Nonaccidental Pediatric Trauma: Which Traditional Clues Predict Abuse?

OBJECTIVES: The objective of this study is to determine which of the child abuse clues quoted in the literature predict nonaccidental trauma (NAT): history incongruent with injuries found on examination or imaging, old injuries present, history of trauma denied by caregivers, multiple fractures present, changing history, fractures of varied duration, metaphyseal fracture, ear bruise, neck bruise, different history (second historian), and metaphyseal fracture. METHODS: This is a 4-year retrospective study of all suspected NAT cases referred to our medical center. In addition to the index visit, medical records were searched for visits before the index visit with patient historical or physical findings that might have suggested NAT but were not investigated. The association of diagnostic clues and the outcome were assessed by chi-square and logistic regression analysis. RESULTS: For 48 months, there were 109 cases of suspected NAT referred for evaluation (age range, 1 week to 15 years). After formal investigation by an abuse specialist, 79.3% of the cases were considered "likely abuse". Those historical or physical findings with a univariate association with a final conclusion of likely abuse included history incongruent with injuries, old injuries present, trauma history denied, changed history, and retinal hemorrhage. In multivariate logistic regression, only a history incongruent with injures remained an independent predictor of likely abuse (odds ratio, 8.65; 95% confidence interval, 1.74-43.07; P = 0.0151). After review of prior records, in only 2 of 109 cases (1.8%) was there a prior visit where NAT could have been suspected; however, history was thought to be congruent with the injury at the original visits. CONCLUSION: In this 4-year study of NAT, the clinical clue that best predicted likely abuse after expert investigation was a history that was incongruent with the injuries found on emergency department evaluation. The incidence of possible early recognition from a prior emergency department visit in this group was very low, <2% of cases.

Association between secondhand marijuana smoke and respiratory infections in children.

BACKGROUND: Little is known about the effects of secondhand marijuana smoke on children. We aimed to determine caregiver marijuana use prevalence and evaluate any association between secondhand marijuana smoke, childhood emergency department (ED) or urgent care (UC) visitation, and several tobacco-related illnesses: otitis media, viral respiratory infections (VRIs), and asthma exacerbations. METHODS: This study was a cross-sectional, convenience sample survey of 1500 subjects presenting to a pediatric ED. The inclusion criteria were as follows: caregivers aged 21-85 years, English- or Spanish-speaking. The exclusion criteria were as follows: children who were critically ill, medically complex, over 11 years old, or using medical marijuana. RESULTS: Of 1500 caregivers, 158 (10.5%) reported smoking marijuana and 294 (19.6%) reported smoking tobacco. Using negative-binomial regression, we estimated rates of reported ED/UC visits and specific illnesses among children with marijuana exposure and those with tobacco exposure, compared to unexposed children. Caregivers who used marijuana reported an increased rate of VRIs in their children (1.31 episodes/year) compared to caregivers with no marijuana use (1.04 episodes/year) (p = 0.02). CONCLUSIONS: Our cohort did not report any difference with ED/UC visits, otitis media episodes, or asthma exacerbations, regardless of smoke exposure. However, caregivers of children with secondhand marijuana smoke exposure reported increased VRIs compared to children with no smoke exposure. IMPACT: Approximately 10% of caregivers in our study were regular users of marijuana. Prior studies have shown that secondhand tobacco smoke exposure is associated with negative health outcomes in children, including increased ED utilization and respiratory illnesses. Prior studies have shown primary marijuana use is linked to negative health outcomes in adults and adolescents, including increased ED utilization and respiratory illnesses. Our study reveals an association between secondhand marijuana smoke exposure and increased VRIs in children. Our study did not find an association between secondhand marijuana smoke exposure and increased ED or UC visitation in children.

Burnout and the Sexual Assault Nurse Examiner: Who Is Experiencing Burnout and Why?

