS: A total of 432 men completed questionnaires: 98 and 160 had mutations in BRCA1 and BRCA2 genes, respectively, and 174 were controls (familial mutation negative). Participants' perception of PCa risk was influenced by genetic status. Knowledge levels were high and unrelated to genetic status. Mean scores for the HADS and SF-36 were within reported general population norms and mean IES scores were within normal range. IES mean intrusion and avoidance scores were significantly higher in BRCA1/BRCA2 carriers than in controls and were higher in men with increased PCa risk perception. At the multivariate level, risk perception contributed more significantly to variance in IES scores than genetic status. CONCLUSION: This is the first study to report the psychosocial profile of men with BRCA1/BRCA2 mutations undergoing PCa screening. No clinically concerning levels of general or cancer-specific distress or poor quality of life were detected in the cohort as a whole. A small subset of participants reported higher levels of distress, suggesting the need for healthcare professionals offering PCa screening to identify these risk factors and offer additional information and support to men seeking PCa screening.

Parent management training for conduct problems in children: Enhancing treatment to improve therapeutic change.

Background/Objective: The study evaluated two variations of Parent Management Training (PMT) for children referred to treatment for oppositional, aggressive, and antisocial behavior. The goal was to evaluate the impact of multiple enhancements to optimize common and placebo factors to augment therapeutic change. Method: The families of all children (N=138, 39 girls and 99 boys, ages 6-13) received PMT. One half of the families were assigned to receive an enhanced version with multiple additions designed to increase bonding of the parent to the therapist, professionalism of treatment and setting, credibility of the intervention, and expectancies for therapeutic change. Assessment included multiple treatment outcome measures of the child (problem behaviors, psychiatric symptoms, social competence, and adaptive functioning) and parents (depression, stress, and family relations) showed marked improvements over the course of treatment, and several process measures (therapeutic alliance, credibility of the procedures, expectancy for change). Results: The results indicated that children and parents made marked improvement in all the treatment outcome measures. The vast majority of children fell within the normative range at posttreatment on problem and prosocial behaviors. The two treatment conditions were no different in outcomes for children or parents. Conclusion: PMT led to marked changes in treatment outcome.

Antecedentes/Objetivo: Se evalúan dos versiones del Parent Management Training (PMT) para tratamiento de conducta oposicionista, agresiva y antisocial en niños. El objetivo fue evaluar el impacto de múltiples mejoras para optimizar los factores comunes y de placebo con el fin de incrementar el efecto terapéutico. Método: Las familias de los niños (N = 138, 39 niñas y 99 niños de 6 a 13 años) recibieron PMT. La mitad fue asignada a una versión mejorada con múltiples adiciones para aumentar la vinculación de los padres con el terapeuta, la profesionalidad del tratamiento y el entorno, la credibilidad de la intervención y las expectativas de cambio terapéutico. La evaluación incluyó medidas del efecto del tratamiento en el niño (problemas de comportamiento, síntomas psiquiátricos, competencia social y funcionamiento adaptativo) y los padres (depresión, estrés y relaciones familiares) y medidas del proceso (alianza terapéutica, credibilidad de los procedimientos y expectativa de cambio). Resultados: Niños y padres mejoraron notablemente en todas las medidas del efecto del tratamiento. La gran mayoría de niños se situaron dentro del rango normativo en el post-tratamiento. Las dos condiciones de tratamiento no fueron diferentes para niños ni padres. Conclusión: PMT produjo cambios significativos en el resultado del tratamiento.

Early Lymphocyte Recovery and Outcome in Osteosarcoma.

