Trends in female first-author abstracts at the Society for Academic Emergency Medicine Annual Meeting, 1990-2020.

OBJECTIVES: To describe first author gender differences and characteristics in 1) Society for Academic Emergency Medicine (SAEM) Annual Meeting abstracts and 2) resulting manuscript publications. METHODS: We performed cross-sectional evaluation of SAEM abstracts from 1990, 1995, 2000, 2005, 2010, 2015, and 2020, compiling and reviewing a random sample of 100 abstracts for each year (total n = 700 abstracts). We documented abstract characteristics, including first author gender, and used the 2020 SAEM scoring rubric. We then searched PubMed to identify manuscript publications resulting from abstracts from 1990 to 2015 (n = 600). Finally, among abstracts that resulted in manuscript publication, we identified first and last author gender on both the abstracts and the resulting publication. RESULTS: Overall, 29% (202/695; n = 5 missing gender) of abstracts had female first authors. Female first authors increased over time (e.g., 17% in 1990 to 35% in 2020). Abstract quality scores were similar (both median [interquartile range] of 11 ([9-12]). Overall, 42% (n = 254/600) of abstracts resulted in a manuscript publication, 39% (n = 65/202) with female and 44% (n = 189/493) with male first authors (p = 0.26). The median time (IQR) from abstract to manuscript publication was longer for abstracts with female first authors vs. those with male first authors (2 [1-3] years and 1 [1, 2] years, p < 0.02); 77% and 78% of publications resulting from abstracts with female and male first authors, respectively, had the same first author. Female first author abstracts more often converted to a male first author manuscript publication (18%, n = 12/65) compared to male first author abstracts converting to female first author publications (7%, n = 14/189). CONCLUSIONS: A minority of SAEM abstracts, and manuscript publications resulting from them, had female first authors. Abstracts with female first authors took longer to achieve manuscript publication, and almost a fifth of female first author abstracts resulted in male first author manuscript publication.

Characteristics of California Emergency Departments in Centers for Disease Control and Prevention-Designated HIV Priority Counties.

BACKGROUND: Refocused national HIV testing initiatives include a geographic focus. OBJECTIVE: Using a geographic focus, we sought to identify which emergency departments (EDs) might be the most efficient targets for future HIV testing efforts, using California as an example. METHODS: Retrospective analysis of California EDs, emergency physicians, and patients served, along with county-level estimates of HIV prevalence and proportion of the population living in poverty. Emphasis was placed on characterizing EDs affiliated with teaching hospitals and those located in Centers for Disease Control (CDC) and Prevention HIV priority counties. RESULTS: Of the 320 EDs studied, 178 were in priority counties, 29 were affiliated with teaching hospitals, and 24 had both characteristics. Of the 12,869,889 ED visits included, 61.8% occurred in priority counties, 14.7% in EDs affiliated with teaching hospitals, and 12.0% in EDs with both characteristics. The subset of EDs in priority counties with teaching hospital affiliations (compared with priority and nonpriority county ED groups without a teaching hospital affiliation) had higher overall median visit volumes and higher proportions of visits by at-risk and CDC-targeted populations (e.g., individuals who were homeless, those who identified as Black or African American race, and those who identified as Hispanic or Latino ethnicity, all p < 0.01). CONCLUSIONS: EDs in priority counties affiliated with teaching hospitals are major sources of health care in California. These EDs more often serve populations disproportionately impacted by HIV. These departments are efficient targets to direct testing efforts. Increasing testing in these EDs could reduce the burden of undiagnosed HIV in California.

United States 2020 Emergency Medicine Resident Workforce Analysis.