INTRODUCTION: A sexual assault nurse examiner role exemplifies the high-stress and highly emotional patient interactions that are often associated with burnout. The purpose of this study was to examine the frequency of burnout among sexual assault nurse examiners in North Carolina. METHODS: This cross-sectional study was an anonymous survey of practicing sexual assault nurse examiners within North Carolina using the Maslach Burnout Inventory and additional demographics. Results were analyzed with odds ratios, confidence intervals, Fisher exact, chi-square, and Kruskal Wallis tests as appropriate. RESULTS: Among 95 respondents, burnout was more frequent in sexual assault nurse examiners who stopped both emergency and nurse examiner work (55.6%, odds ratio 4.41, 95% confidence interval 1.07-18.06) and in dual function nurses (both emergency and nurse examiner work, 35.7%, odds ratio 2.71, 95% confidence interval 1.04-7.06). Sexual assault nurse examiners who had a high percentage of pediatric cases (above the median of 40%) were more likely to meet burnout thresholds for emotional exhaustion scores > 26 (48.78% vs 25.93%, χ2 = 5.30, P = .02) and more likely to meet burnout thresholds for depersonalization scores > 9 (48.78% vs 24.07%, χ2 = 6.28, P = .01). DISCUSSION: Higher frequency of burnout threshold criteria was found in those people who worked concurrently as a sexual assault nurse examiner and an emergency nurse and in those who had retired from both specialties. We also found that sexual assault nurse examiners with a higher case mix of pediatric cases had higher emotional exhaustion scores and higher depersonalization scores.

Social Media Usage Among Nurses: Perceptions and Practices.

OBJECTIVE: This study aims to examine the existing perceptions and social media practices of nurses in a large academic medical center. BACKGROUND: Limited data are available about the perceptions and social media practices among healthcare providers. An understanding of the social networking landscape within the nursing profession is necessary to inform policy and develop effective guidelines. METHODS: This was a single-center prospective observational study involving nurses at a large academic medical center. Nurses completed an anonymous questionnaire regarding their personal use and perceptions of social media in the context of clinical medicine. RESULTS: A total of 397 nurses participated in the study survey. Overall, 87% of participants reported using a general social media account currently. Increasing age was associated with decreasing frequency of social media use. CONCLUSION: Social media usage is common among nurses. Social media perceptions and practices among nurses vary considerably. Well-informed policy and targeted education are needed to guide social media use among healthcare workers.

Missed Opportunities: Integrating Palliative Care into the Emergency Department for Older Adults Presenting as Level I Triage Priority from Long-Term Care Facilities.

BACKGROUND: Early integration of palliative care from the emergency department (ED) is an underutilized care modality with potential benefits, but few studies have identified who is appropriate for such care. OBJECTIVE: Our hypothesis is that patients aged 65 years or older who present to the ED as level I Emergency Severity Index from a long-term care (LTC) facility have high resource utilization and mortality and may benefit from early palliative care involvement. METHODS: We performed a retrospective chart review of patients aged 65 years or older who arrived in the ED of an academic suburban southeastern level I trauma center from an LTC facility and triaged as level I priority. The ED course, hospital course, and final outcomes were analyzed. RESULTS: Of the 198 patients studied, 54% were deceased 30 days after discharge, with only 29.8% alive at 12 months. Admitted patients had a median hospital length of stay of 5 days and 73% required intensive care. Formal palliative care intervention was provided in 40.4%, occuring a median of 4 days into hospitalization and leading to 85% downgrading their advanced directive wishes, and discharge occuring a median of 1 day later. Few formal palliative care interventions occurred in the ED (9.1%). CONCLUSIONS: Elderly patients from LTC facilities presenting with severe acute illness have high mortality and seldom receive early palliative care. Introduction of palliative care has the ability to change the course of treatment in this vulnerable population and should be considered early in the hospitalization and, where available, be initiated in the ED.

Cost analysis of the History, ECG, Age, Risk factors, and initial Troponin (HEART) Pathway randomized control trial.