BACKGROUND: Early lymphocyte recovery following chemotherapy has been associated with improved outcome in many cancers, including in one small study of osteosarcoma patients. MATERIALS AND METHODS: To confirm this finding, we retrospectively reviewed data from 53 patients with newly diagnosed osteosarcoma who had blood counts on day 14 (±1 d) following the first cycle of cisplatin and doxorubicin. RESULTS: The median absolute lymphocyte count (ALC) 14 days after starting the first cycle of chemotherapy (ALC-14) was 1990 cells/µL (range: 600 to 6470). For 32 patients with an ALC-14≥1800 cells/µL, the 5-year progression-free survival (PFS) was 69%, compared with 33% for patients with an ALC-14 of <1800 cell/µL (P=0.036). In multivariable analysis of factors including age, sex, metastatic disease, and favorable histologic response to induction chemotherapy, ALC-14 was significantly associated with PFS (P=0.0081) and overall survival (P=0.0131). The use of ALC-14 appears to further stratify PFS and overall survival among patients when grouped by histologic response. CONCLUSIONS: We confirmed that early lymphocyte recovery was associated with outcome in pediatric osteosarcoma. Although presumably reflecting immune-mediated tumor control, the precise mechanism for this is unclear. Further study of peripheral blood lymphocyte subpopulations in prospectively treated patients is underway.

The Integration of Electronic Medical Student Evaluations Into an Emergency Department Tracking System is Associated With Increased Quality and Quantity of Evaluations.

BACKGROUND: Medical student evaluations are essential for determining clerkship grades. Electronic evaluations have various advantages compared to paper evaluations, such as increased ease of collection, asynchronous reporting, and decreased likelihood of becoming lost. OBJECTIVES: To determine whether electronic medical student evaluations (EMSEs) provide more evaluations and content when compared to paper shift card evaluations. METHODS: This before and after cohort study was conducted over a 2.5-year period at an academic hospital affiliated with a medical school and emergency medicine residency program. EMSEs replaced the paper shift evaluations that had previously been used halfway through the study period. A random sample of the free text comments on both paper and EMSEs were blindly judged by medical student clerkship directors for their helpfulness and usefulness. Logistic regression was used to test for any relationship between quality and quantity of words. RESULTS: A total of 135 paper evaluations for 30 students and then 570 EMSEs for 62 students were collected. An average of 4.8 (standard deviation [SD] 3.2) evaluations were completed per student using the paper version compared to 9.0 (SD 3.8) evaluations completed per student electronically (p < 0.001). There was an average of 8.8 (SD 8.5) words of free text evaluation on paper evaluations when compared to 22.5 (SD 28.4) words for EMSEs (p < 0.001). A statistically significant (p < 0.02) association between quality of an evaluation and the word count existed. CONCLUSIONS: EMSEs that were integrated into the emergency department tracking system significantly increased the number of evaluations completed compared to paper evaluations. In addition, the EMSEs captured more "helpful/useful" information about the individual students as evidenced by the longer free text entries per evaluation.

Reducing Therapist Contact in Parenting Programs: Evaluation of Internet-Based Treatments for Child Conduct Problems.

This study evaluated two Internet-based versions of Parent Management Training (PMT) and the effects of greatly reducing the contact required of a mental health professional on treatment of children referred for conduct problems. We were interested whether reduced contact with a therapist influenced treatment outcome, therapeutic alliance, parent adherence to treatment prescriptions, and parent reactions to and evaluations of the treatment procedures. Sixty children and their caregivers were assigned to receive either Full Contact PMT (with the amount of weekly contact similar to traditional PMT; approximately 50 minutes of direct therapist contact each week) or Reduced Contact PMT (with most information provided through recordings; approximately 10 minutes of therapist contact each week). Children in both groups showed significant and similar reductions in antisocial behaviors specifically, internalizing and externalizing symptoms more generally, and improvements in overall adaptive functioning. Therapeutic alliance also was similar across the two treatment groups. However, parents rated Full Contact treatment as more acceptable than the reduced version. Both treatments were similar in outcomes to in-person treatment as evaluated by a nonrandomized matched sample used as a benchmark in supplementary analyses. Overall, the findings indicate that therapist contact can be reduced while positive treatment outcomes are maintained but that interventions that reduce direct time with a therapist may be viewed less positively by clients.

Types of diagnostic errors in neurological emergencies in the emergency department.

