The impact of month and season on the incidence of giant cell arteritis: an Intelligent Research in Sight (IRIS) Registry analysis.

PURPOSE: Previous investigations into the relationship between season and the incidence of giant cell arteritis (GCA) have produced conflicting results. This study aimed to explore the impact of season and new diagnoses of GCA in a more definitive sense by employing the large dataset of the Intelligent Research in Sight (IRIS) database. METHODS: The IRIS Registry was queried to identify new cases of GCA from 2013 to 2021. Statistical analyses were performed to determine the significance of the relationship between the time of year and the incidence of GCA on regional and nationwide bases via Cochran's Q statistical test. RESULTS: A total of 27,339 eyes with a new diagnosis of GCA were identified. Neither the month nor the season of the year correlated with the incidence of GCA, regardless of geographic location within the USA (p > 0.05 for each variable). CONCLUSIONS: In the USA, the incidence of GCA does not appear to vary by month or season. While this finding contradicts certain previous studies that identified a relationship, the cohort of patients identified from the IRIS Registry is much larger than that of previous investigations. Clinicians should be mindful of the possibility of GCA, regardless of the time of the year.

Patients' Perspectives on Emergency Department COVID-19 Vaccination and Vaccination Messaging Through Randomized Vignettes.

OBJECTIVES: Emergency departments (EDs) could play an important role in the COVID-19 pandemic response by reaching patients who would otherwise not seek vaccination in the community. Prior to expanding COVID-19 vaccination to the acute care setting, we assessed ED patients' COVID-19 vaccine status, perspectives, and hypothetical receptivity to ED-based vaccination. METHODS: From January 11 through March 31, 2021, we conducted a multisite (Albany Medical Center, Boston Medical Center, Buffalo General Hospital, University of Cincinnati Medical Center, and Upstate Medical Center), cross-sectional survey of ED patients, with embedded randomization for participants to receive 1 of 4 vignette vaccination messages (simple opt-in message, recommendation by the hospital, community-oriented message, and acknowledgment of vaccine hesitancy). Main outcomes included COVID-19 vaccination status, prior intention to be vaccinated, and receptivity to randomized hypothetical vignette messages. RESULTS: Of 610 participants, 122 (20.0%) were vaccinated, 234 (38.4%) had prior intent to be vaccinated, 111 (18.2%) were unsure as to prior intent, and 143 (23.4%) had no prior intent to be vaccinated. Vaccine hesitancy (participants who were vaccine unsure or did not intend to receive the vaccine) was associated with the following: age <45 years, female, non-Hispanic Black, no primary health care, and no prior influenza vaccination. Overall, 364 of 565 (64.4%; 95% CI, 60.3%-68.4%) were willing to accept a hypothetical vaccination in the ED. Among participants with prior vaccine hesitancy, a simple opt-in message resulted in the highest acceptance rates to hypothetical vaccination (39.7%; 95% CI, 27.6%-52.8%). CONCLUSIONS: EDs have appropriate patient populations to initiate COVID-19 vaccination programs as a supplement to community efforts. A simple opt-in approach may offer the best messaging to reach vaccine-hesitant ED patients.

COVID-19 and beyond: Lessons learned from emergency department HIV screening for population-based screening in healthcare settings.

Emergency departments (EDs) have played a major role in the science and practice of HIV population screening. After decades of experience, EDs have demonstrated the capacity to provide testing and linkage to care to large volumes of patients, particularly those who do not otherwise engage the healthcare system. Efforts to expand ED HIV screening in the United States have been accelerated by a collaborative national network of emergency physicians and other stakeholders called EMTIDE (Emergency Medicine Transmissible Infectious Diseases and Epidemics). As the COVID-19 pandemic evolves, EDs nationwide are being tasked with diagnosing and managing COVID-19 in a myriad of capacities, adopting varied approaches based in part on know-how, local disease trends, and the supply chain. The objective of this article is to broadly summarize the lessons learned from decades of ED HIV screening and provide guidance for many analogous issues and challenges in population screening for COVID-19. Over time, and with the accumulated experience from other epidemics, ED screening should develop into an overarching discipline in which the disease in question may vary, but the efficiency of response is increased by prior knowledge and understanding.