INTRODUCTION: The HEART Pathway is a diagnostic protocol designed to identify low-risk patients presenting to the emergency department with chest pain that are safe for early discharge. This protocol has been shown to significantly decrease health care resource utilization compared with usual care. However, the impact of the HEART Pathway on the cost of care has yet to be reported. METHODS AND RESULTS: We performed a cost analysis of patients enrolled in the HEART Pathway trial, which randomized participants to either usual care or the HEART Pathway protocol. For low-risk patients, the HEART Pathway recommended early discharge from the emergency department without further testing. We compared index visit cost, cost at 30 days, and cardiac-related health care cost at 30 days between the 2 treatment arms. Costs for each patient included facility and professional costs. Cost at 30 days included total inpatient and outpatient costs, including the index encounter, regardless of etiology. Cardiac-related health care cost at 30 days included the index encounter and costs adjudicated to be cardiac-related within that period. Two hundred seventy of the 282 patients enrolled in the trial had cost data available for analysis. There was a significant reduction in cost for the HEART Pathway group at 30 days (median cost savings of $216 per individual), which was most evident in low-risk (Thrombolysis In Myocardial Infarction score of 0-1) patients (median savings of $253 per patient) and driven primarily by lower cardiac diagnostic costs in the HEART Pathway group. CONCLUSIONS: Using the HEART Pathway as a decision aid for patients with undifferentiated chest pain resulted in significant cost savings.

A Prospective Emergency Department Quality Improvement Project to Improve the Treatment of Vaso-Occlusive Crisis in Sickle Cell Disease: Lessons Learned.

BACKGROUND: Guidelines recommend rapid, aggressive management of vaso-occlusive crisis (VOC) for patients with sickle cell disease (SCD). A large prospective research and quality improvement (QI) project was conducted to measure changes in clinical outcomes in two EDs-academic medical centers with emergency medicine residency programs and Level 1 trauma centers-during a 2.5-year time period (October 2011-March 2014). METHODS: A QI team used a Plan-Do-Study-Act approach to modify and implement changes to opioid analgesic protocols for the emergency department (ED) treatment of VOC. Data were collected quarterly; the team reviewed the results and made modifications to improve outcomes. A structured health record review was conducted to assess clinical outcomes (10 records/quarter/site). Patient interviews were conducted to measure satisfaction with pain management. Outcomes were compared before (T1) and after (T2) implementation of an electronic health record (EHR). RESULTS: One hundred ninety-six ED health records (118 unique patients, mean age = 32 [standard deviation, 11], 51% male) were analyzed. Before implementation, trends in decreasing time to initial analgesic administration were noted. There was a statistically significant increase in arrival to administration of first analgesic time between T1 and T2 at Site 1 but not at Site 2. Neither site showed significant changes in time between the administration of the first and second opioid doses, total opioid dose administered, or patient satisfaction. CONCLUSION: While QI efforts initially shortened door-to-analgesic times, these gains were not sustained. The lessons learned can help other EDs improve the timely delivery of analgesics to patients with SCD.

Social Media in Professional Medicine: New Resident Perceptions and Practices.

BACKGROUND: For younger generations, unconstrained online social activity is the norm. Little data are available about perceptions among young medical practitioners who enter the professional clinical arena, while the impact of existing social media policy on these perceptions is unclear. OBJECTIVE: The objective of this study was to investigate the existing perceptions about social media and professionalism among new physicians entering in professional clinical practice; and to determine the effects of formal social media instruction and policy on young professionals' ability to navigate case-based scenarios about online behavior in the context of professional medicine. METHODS: This was a prospective observational study involving the new resident physicians at a large academic medical center. Medical residents from 9 specialties were invited to participate and answer an anonymous questionnaire about social media in clinical medicine. Data were analyzed using SAS 9.4 (Cary, NC), chi-square or Fisher's exact test was used as appropriate, and the correct responses were compared between different groups using the Kruskal-Wallis analysis of variance. RESULTS: Familiarity with current institutional policy was associated with an average of 2.2 more correct responses (P=.01). Instruction on social media use during medical school was related to correct responses for 2 additional questions (P=.03). On dividing the groups into no policy exposure, single policy exposure, or both exposures, the mean differences were found to be statistically significant (3.5, 7.5, and 9.4, respectively) (P=.03). CONCLUSIONS: In this study, a number of young physicians demonstrated a casual approach to social media activity in the context of professional medical practice. Several areas of potential educational opportunity and focus were identified: (1) online privacy, (2) maintaining digital professionalism, (3) safeguarding the protected health information of patients, and (4) the impact of existing social media policies. Prior social media instruction and/or familiarity with a social media policy are associated with an improved performance on case-based questions regarding online professionalism. This suggests a correlation between an instruction about online professionalism and more cautious online behavior. Improving the content and delivery of social media policy may assist in preserving institutional priorities, protecting patient information, and safeguarding young professionals from online misadventure.