BACKGROUND: Neurological emergencies often pose diagnostic challenges for emergency physicians because these patients often present with atypical symptoms and standard imaging tests are imperfect. Misdiagnosis occurs due to a variety of errors. These can be classified as knowledge gaps, cognitive errors, and systems-based errors. The goal of this study was to describe these errors through review of quality assurance (QA) records. METHODS: This was a retrospective pilot study of patients with neurological emergency diagnoses that were missed or delayed at one urban, tertiary academic emergency department. Cases meeting inclusion criteria were identified through review of QA records. Three emergency physicians independently reviewed each case and determined the type of error that led to the misdiagnosis. Proportions, confidence intervals, and a reliability coefficient were calculated. RESULTS: During the study period, 1168 cases were reviewed. Forty-two cases were found to include a neurological misdiagnosis and twenty-nine were determined to be the result of an error. The distribution of error types was as follows: knowledge gap 45.2% (95% CI 29.2, 62.2), cognitive error 29.0% (95% CI 15.9, 46.8), and systems-based error 25.8% (95% CI 13.5, 43.5). Cerebellar strokes were the most common type of stroke misdiagnosed, accounting for 27.3% of missed strokes. CONCLUSIONS: All three error types contributed to the misdiagnosis of neurological emergencies. Misdiagnosis of cerebellar lesions and erroneous radiology resident interpretations of neuroimaging were the most common mistakes. Understanding the types of errors may enable emergency physicians to develop possible solutions and avoid them in the future.

Practicing emergency physicians report performing well on most emergency medicine milestones.

BACKGROUND: The Accreditation Council for Graduate Medical Education's Next Accreditation System endorsed specialty-specific milestones as the foundation of an outcomes-based resident evaluation process. These milestones represent five competency levels (entry level to expert), and graduating residents will be expected to meet Level 4 on all 23 milestones. Limited validation data on these milestones exist. It is unclear if higher levels represent true competencies of practicing emergency medicine (EM) attendings. OBJECTIVE: Our aim was to examine how practicing EM attendings in academic and community settings self-evaluate on the new EM milestones. METHODS: An electronic self-evaluation survey outlining 9 of the 23 EM milestones was sent to a sample of practicing EM attendings in academic and community settings. Attendings were asked to identify which level was appropriate for them. RESULTS: Seventy-nine attendings were surveyed, with an 89% response rate. Sixty-one percent were academic. Twenty-three percent (95% confidence interval [CI] 20%-27%) of all responses were Levels 1, 2, or 3; 38% (95% CI 34%-42%) were Level 4; and 39% (95% CI 35%-43%) were Level 5. Seventy-seven percent of attendings found themselves to be Level 4 or 5 in eight of nine milestones. Only 47% found themselves to be Level 4 or 5 in ultrasound skills (p = 0.0001). CONCLUSIONS: Although a majority of EM attendings reported meeting Level 4 milestones, many felt they did not meet Level 4 criteria. Attendings report less perceived competence in ultrasound skills than other milestones. It is unclear if self-assessments reflect the true competency of practicing attendings. The study design can be useful to define the accuracy, precision, and validity of milestones for any medical field.

Social capital and disaster preparedness among low income Mexican Americans in a disaster prone area.

Examination of social capital and its relationship to disaster preparedness has grown in prominence partially due to world-wide need to effectively respond to terrorist attacks, viral epidemics, or natural disasters. Recent studies suggested that social capital may be related to a community's ability to plan for and respond to such disasters. Few studies, however, have examined social capital constructs among low income populations living in disaster prone areas and accounted for the influence of social capital at the individual and community level. We examined social capital as measured by perceived fairness, perceived civic trust, perceived reciprocity and group membership. We undertook a multistage random cluster survey in three coastal counties in Texas (U.S.) noted for their high levels of poverty. Individuals from 3088 households provided data on social capital, socioeconomic and demographic characteristics, and self-reported level of preparedness for a hurricane. We used multivariable logistic regression to test potential associations between social capital measures and disaster preparedness. After adjusting for age, gender, marital status, ethnicity, education, employment, household income, acculturation, self-reported health, special needs persons in household, household size, and distance to the shore we found a higher prevalence of preparedness among individuals who reported the highest perception of fairness [AOR = 3.12, 95% CI: (1.86, 5.21)] compared to those individuals who reported lowest perceptions of fairness. We also found a higher prevalence of preparedness [AOR = 2.06; 95% CI: (1.17, 3.62)] among individuals who reported highest perceptions of trust compared to individuals who reported lowest perceptions of trust. Perceived reciprocity and group membership were not associated with preparedness. These results extend previous findings on social capital and disaster preparedness and further characterize social capital's presence among a low income population living in a hurricane prone area.