Lack of active SARS-CoV-2 virus in a subset of PCR-positive COVID-19 congregate care patients.

Highly sensitive nucleic acid amplification tests (NAATs) designed to detect SARS-CoV-2 RNA are the standard of care for the diagnosis of COVID-19. However, the accuracy of these methods for the quantitation of active virus rather than non-infectious RNA fragments that can persist for extended periods of time has been unclear. This issue is particularly relevant for congregate care patients who are unable to return to their home residence until fully negative by NAATs. We tested paired samples from individual patients for the presence of virus at both early and later stages of disease. Culture of nasopharyngeal swab samples for 10 days in Vero E6 cells revealed active virus in only 4 out of 14 (28.6%) patients. The ability to isolate viral plaque-forming units (PFU) correlated with viral RNA loads of >6.79 log genomic copies/ml and only occurred in samples collected from patients early after symptom onset and before development of antibody. Culture in Vero E6 cells lacking the STAT1-dependent interferon signaling pathway increased the numbers of viral PFU detected but did not affect the incidence of positive cultures. We conclude that culturable virus is correlated with SARS-CoV-2 NAATs detection only during early symptom onset and with high viral titers/low antibody titers in non-immunosuppressed patients.

Compliance with American College of Chest Physicians (ACCP) recommendations for thromboembolic prophylaxis in the intensive care unit: a level I trauma center experience.

BACKGROUND: Recommendations are for nearly universal venous thromboembolism (VTE) prophylaxis in critically ill hospitalized patients because of their well-recognized risks. In those intensive care units (ICUs) where patient care is more uniformly directed, it may be expected that VTE prophylaxis would more closely follow this standard over units that are less uniform, such as open-model ICUs. METHODS: This was a retrospective cohort study on all patients aged 18+ admitted to an open ICU between 6/1/2017 and 5/31/2018. Patients were excluded if they had instructions to receive comfort measures only or required therapeutic anticoagulant administration. Prophylaxis administration practices, including administration of mechanical and/or pharmacologic prophylaxis and delayed (≥48 h post-ICU admission) initiation of pharmacologic prophylaxis, were compared between patients admitted to the ICU by the trauma service versus other departments. Root causes for opting out of pharmacological prophylaxis were documented and compared between the two study groups. RESULTS: One-hundred two study participants were admitted by the trauma service, and 98 were from a non-trauma service. Mechanical (98% trauma vs. 99% non-trauma, P = 0.99) and pharmacologic (54% vs. 44%, P = 0.16) prophylaxis rates were similar between the two admission groups. The median time from ICU admission to pharmacologic prophylaxis initiation was 53 h for the trauma service and 10 h for the non-trauma services (P ≤ 0.01). In regression analyses, trauma-service admission (odds ratio (OR) = 2.88, 95% confidence interval (CI) 1.21-6.83) and increasing ICU length of stay (OR = 1.13, 95% CI 1.05-1.21) were independently associated with pharmacologic prophylaxis use. Trauma-service admission (OR = 8.30, 95% CI 2.18-31.56) and increasing hospital length of stay (OR = 1.15, 95% CI 1.03-1.28) were independently associated with delayed prophylaxis initiation. CONCLUSIONS: Overall, the receipt of VTE prophylaxis of any type was close to 100%, due to the nearly universal use of mechanical compression devices among ICU patients in this study. However, when examining pharmacologic prophylaxis specifically, the rate was considerably lower than is currently recommended: 54% among the trauma services and 44% among non-trauma services.

Basic Life Support Awareness and Knowledge in High School Students.

INTRODUCTION: Cardiovascular disease is the leading cause of death in the United States. When cardiovascular disease results in cardiac arrest, the ability to perform basic life support (BLS) can change the outcome from death to survival. There is no definitive statistical data on high schoolers' awareness of basic life support (BLS). METHODS: A survey-based research study was conducted to find high schoolers' awareness of BLS. A total of 105 students, primarily from Kansas City suburbs, took a survey with questions ranging from their views on whether BLS courses should be integrated into the high school curriculum to the steps they would take when a person collapses on the ground. Results were analyzed to determine the students' knowledge of different aspects of BLS and their interest in taking a BLS course in school. RESULTS: Over 70% of the students would take a BLS course should it be offered in a high school class. Most students answered questions regarding BLS steps correctly but lacked critical knowledge on an automated external defibrillator (AED). CONCLUSIONS: Although over 70% of the students were aware of the basics of BLS, most students lacked knowledge on the critical aspects of BLS, such as the use of an AED. Most students recognize the importance of BLS in the high school curriculum and would acquire the skills in a high school class. Introducing a BLS course in the high school curriculum would improve the students' knowledge and contribute to improved survival rates of victims of out-of-hospital cardiac arrest.