Self-reported cardiovascular disease risk factors and associated hopelessness in African American participants of a church-placed health screening program.

OBJECTIVE: This study evaluates patient inertia (PtInert) factors including hopelessness in African Americans participating in church cardiovascular screening programs in low income areas in Forsyth County, North Carolina. Patient inertia is defined as an inability to assume adequate hypertension self-management behaviors, leading to poorly controlled hypertension. Previous findings revealed hopelessness related to blood pressure (BP) control as a key PtInert factor in acute medical environment participants. DESIGN: Questionnaires were administered by facilitated interview. Clinical components of the cardiometabolic syndrome were obtained. SETTING: The study was conducted within six Forsyth County churches that were participating in cardiovascular screening programs sponsored by the Consortium for Southeastern Hypertension Control. PARTICIPANTS: 67 African Americans (72% female; 49% personal history of hypertension) with an average age of 55 years served as study participants. RESULTS: Participants without a history of hypertension were overweight, pre-hypertensive, and normocholesterolemic while those with a history of high BP receiving antihypertensive treatment were normocholesterolemic, obese, and on average had a BP of 143/75 mm Hg. Hopelessness related to BP control was found in 18% of those with a personal history of high BP. A significant relationship was found between hopelessness and family history of high BP, perceived ability to control high BP, and frustration with BP treatment. CONCLUSIONS: Our findings suggest that hopelessness, while exhibited less often in church participants as compared to previous findings in the acute medical environment, is associated with participant thoughts, feelings, and histories but is not associated with clinical components of the metabolic syndrome.

Diagnosing aortic dissection: A review of this elusive, lethal diagnosis.

Aortic dissection (AD) remains a difficult diagnosis in the emergency setting. Despite its rare occurrence, it is a life-threatening pathology that, if missed, is typically fatal. Previous studies have documented minimal improvement in timely and accurate diagnoses despite the advancement of computed tomography. Previous literature has highlighted aortic dissections as a major cause of serious misdiagnosis-related harm. The aim of this article is to review the available literature on AD, discussing the diversity in presentations and the prevalence of historical and exam features to better aid in the diagnosis of AD. AD remains a difficult diagnosis, even with the widespread prevalence of computed tomography angiography usage. No single feature of the history or physical examination is enough to raise suspicion. The diagnosis should be strongly considered in any patient with chest pain that is severe and unexplained by other findings or testing. Those who do not present with acute pain are often complicated by neurologic deficits, hypotension, or syncope. These patients suffer from a change in mental status limiting their ability to participate in the history and physical examination and have a higher rate of complications and mortality. An educated understanding of the atypical presentations of aortic dissection helps the clinician to realistically rank it on the differential diagnosis, culminating in judicious use of definitive imaging.

The impact of implementing the single provider model of emergency medicine in a paediatric hospital: a retrospective cohort analysis.