Avoiding misdiagnosis in patients with neurological emergencies.

Approximately 5% of patients presenting to emergency departments have neurological symptoms. The most common symptoms or diagnoses include headache, dizziness, back pain, weakness, and seizure disorder. Little is known about the actual misdiagnosis of these patients, which can have disastrous consequences for both the patients and the physicians. This paper reviews the existing literature about the misdiagnosis of neurological emergencies and analyzes the reason behind the misdiagnosis by specific presenting complaint. Our goal is to help emergency physicians and other providers reduce diagnostic error, understand how these errors are made, and improve patient care.

Klebsiella pneumoniae liver abscess: an emerging problem in North America.

BACKGROUND: Before the 1980s, Escherichia coli was the most common cause of pyogenic liver abscess, but more recently, Klebsiella pneumoniae has emerged as the most common organism in the United States and Taiwan. OBJECTIVE: Our goal is to present a case of K. pneumoniae liver abscess (KLA) and review the risk factors, presenting symptoms, complications, and treatment of this disease that is emerging in North America. CASE REPORT: We present a patient who was found to have KLA complicated by bacteremia and sepsis. CONCLUSIONS: Initially described in the Asian literature, KLA is an emerging problem in North America. We present this case to increase awareness among emergency physicians of the diagnosis, risk factors, potential complications-including bacteremia and disseminated infection-and treatment.

Multicenter study of central venous oxygen saturation (ScvO(2)) as a predictor of mortality in patients with sepsis.

STUDY OBJECTIVE: Abnormal (both low and high) central venous saturation (ScvO(2)) is associated with increased mortality in emergency department (ED) patients with suspected sepsis. METHODS: This was a secondary analysis of 4 prospectively collected registries of ED patients treated with early goal-directed therapy-based sepsis resuscitation protocols from 4 urban tertiary care hospitals. Inclusion criteria were sepsis, hypoperfusion defined by systolic blood pressure less than 90 mm Hg or lactate level greater than or equal to 4 mmol/L, and early goal-directed therapy treatment. ScvO(2) levels were stratified into 3 groups: hypoxia (ScvO(2) <70%); normoxia (ScvO(2) 71% to 89%); and hyperoxia (ScvO(2) 90% to 100%). The primary exposures were initial ScvO(2) and maximum ScvO(2) achieved, with the primary outcome as inhospital mortality. Multivariate analysis was performed. RESULTS: There were 619 patients who met criteria and were included. For the maximum ScvO(2), compared with the mortality rate in the normoxia group of 96 of 465 (21%; 95% confidence interval [CI] 17% to 25%), both the hypoxia mortality rate, 25 of 62 (40%; 95% CI 29% to 53%) and hyperoxia mortality rate, 31 of 92 (34%; 95% CI 25% to 44%) were significantly higher, which remained significant in a multivariate modeling. When the initial ScvO(2) measurement was analyzed in a multivariate model, only hyperoxia was significantly higher. CONCLUSION: The maximum ScvO(2) value achieved in the ED (both abnormally low and high) was associated with increased mortality. In multivariate analysis for initial ScvO(2), the hyperoxia group was associated with increased mortality, but not the hypoxia group. This study suggests that future research aimed at targeting methods to normalize high ScvO(2) values by therapies that improve microcirculatory flow or mitochondrial dysfunction may be warranted.

Multicenter study of early lactate clearance as a determinant of survival in patients with presumed sepsis.