Evaluation of Specimen Types and Saliva Stabilization Solutions for SARS-CoV-2 Testing.

Identifying SARS-CoV-2 infections through aggressive diagnostic testing remains critical to tracking and curbing the spread of the COVID-19 pandemic. Collection of nasopharyngeal swabs (NPS), the preferred sample type for SARS-CoV-2 detection, has become difficult due to the dramatic increase in testing and consequent supply strain. Therefore, alternative specimen types have been investigated that provide similar detection sensitivity with reduced health care exposure and the potential for self-collection. In this study, the detection sensitivity of SARS-CoV-2 in nasal swabs (NS) and saliva was compared to that of NPS using matched specimens from two outpatient cohorts in New York State (total n = 463). The first cohort showed only a 5.4% positivity, but the second cohort (n = 227) had a positivity rate of 41%, with sensitivity in NPS, NS, and saliva of 97.9%, 87.1%, and 87.1%, respectively. Whether the reduced sensitivity of NS or saliva is acceptable must be assessed in the settings where they are used. However, we sought to improve on it by validating a method to mix the two sample types, as the combination of nasal swab and saliva resulted in 94.6% SARS-CoV-2 detection sensitivity. Spiking experiments showed that combining them did not adversely affect the detection sensitivity in either. Virus stability in saliva was also investigated, with and without the addition of commercially available stabilizing solutions. The virus was stable in saliva at both 4°C and room temperature for up to 7 days. The addition of stabilizing solutions did not enhance stability and, in some situations, reduced detectable virus levels.

Effects of propofol on ischemia-reperfusion and traumatic brain injury.

Oxidative stress exacerbates brain damage following ischemia-reperfusion and traumatic brain injury (TBI). Management of TBI and critically ill patients commonly involves use of propofol, a sedation medication that acts as a general anesthetic with inherent antioxidant properties. Here we review available evidence from animal model systems and clinical studies that propofol protects against ischemia-reperfusion injury. However, evidence of propofol toxicity in humans exists and manifests as a rare complication, "propofol infusion syndrome" (PRIS). Evidence in animal models suggests that brain injury induces expression of the p75 neurotrophin receptor (p75NTR), which is associated with proapoptotic signaling. p75NTR-mediated apoptosis of neurons is further exacerbated by propofol's superinduction of p75NTR and concomitant inhibition of neurotrophin processing. Propofol is toxic to neurons but not astrocytes, a type of glial cell. Evidence suggests that propofol protects astrocytes from oxidative stress and stimulates astroglial-mediated protection of neurons. One may speculate that in brain injury patients under sedation/anesthesia, propofol provides brain tissue protection or aids in recovery by enhancing astrocyte function. Nevertheless, our understanding of neurologic recovery versus long-term neurological sequelae leading to neurodegeneration is poor, and it is also conceivable that propofol plays a partial as yet unrecognized role in long-term impairment of the injured brain.

Teaching for Practice: The Impact of a Large-Scale Interprofessional Foundational Program.

PURPOSE: The University of Kansas Medical Center has developed an interprofessional education (IPE) foundational program using TeamSTEPPS, a curriculum designed to improve patient care through effective communication and teamwork. The purpose of this study was to understand the impact of the Level 1 program on learners as they develop the attitudes, knowledge, and skills related to interprofessional collaborative practice. METHODS: Learners (n=715) representing 15 professions participated in the Level 1 program. A mixed-methods approach was used to assess achievement of learning objectives, learner reactions, modifications of perceptions and attitudes, acquisition of knowledge and skills, and anticipated behaviors. RESULTS: Learners (n=585, 81.8%) agreed that the program was valuable. Positive changes in attitudes were significant pre-post (p<0.001). An average of 80.3% of learners who responded (n=196, 27.4%) correctly answered knowledge survey questions. Furthermore, analysis of open-ended questions suggested that learners gained an increased appreciation for interprofessional communication and better understanding of the roles of other healthcare professions. CONCLUSIONS: Based on positive learner reactions, changes in attitudes and knowledge, and anticipated behaviors associated with this program, similar approaches that incorporate TeamSTEPPS early in professional curricula may be useful for foundational IPE programming due to the intentional alignment with collaborative practice and orientation towards the Quadruple Aim.