STUDY OBJECTIVE: The Meyer Pediatric Hospital in Florence, Italy recently implemented the single provider model of emergency medicine. Prior to these changes, patients were triaged to a paediatric surgeon or paediatrician based on the complaint. The authors assess the outcomes of patients evaluated by surgeons prior to this change and compare them with those of patients seen by emergency physicians. METHODS: A retrospective, cohort study was performed reviewing patients seen in the emergency department between 2005 and 2008 for the three most common surgical complaints encountered before the systems change: head trauma, testicular pain and abdominal pain. Outcomes include misdiagnoses, consultation rates, dispositions, imaging, interventions and surgeries. RESULTS: A total of 2415 patient visits were included. Emergency physicians saw more patients (1388 vs 1027) and obtained more consultations (25.6% vs 8.1%) than surgeons. Patients triaged directly to surgeons were more likely to be admitted to the hospital (10.3% vs 7.6%), undergo urgent interventions (9.5% vs 6.7%), undergo surgery (8.0% vs 4.8%), have more radiographic images to evaluate head trauma (12.1% vs 5.3%), be misdiagnosed (1.0% vs 0.3%) and have more plain films for abdominal pain (3.1% vs 1.3%). There is an overall trend towards fewer missed diagnoses by emergency physicians (0.3% vs 0.9%), but this difference is only statistically significant in the abdominal pain subset analysis (p=0.032, combined data p=0.052). CONCLUSIONS: The single provider model of emergency medicine where emergency physicians manage all patients presenting to the emergency department appears to be a safe and efficient model of emergency medical care.

Diagnostic Inaccuracies Using Extended Focused Assessment With Sonography in Trauma for Traumatic Pneumothorax.

BACKGROUND: Traumatic pneumothorax (PTX) can be deadly, and rapid diagnosis is vital. Ultrasound (US) is rapidly gaining acceptance as an accurate bedside diagnostic tool. While making the diagnosis is important, not all PTX require tube thoracostomy. Our goal was to evaluate the predictive ability of ultrasound in identifying clinically significant PTX. METHODS: Over 13 months, data was collected on patients undergoing evaluation for trauma. Patients were included if they underwent US, radiograph chest X-ray (CXR), and computed tomography of the chest. Predictive ability of ultrasound was evaluated in identifying clinically significant PTX. RESULTS: Ninety-four patients received evaluation by all 3 modalities. Of these, 32% were diagnosed with PTX. Sixteen patients (17%) had a clinically significant PTX. Chest X-ray and US both had a sensitivity of 75%; however, US had more than twice as many false positives, resulting in a much lower positive predictive value (63% vs 80%). CONCLUSIONS: While US can reliably rule out PTX, it may be overly sensitive diagnosing clinically significant PTX. Ultrasound alone should not be used in determining the need for tube thoracostomy as many patients will not require acute intervention.

Clinical Characteristics of SARS-CoV-2 Acute Pulmonary Embolism and Adjusted D-dimer for Emergency Department Patients.

Introduction: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and acute pulmonary embolism (APE) present a diagnostic challenge in the emergency department (ED) setting. We aimed to identify key clinical characteristics and D-dimer thresholds associated with APE in SARS-CoV-2 positive ED patients. Methods: We performed a multicenter, retrospective cohort study for adult patients who were diagnosed with coronavirus 2019 (COVID-19) and had computed tomography pulmonary angiogram (CTPA) performed between March 17, 2020-January 31, 2021. We performed univariate analysis to determine numeric medians, chi-square values for association between clinical characteristic and positive CTPA. Logistic regression was used to determine the odds of a clinical characteristic being associated with a diagnosis of APE. Results: Of 408 patients who underwent CTPA, 29 (7.1%) were ultimately found to have APE. In multivariable analysis, patients with a body mass index greater than 32 (odds ratio [OR] 4.4, 95% confidence interval [CI] 1.0 -19.3), a heart rate greater than 90 beats per minute (bpm) (OR 5.0, 95% CI 1.0-24.9), and a D-dimer greater than 1,500 micrograms per liter (µg/L) (OR 5.6, 95% CI 1.6-20.2) were significantly associated with pulmonary embolism. In our population that received a D-dimer and was SARS-CoV-2 positive, limiting CTPA to patients with a heart rate over 90 or a D-dimer value over 1500 µg/L would reduce testing 27.2% and not miss APE. Conclusion: In patients with acute COVID-19 infections, D-dimer at standard cutoffs was not usable. Limiting CTPA using a combination of heart rate greater than 90 bpm or D-dimer greater than 1,500 µg/L would significantly decrease imaging in this population.