We sought to determine (a) if early lactate clearance is associated with improved survival in emergency department patients with severe sepsis and (b) the concordance between central venous oxygen saturation (ScvO2) optimization and lactate clearance during early sepsis resuscitation. Within a multicenter shock research network that uses quantitative resuscitation for severe sepsis, we analyzed prospectively collected registries of consecutive emergency department patients diagnosed with severe sepsis at three urban hospitals. Inclusion criteria are as follows: (a) age older than 17 years, (b) two or more systemic inflammation criteria, (c) systolic blood pressure 90 mmHg or less after fluid challenge or initial lactate of 4 mmol/L or greater, and (d ) initial and repeat lactate measurement within 6 h of resuscitation initiation. We stratified patients into two groups defined a priori based on previously published data: (a) lactate clearance--repeat lactate decrease by 10% or greater from initial (or both initial and repeat levels < or = 2.0 mmol/L), and (b) lactate non-clearance--repeat lactate decrease by less than 10% from initial. The primary outcome was in-hospital mortality. Among 166 patients, lactate non-clearance occurred in 15 (9%) of 166. Mortality was 60% for lactate nonclearance versus 19% for lactate clearance, P < 0.001. On multivariate analysis, lactate non-clearance was an independent predictor of death (odds ratio, 4.9 [confidence interval, 1.5-15.9]). We found discordance between ScvO2 optimization and lactate clearance; 79% of lactate non-clearance had concomitant ScvO2 of 70% or greater. In this multicenter cohort of sepsis patients, failing to clear lactate during resuscitation carried a high risk of death, and ScvO2 optimization did not reliably exclude lactate non-clearance. These data provide rationale for a clinical trial of lactate clearance as a distinct end point of early sepsis resuscitation.

Favorable response to analgesics does not predict a benign etiology of headache.

BACKGROUND: Distinguishing between primary and secondary headaches (HAs) is essential for the safe and effective management of patients with HA. A favorable response to analgesics may be observed with both classes of HAs and therefore is not a good predictor of who needs further evaluation. OBJECTIVE: To systematically review the data that a favorable response to analgesics including triptans should not be used to exclude a serious secondary cause of HA. DESIGN: PubMed search of English-language articles between 1980 and 2007 and reference lists of these articles. Two authors independently reviewed articles for study results and quality. Inclusion was based on 100% agreement between authors. We included articles that described secondary HAs as (1) having a favorable response to analgesics and/or (2) having a favorable response to sumatriptan. Of the 548 studies identified by our search strategy, 18 were included in our final analysis. RESULTS: Seven of the 18 studies found that 46/103 patients (44%) described a significant or complete resolution of secondary HA from medications such as anti-emetics and nonsteroidal anti-inflammatory drugs (NSAIDs). Eleven of the 18 articles including 25/25 patients (100%) described a significant or complete resolution of secondary HA from sumatriptan, a serotonin 5HT agonist. CONCLUSIONS: A favorable response to analgesics including triptans should not be used to exclude a serious secondary cause of HA.

The epidemiology of chronic hepatitis C infection in survivors of childhood cancer: an update of the St Jude Children's Research Hospital hepatitis C seropositive cohort.

Childhood cancer survivors transfused before 1992 are at risk for chronic hepatitis C (HCV) infection. In 1995, St Jude Children's Research Hospital initiated an epidemiologic study of childhood cancer survivors with transfusion-acquired HCV. Of the 148 survivors with HCV confirmed by second-generation enzyme immunoassay, 122 consented to participate in the study. Their current median age is 29 years (range, 9 to 47 years). At enrollment, polymerase chain reaction (PCR) testing indicated chronic infection in 81.1%; genotype 1 was the most common viral genotype. Liver biopsy in 60 patients at a median of 12.4 years from the diagnosis of malignancy showed mild (28.8%) or moderate (35.6%) fibrosis; 13.6% had cirrhosis. Elevated body mass index was associated with histologic findings of increased steatosis (P=.008). Antimetabolite chemotherapy exposure was associated with early progression of fibrosis. Significant quality-of-life deficits were observed in noncirrhotic adult survivors. Antiviral therapy resulted in clearance of infection in 17 (44%) of 38 patients to date. Six patients have died; 1 patient with decompensated cirrhosis died of variceal bleeding. Despite a young age at HCV infection, the progression of liver disease in childhood cancer survivors is comparable to that seen in adults.