Hospitalized patients' and family members' preferences for real-time, transparent access to their hospital records.

OBJECTIVES: To better understand patient satisfaction and perceived engagement with traditional hospital-based communication and to elicit patient preferences for health information technologies that would lead to improved satisfaction and engagement. STUDY DESIGN: We performed a mixed-methods study involving qualitative interviews followed by a survey of hospitalized patients and their family members at a single large academic medical center. METHODS: We conducted semi-structured interviews with 41 patients and surveyed 267 patients or family members to elicit their perspectives on satisfaction with traditional hospital communication methods, information needed to more fully engage in the patients' medical care, and potential solutions for improved hospital-based communication. RESULTS: Qualitative interviews revealed patients' and family members' dissatisfaction with current hospital-based communication methods. They would prefer more information, in more flexible forms, with real-time digital access and the ability to share within their social and healthcare networks. Quantitative results from the survey supported these premises, with at least the majority of the 267 patients surveyed agreeing across each survey question. Furthermore, participants identified a "communications point person" as the individual who organizes, understands, and communicates about the patient's care, who was often a family member not available at the bedside during daily rounds. Potential solutions included improved transparency about hospital processes, creating systems that allow patients and family to help coordinate and double-check their own health-related communications, and delivering hospital-based communications through digital media. CONCLUSIONS: These study findings provide empiric evidence to hospital decision-makers regarding patient and family preferences for 21st-century hospital-based communication systems.

Pediatric Patients Discharged from the Emergency Department with Abnormal Vital Signs.

INTRODUCTION: Children often present to the emergency department (ED) with minor conditions such as fever and have persistently abnormal vital signs. We hypothesized that a significant portion of children discharged from the ED would have abnormal vital signs and that those discharged with abnormal vital signs would experience very few adverse events. METHODS: We performed a retrospective chart review encompassing a 44-month period of all pediatric patients (aged two months to 17 years) who were discharged from the ED with an abnormal pulse rate, respiratory rate, temperature, or oxygen saturation. We used a local quality assurance database to identify pre-defined adverse events after discharge in this population. Our primary aim was to determine the proportion of children discharged with abnormal vital signs and the frequency and nature of adverse events. Additionally, we performed a sub-analysis comparing the rate of adverse events in children discharged with normal vs. abnormal vital signs, as well as a standardized review of the nature of each adverse event. RESULTS: Of 33,185 children discharged during the study period, 5,540 (17%) of these patients had at least one abnormal vital sign. There were 24/5,540 (0.43%) adverse events in the children with at least one abnormal vital sign vs. 47/27,645 (0.17%) adverse events in the children with normal vital signs [relative risk = 2.5 (95% confidence interval, 1.6 to 2.4)].However, upon review of each adverse event we found only one case that was related to the index visit, was potentially preventable by a 23-hour hospital observation, and caused permanent disability. CONCLUSION: In our study population, 17% of the children were discharged with at least one abnormal vital sign, and there were very few adverse (0.43%) events associated with this practice. Heart rate was the most common abnormal vital sign leading to an adverse event. Severe adverse events that were potentially related to the abnormal vital sign(s) were exceedingly rare. Additional research is needed in broader populations to better determine the rate of adverse events and possible methods of avoiding them.

Tension bulla: a cause of reversible pulmonary hypertension.