System design and production practices of aquaponic stakeholders.

Aquaponics is an agricultural practice incorporating aquaculture and hydroponic principles. This study assesses the current system design and production practices of the aquaponic industry, compares these metrics by stakeholder group, identifies trends, and provides recommendations for future development. An electronic survey of aquaponic stakeholders was conducted from December 2019 to June 2020 targeting hobbyists, producers, and educators from various aquaponic-focused professional associations, email and social media groups. Of 378 total responses, 84% came from the United States and were clustered in plant hardiness zones five to nine. Aquaponic systems were commonly homemade/do-it-yourself (DIY), many of which incorporated commercially available (turn-key) technology. Most growers used coupled systems that integrated recirculating aquaculture systems and either deep-water culture (DWC) or media bed hydroponic units. Common plant lighting sources were sunlight and light emitting diode (LED). Water sources were typically municipal or wells. Personal labor input was typically less than 20 hrs/wk. Funding sources were primarily personal funds, followed by government grants, and private investor funds. System sizes varied greatly, but the median area was 50 to 500 ft2 for hobbyists and educators and 500 to 3,000 ft2 for producers. Respondents commonly sold vegetable produce, training and education, food fish, and microgreens. Tilapia and ornamental fish were commonly grown, with 16 other species reported. Common crops were lettuce, leafy greens, basil, tomatoes, peppers, and herbs with many additional lesser-grown crops reported, including cannabis. Overall, the industry still growing, with a large portion of stakeholders having less than two years of experience. However, veteran growers have remained in operation, particularly in the producer and educator groups. The survey results suggest a shift away from outdoor systems, media beds, tomatoes, ornamental fish, and perch production, and a shift toward decoupled systems, DWC, drip irrigation, and wicking beds, larger system area, leafy greens, and trout/salmon production compared to previous industry surveys. The reduced diversity of plant species grown suggest some level of crop standardization. Commercial producers tended to sell more types of products than other stakeholders, suggesting that diversification of offerings may be key to profitability. The combined production area specified by respondents indicates the industry has grown substantially in recent years. Finally, the presence of bank loan-funded operations suggests increased knowledge and comfort with aquaponics among lenders.

CLUE: a randomized comparative effectiveness trial of IV nicardipine versus labetalol use in the emergency department.

INTRODUCTION: Our purpose was to compare the safety and efficacy of food and drug administration (FDA) recommended dosing of IV nicardipine versus IV labetalol for the management of acute hypertension. METHODS: Multicenter randomized clinical trial. Eligible patients had 2 systolic blood pressure (SBP) measures ≥180 mmHg and no contraindications to nicardipine or labetalol. Before randomization, the physician specified a target SBP ± 20 mmHg (the target range: TR). The primary endpoint was the percent of subjects meeting TR during the initial 30 minutes of treatment. RESULTS: Of 226 randomized patients, 110 received nicardipine and 116 labetalol. End organ damage preceded treatment in 143 (63.3%); 71 nicardipine and 72 labetalol patients. Median initial SBP was 212.5 (IQR 197, 230) and 212 mmHg (IQR 200,225) for nicardipine and labetalol patients (P = 0.68), respectively. Within 30 minutes, nicardipine patients more often reached TR than labetalol (91.7 vs. 82.5%, P = 0.039). Of 6 BP measures (taken every 5 minutes) during the study period, nicardipine patients had higher rates of five and six instances within TR than labetalol (47.3% vs. 32.8%, P = 0.026). Rescue medication need did not differ between nicardipine and labetalol (15.5 vs. 22.4%, P = 0.183). Labetalol patients had slower heart rates at all time points (P < 0.01). Multivariable modeling showed nicardipine patients were more likely in TR than labetalol patients at 30 minutes (OR 2.73, P = 0.028; C stat for model = 0.72) CONCLUSIONS: Patients treated with nicardipine are more likely to reach the physician-specified SBP target range within 30 minutes than those treated with labetalol.

