Emergency Medicine Telehealth: A Pandemic Becomes a Gateway for Virtual Care in Missouri.

Telehealth provides a novel bridge between patient needs and available resources. On-demand telehealth visits provide urgent medical services in a virtual setting. Telehealth can be used to provide care for patients despite geographical distance. Emergency Medicine quickly adapted in response to the COVID-19 pandemic through utilization of telehealth to solve various problems. Tele-triage was used to coordinate COVID-19 testing and treatment. Greater utilization of all current and emerging telehealth modalities could increase access and quality of care for all Missourians.

Missed opportunities to transition from nebulizers to inhalers during hospitalization for acute asthma: A multicenter observational study.

OBJECTIVE: Hospitalizations for acute asthma are thought to be highly preventable through the use of efficacious medications, though many patients have poor metered-dose inhaler (MDI) techniques, thus lessening these medications' real-world effectiveness. Teaching MDI techniques during hospitalization may therefore lead to improved outcomes. However, MDIs may be underutilized to deliver short-acting ß-agonists (SABAs) in the inpatient setting, despite equivalent efficacy to nebulizer delivery. We sought to characterize delivery methods of SABAs among hospitalized patients with acute asthma to understand if there are missed opportunities for self-management education. METHODS: In this secondary analysis of a cross-sectional 25-center chart review study of children and adults (ages 2-54 years) hospitalized for acute asthma across 18 states (2012-2013), we studied SABA therapy delivery methods during hospitalization and receipt of action plans and follow-up visits. Unadjusted associations were analyzed using chi-square, Fisher's exact, or Kruskal-Wallis tests. MEASUREMENTS AND MAIN RESULTS: Of 987 patients, 44% received only nebulizer-SABA (children 32% vs. adults 53%; p < 0.001) during hospitalization, and 55% (children 68% vs. adults 47%; p < 0.001) received any MDI-SABA during hospitalization. Children receiving only nebulizer- vs. MDI-SABA were significantly less likely to receive individualized action plans (p < 0.001). Compared to children, adults were overall less likely to receive written plans (47% vs. 78%, p < 0.001) or to have a follow-up appointment (38% vs. 59%, p < 0.001) at discharge. CONCLUSIONS: Opportunities exist to increase the delivery of MDI-SABA during hospitalization, particularly for adult inpatients with asthma. Further studies are needed to determine if increased use of MDI-delivered therapies improves patient education and outcomes.

Physical therapy in the Emergency Department: A prospective cohort study from an Alternatives to Opioids program.

Objective: Musculoskeletal pain complaints are common in the emergency department (ED). The objective of this study was to determine the impact of physical therapy (PT) in the ED on pain and ED return. Methods: A prospective cohort study was performed with those presenting to the ED or Urgent Care at a single academic center for musculoskeletal pain between November 2020 and December 2022. All patients were referred to outpatient PT. During business hours, PT was available to begin treatment in the ED. Long-term follow-up was performed using the electronic health records. Statistical analyses included descriptive and non-parametric pairwise comparisons, Fisher's exact test, and multiple logistic regression. Results: A total of 974 patients were included in the study with 553 completing optional surveys. Back pain was most common. Pain was reduced at ED discharge for all patients, but pain was significantly improved if patients saw PT in the ED. Patients in the ED were less likely to keep their outpatient PT appointments than others, but importantly, patients who saw PT in the ED were less likely to return to the ED for the same complaint up to 1 year later. Those who kept PT appointments were likely to establish or maintain healthcare outside emergency services later. Conclusions: Initiating PT in this ED reduces pain at ED discharge. However, patients who utilized PT were more likely to later utilize health care resources outside of emergency services. Those who saw PT in this ED were less likely to return to the ED for the same complaint up to 1 year later.

The development of the emergency medicine milestones.

The Accreditation Council for Graduate Medical Education (ACGME) has outlined its "Next Accreditation System" (NAS) that will focus on resident and residency outcome measurements. Emergency medicine (EM) is one of seven specialties that will implement the NAS beginning July 2013. All other specialties will follow in July 2014. A key component of the NAS is the development of assessable milestones, which are explicit accomplishments or behaviors that occur during the process of residency education. Milestones describe competencies more specifically and identify specialty-specific knowledge, skills, attitudes, and behaviors (KSABs) that can be used as outcome measures within the general competencies. The ACGME and the American Board of Emergency Medicine (ABEM) convened an EM milestone working group to develop the EM milestones. This article describes the development, use within the NAS, and challenges of the EM milestones.

The 2011 model of the clinical practice of emergency medicine.

The 2011 Model of the Clinical Practice of Emergency Medicine.

Bre1, an E3 ubiquitin ligase required for recruitment and substrate selection of Rad6 at a promoter.

Ubiquitination of histone H2B catalyzed by Rad6 is required for methylation of histone H3 by COMPASS. We identified Bre1 as the probable E3 for Rad6's role in transcription. Bre1 contains a C3HC4 (RING) finger and is present with Rad6 in a complex. The RING finger of Bre1 is required for ubiquitination of histone H2B, methylation of lysine 4 and 79 of H3 and for telomeric silencing. Chromatin immunoprecipitation experiments indicated that both Rad6 and Bre1 are recruited to a promoter. Bre1 is essential for this recruitment of Rad6 and is dedicated to the transcriptional pathway of Rad6. These results suggest that Bre1 is the likely E3 enzyme that directs Rad6 to modify chromatin and ultimately to affect gene expression.

The Paf1 complex is required for histone H3 methylation by COMPASS and Dot1p: linking transcriptional elongation to histone methylation.

Methylation of histone proteins is one of their many modifications that affect chromatin structure and regulate gene expression. Methylation of histone H3 on lysines 4 and 79, catalyzed by the Set1-containing complex COMPASS and Dot1p, respectively, is required for silencing of expression of genes located near chromosome telomeres in yeast. We report that the Paf1 protein complex, which is associated with the elongating RNA polymerase II, is required for methylation of lysines 4 and 79 of histone H3 and for silencing of expression of a telomere-associated gene. We show that the Paf1 complex is required for recruitment of the COMPASS methyltransferase to RNA polymerase II and that the subunits of these complexes interact physically and genetically. Collectively, our results suggest that the Paf1 complex is required for histone H3 methylation, therefore linking transcriptional elongation to chromatin methylation.