A tension pneumothorax represents a medical emergency warranting urgent diagnosis and treatment. A rapidly expanding bulla may resemble the same clinical presentation but requires an entirely different treatment. A 53-year-old woman presented with increasing shortness of breath and her physical examination and chest x-ray were interpreted as showing a tension pneumothorax. A chest tube was placed which did not resolve the process. Placement of a second chest tube was likewise unsuccessful. A chest CT was then performed and was interpreted as showing an unresolved tension pneumothorax, despite seemingly adequate placement of the 2 chest tubes. Further review of the CT showed the border of a giant bulla and a tentative diagnosis was made of a rapidly expanding bulla with tension physiology. Echocardiogram revealed significant pulmonary hypertension. The bulla was surgically excised, the patient had marked improvement in her clinical symptoms and signs, and echocardiographic follow-up showed complete resolution of the pulmonary hypertension.

Perspectives on the ethical concerns and justifications of the 2006 Centers for Disease Control and Prevention HIV testing: HIV screening policy changes.

BACKGROUND: The 2006 Centers for Disease Control and Prevention (CDC) revised recommendations for HIV testing in clinical settings contained seven specific changes to how health care facilities should provide HIV testing. These seven elements have been both supported and challenged in the lay and medical literature. Our first paper in BMC Medical Ethics presented an analysis of the three HIV testing procedural changes included in the recommendations. In this paper, we address the four remaining elements that concern HIV screening policy changes: (1) nontargeted HIV screening, (2) making HIV screening similar to screening for other treatable conditions, (3) increasing HIV screening without assured additional funding for linkage to care, and (4) making patients bear the costs of increased HIV screening in health care settings. METHODS: We interviewed 25 members from the fields of US HIV advocacy, care, policy, and research about the ethical merits and demerits of the four changes to HIV screening policies. We performed a qualitative analysis of the participant responses in the interviews and summarized the major themes. RESULTS: Participants commented that nontargeted HIV screening and making HIV screening similar to screening for other treatable medical conditions was ethical when it broadened the scope of people being tested for HIV. However, they believed it was unethical when it did not respect the exceptional nature of HIV and HIV testing. Some participants favored more testing regardless if there was assured additional funding for linkage to care or if patients might bear the costs of testing because they believed that merely alerting patients of their status was beneficial and would lead to positive consequences. Other participants found ethical flaws with testing without assured linkage to care and patients bearing the costs of testing, as this could discriminate against those who could not pay. CONCLUSIONS: Our findings suggest that there are fundamental ethical disagreements that shape views on CDC's recommended HIV testing policies. Differences remain on whether or not HIV remains an exceptional condition that requires it to be treated differently than other treatable conditions. Disagreement also exists on the responsibilities of health care providers and rights of patients in regards to screening in (1) the absence of assured linkage to care after an HIV diagnosis and (2) paying for the costs of HIV screening. Resolution of these disagreements is needed to serve the common goal of using testing to facilitate medical care for those who are HIV infected and for reducing HIV transmission.

Overtreatment of presumed urinary tract infection in older women presenting to the emergency department.

OBJECTIVES: To determine how often older women presenting to an emergency department (ED) are diagnosed with a urinary tract infection (UTI) without a positive urine culture and to investigate whether collecting urine by catheterization instead of clean catch improves the accuracy of the urinalysis (UA). DESIGN: Retrospective chart review. SETTING: Academic-affiliated ED in Providence, Rhode Island. PARTICIPANTS: One hundred fifty-three women aged 70 and older with diagnosis of UTI in the ED between December 1, 2008, and March 1, 2010. MEASUREMENTS: Chief complaint, review of systems, results of UA and culture, urine procurement (clean catch, straight catheter, or newly inserted Foley catheter), antibiotic administered or prescribed, and diagnosis. A confirmed UTI was defined as a positive urine culture, with microbial growth of 10,000 colony-forming units (CFU)/ mL or more for clean-catch specimens and 100 CFU/mL or more for newly inserted catheter specimens; an ED diagnosis of UTI was defined as the designation by an ED physician. RESULTS: Of 153 individuals with an ED-diagnosed UTI, only 87 (57%) had confirmed UTI according to culture. Of the remaining 66 with negative cultures, 63 (95%) were administered or prescribed antibiotics in the ED. The method of urine procurement affected the ability of a UA to predict the culture result (P = .02), with catheterization yielding a lower proportion of false-positive UA (31%) than clean catch (48%). CONCLUSION: Nearly half of older women diagnosed with a UTI in an ED setting did not have confirmatory findings on urine culture and were therefore inappropriately treated. Catheterization improved the accuracy of UA when assessing older women for possible UTI.