Pediatric all-terrain vehicle injuries: does legislation make a dent?

OBJECTIVES: We sought to determine whether North Carolina legislation pertaining to all-terrain vehicles (ATVs) has affected the frequency, distribution, or severity of injury in children. METHODS: This retrospective study reviewed the Wake Forest University Baptist Medical Center Trauma Registry from 2003 to 2008 along with North Carolina Medical Examiner's child fatality data for all children injured on an ATV. Patients were excluded if the accident did not occur in North Carolina, incomplete data, or if the vehicle was not an ATV. We evaluated the use of helmets, the extent of injury, and the mechanism of injury, comparing the patterns before the laws went into effect (2003-2005) with those after the law was enacted (2006-2008). RESULTS: Eighty-eight patients were included for analysis, predominantly white boys with a mean age of 12.1 ± 4.1 years. Children not wearing helmets were 5-fold more likely to have a significant head/neck injury (odds ratio [OR], 5.1; confidence interval [CI], 1.61-15.88; P = 0.01) and 3.7-fold more likely to have a significant chest injury (OR, 3.73; CI, 1.01-13.86; P = 0.05). Passengers were 5-fold more likely to die or require inpatient rehabilitation (OR, 5.0; CI, 1.2-20.8; P = 0.03) and 13.7 times as likely to have a significant injury to their head/neck (OR, 13.7; CI, 3.07-60.93; P = 0.01). CONCLUSIONS: There were no significant changes seen in the children injured without and then with legislation, which may be significant if ATV use indeed is increasing. A child's vehicular position was the most significant predictor of morbidity and mortality. Helmet use was not increased once mandated by law. Further efforts to implement such legislation and educate the public are necessary to make a significant change in injuries.

Barriers to screening and intervention for ED patients at risk for undiagnosed or uncontrolled hypertension.

OBJECTIVES: We describe clinician-reported knowledge of the Joint National Committee (JNC7) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure definitions of Stage I hypertension; perceived causes of elevated blood pressure; barriers to blood pressure re-assessment; risk of adverse events associated with the elevated blood pressure. METHODS: Health care providers from five emergency departments completed a questionnaire assessing knowledge of blood pressure criteria for hypertension, perceived causes of elevated blood pressures, barriers to re-assessment, and perceived risk of an adverse event at one year in a patient within three defined systolic and diastolic blood pressure ranges. Descriptive statistics were used to analyze the data. RESULTS: Seventy-two percent (379/524) of providers (68 attending physicians, 87 residents, 209 nurses, and 15 nurse practitioners) completed questionnaires. One hundred and four providers (27%) correctly listed the systolic and diastolic criteria for Stage 1 hypertension. Nurses and physicians rated uncontrolled, known hypertension [mean (standard deviation)] [8.7 (2.1), 8.9 (1.9)] the highest and pain [8.3 (2.3), 8.3 (2.1)] as the second highest cause of elevated BP. Nurses and physicians rated the lack of time to perform a reassessment [5.2 (3.4), 4.7 (2.8)] and a lack of adequate staffing [4.7 (3.4), 4.6 (2.9)] the highest as barriers to re-assessment. Nurses' mean adverse risk assessment twice that of physicians. DISCUSSION: Twenty seven percent of providers were aware of the JNC7 criteria and often attributed elevated blood pressures to chronic, uncontrolled hypertension, pain or anxiety. No single barrier to repeating elevated blood pressures was identified.

A Model Research Curriculum for Emergency Medicine Residency: A Modified Delphi Consensus.