Patient and clinician ethical perspectives on the 2006 Centers for Disease Control and prevention HIV testing methods.

OBJECTIVES: CDC 2006 recommendations for new HIV testing methods in U.S. health-care settings (opt-out approach, general medical consent, and optional prevention counseling) have been the subject of a public ethical debate. Ethical concerns might limit their implementation and affect expanded HIV screening efforts. We compared clinicians' and patients' perspectives on the ethical concerns raised about, justifications provided in support of, and preferences for the 2006 CDC-recommended HIV testing methods for the U.S. health-care setting, in contrast with the 2001 CDC-recommended HIV testing methods (opt-in approach, specific written consent, and mandatory prevention counseling). METHODS: We conducted a non-inferiority trial and survey of 249 clinicians and random samples of 1,013 of their patients at three emergency departments and three ambulatory care clinics at university-affiliated hospitals in Rhode Island from June to December 2007. RESULTS: Clinicians found the 2006 CDC HIV testing methods to be more ethically concerning than the 2001 testing methods (i.e., ethically inferior), while patients had few ethical concerns. In regard to ethical justifications cited for the 2006 CDC HIV testing methods, clinicians were more supportive of the ethical justifications cited for using an opt-out approach and general medical consent, while patients were more supportive of the justifications for optional HIV prevention counseling. Clinicians showed a relatively greater preference for the opt-out approach and use of general medical consent, while patients had a relatively greater preference for optional HIV prevention counseling. CONCLUSIONS: Clinicians and their patients hold divergent ethical perspectives on CDC's 2006 HIV testing methods. The results indicate an opportunity to review not only these but also future HIV testing recommendations, as well as how they are presented for implementation.

Perspectives on the ethical concerns and justifications of the 2006 Centers for Disease Control and Prevention HIV testing recommendations.

BACKGROUND: In 2006, the Centers for Disease Control and Prevention (CDC) recommended three changes to HIV testing methods in US healthcare settings: (1) an opt-out approach, (2) removal of separate signed consent, and (3) optional HIV prevention counseling. These recommendations led to a public debate about their moral acceptability. METHODS: We interviewed 25 members from the fields of US HIV advocacy, care, policy, and research about the ethical merits and demerits of the three changes to HIV testing methods. We performed a qualitative analysis of the participant responses in the interviews and summarized the major themes. RESULTS: In general, arguments in favor of the methods were based upon their ultimate contribution to increasing HIV testing and permitting the consequent benefits of identifying those who are HIV infected and linking them to further care. CONCLUSIONS: The prevailing theme of ethical concern focused on suspicions that the methods might not be properly implemented, and that further safeguards might be needed.

Ethical, financial, and legal considerations to implementing emergency department HIV screening: a report from the 2007 conference of the National Emergency Department HIV Testing Consortium.

OBJECTIVES: We seek to identify and analyze, from a group of participants experienced with HIV screening, the perceived challenges and solutions to the ethical, financial, and legal considerations of emergency department (ED)-based HIV screening. METHODS: We performed a qualitative analysis of the focus group discussions from the ethical, financial, and legal considerations portion of the inaugural National Emergency Department HIV Testing Consortium conference. Four groups composed of 20 to 25 consortium participants engaged in semistructured, facilitated focus group discussions. The focus group discussions were audiotaped and transcribed. A primary reader identified major themes and subthemes and representative quotes from the transcripts and summarized the discussions. Secondary and tertiary readers reviewed the themes, subthemes, and summaries for accuracy. RESULTS: The focus group discussions centered on the following themes. Ethical considerations included appropriateness of HIV screening in the ED and ethics of key elements of the 2006 Centers for Disease Control and Prevention HIV testing recommendations. Financial considerations included models of payment and support, role of health care insurance, financial ethics and downstream financial burdens, and advocacy approaches. Legal considerations included the adequacy of obtaining consent, partner notification, disclosure of HIV results, difficulties in addressing special populations, failure of not performing universal screening, failure to notify a person of being tested, failure to notify someone of their test results, liability of inaccurate tests, and failure to link to care. CONCLUSION: This qualitative analysis provides a broadly useful foundation to the ethical, financial, and legal considerations of implementing HIV screening programs in EDs throughout the United States.