BACKGROUND: Research training is important for all resident physicians to be able to interpret and critically appraise scientific literature. It is particularly important for those desiring future careers in academics or research. However, there is limited literature on research training in residency. The ideal scope and content of a model curriculum for research in emergency medicine (EM) residency programs has not been recently defined. METHODS: We used a modified Delphi method to achieve expert consensus as to what content should be included in a model research curriculum for EM residents as well as for those who choose to undertake an elective in EM research. RESULTS: Eight experts in EM clinical and education research participated in the modified Delphi process with two rounds of responses. Cronbach's alpha was 0.82 for round 1 and 0.95 for round 2. A curricular outline of 44 items was produced by this consensus process. CONCLUSIONS: A model curriculum for EM research is proposed here, along with references to assist residencies in building curricular components.

An Examination of Prospective Uses and Future Directions of Neuralink: The Brain-Machine Interface.

The human brain is one of the most mystifying biological structures in nature. Overwhelming research, technology, and innovations in neuroscience have augmented clinical assessments, diagnosis, and treatment capabilities. Nonetheless, there is still much to be discovered about nervous system disorders and defects. Neuralink, a neurotechnology company, is advancing the field of neuroscience and neuroengineering. The company's initial aim is to develop an implantable brain-machine interface device that will enhance the lives of people with severe brain and spinal cord injuries. Here, we provide insight into Neuralink's design, early testing, and future applications in neurosurgery. While early testing with small and large animals show promising results, no clinical trials have been conducted to date. Additionally, a term search for "Neuralink" was performed in PubMed. The literature search yielded only 28 references, of which most indirectly mentioned the device but not in direct testing. In order to conclude the safety and viability of the Neuralink device, further research studies are needed to move forward beyond speculation.

Intern Orthopedic Rotation Versus Emergency Medicine Procedure Month: Which one Derives More Opportunity?

INTRODUCTION: The American College of Graduate Medical Education (ACGME) defines 18 "key procedures" as requirements in emergency medicine (EM) residency programs. The post-graduate year-1 (PGY-1) curriculum provides an early foundation for EM trainees to gain procedural experience, but traditional PGY-1 rotations may not provide robust procedural opportunities. Our objective was to replace a traditional orthopedic rotation with a 4-week rotation that emphasized EM procedure acquisition and comprehension. Although all residents met ACGME procedural requirements before the curricular modification, the purpose of this month was to increase overall procedure numbers. The block contained dedicated procedure shifts in the emergency department as well as an asynchronous, self-directed learning course. We sought to compare the number of procedures performed by PGY-1 residents during their orthopedic rotation (the year before implementation), to the number of procedures performed during their procedure rotation (the year after implementation). METHODS: The total number of procedures performed and logged by PGY-1 residents during the traditional orthopedic rotation (during the year prior to implementation of the new procedure rotation) were compared to the total number of procedures by the first class to undergo the new procedure rotation the following year. Thirty resident logs were reviewed (15 per class). Data were analyzed using SAS NPAR1WAY; Z < 0.05 was considered significant. RESULTS: When compared to the orthopedic rotation, the procedure rotation had statistically significant higher numbers of procedures per resident (22, standard deviation [SD] 12, vs 11.4, SD 7.6; Z = 0.0177). A wide variety of nonorthopedic procedures accounted for the increased numbers, (13.6, SD 10.3, vs 0.9, SD 0.9; Z < 0.001). While the average number of orthopedic procedures was slightly less on the procedure rotation, there was no statistical difference (orthopedic rotation 10.13, procedure rotation 8.26; Z = 0.4605). Notably, fewer procedures were performed when 2 residents were on the procedure rotation at the same time (21 vs 10.1). CONCLUSION: This analysis demonstrated a larger number and a wider variety of procedures performed by PGY-1 residents during a dedicated procedure rotation compared to a traditional orthopedic rotation. Furthermore, exposure to orthopedic procedures did not decline significantly. Limitations of the study include a modest number of subjects. Data may be limited by the consistency of procedure logging by individual residents. Further studies may assess procedural competency after PGY-1 year of training.