STUDY OBJECTIVE: To characterize the emergency medicine resident physician workforce and the residency programs training them. METHODS: We identified emergency medicine residents in the 2020 American Medical Association (AMA) Physician Masterfile, analyzed demographic information, mapped both county-level population-adjusted and hospital referral region densities, and compared 2020 versus 2008 resident physician densities. We also analyzed all Accreditation Council for Graduate Medical Education (ACGME)-accredited emergency medicine residency programs from 2013 to 2020, mapped state-level population-adjusted densities, and identified temporal trends in program location and state-level program densities. All population-adjusted densities were calculated using the US Census Bureau resident population estimates. RESULTS: There were 6,993 emergency medicine residents in the 2020 AMA dataset with complete information. Most of them (98%) were in urban areas. Compared with 2008, per 100,000 US population, this represents disproportionate increases in urban areas (total [0.5], urban [0.5], large rural [0.2] and small rural [0.05]). We further identified 160 (2013) to 265 (2020) residency programs using the ACGME data. The new programs were 3-year training programs that were disproportionately added to states with an already higher number of programs (Florida [5 to 19], Michigan [11 to 25], New York [21 to 31], Ohio [9 to 18], Pennsylvania [12 to 21], California [14 to 22]). CONCLUSION: The number of emergency medicine residency programs has increased; most new programs were added to the states that already had emergency medicine residency programs. There is an emergency physician "desert" in the rural United States, lacking both residents and residency training programs. This analysis provides essential context to the ongoing conversation about the future of the emergency physician workforce.

Examining Parity among Black and Hispanic Resident Physicians.

BACKGROUND: The US physician workforce does not represent the racial or ethnic diversity of the population it serves. OBJECTIVES: To assess whether the proportion of US physician trainees of Black race and Hispanic ethnicity has changed over time and then provide a conceptual projection of future trends. DESIGN: Cross-sectional, retrospective, analysis based on 11 years of publicly available data paired with recent US census population estimates. PARTICIPANTS: A total of 86,303 (2007-2008) to 103,539 (2017-2018) resident physicians in the 20 largest US Accreditation Council for Graduate Medical Education resident specialties. MAIN MEASURES: Changes in proportion of physician trainees of Black race and Hispanic ethnicity per academic year. Projected number of years it will then take, for specialties with positive changes, to reach proportions of Black race and Hispanic ethnicity comparable to that of the US population. KEY RESULTS: Among the 20 largest specialty training programs, Radiology was the only specialty with a statistically significant increase in the proportion of Black trainees, but it could take Radiology 77 years to reach levels of Black representation comparable to that of the US population. Obstetrics/Gynecology, Emergency Medicine, Internal Medicine/Pediatrics, and Orthopedic Surgery demonstrated a statistically significant increase in the proportion of Hispanic trainees, but it could take these specialties 35, 54, 61, and 93 years respectively to achieve Hispanic representation comparable to that of the US population. CONCLUSIONS: Among US residents in the 20 largest specialties, no specialty represented either the Black or Hispanic populations in proportions comparable to the overall US population. Only a small number of specialties demonstrated statistically significant increases. This conceptual projection suggests that current efforts to promote diversity are insufficient.

National Study of the Emergency Physician Workforce, 2020.

STUDY OBJECTIVE: We describe the current US emergency physician workforce. METHODS: We analyzed the 2020 American Medical Association Physician Masterfile data set. All physicians who designated emergency medicine as their primary or secondary specialty were included; nonactive physicians, residents, primarily research or teaching faculty, or those primarily involved in administration or nonclinical work were excluded. We calculated emergency physician population density, using 2018 Census Bureau estimates of the US population; urban-rural assignments were based on Urban Influence Codes. We compared 2020 results with our previous analysis of the 2008 emergency physician workforce. Again, we were unable to account for American Osteopathic Board of Emergency Medicine certification. RESULTS: There were 48,835 clinically active emergency physicians in 2020. The median age was 50 years (interquartile range [IQR] 41 to 62 years) and 28% were women. Overall density of emergency physicians per 100,000 population was 14.9. Most emergency physicians were in urban areas (92%), whereas 2,730 (6%) were in large rural areas and 1,197 (2%) in small rural areas. Urban emergency physicians were younger (median age 50 years; IQR 41 to 61 years) than those in large rural areas (median age 58 years; IQR 47 to 67 years) or small rural areas (median age 62 years; IQR 51 to 68 years), and more likely to be women (29%, 20%, and 19%, respectively). Most emergency physicians in small rural areas (71%) completed their medical training more than 20 years ago. Compared with 2008, the total number of clinically active emergency physicians has increased by 9,774, but, per 100,000 US population in 2020, emergency physician density decreased in both large rural (-0.4) and small rural (-3.7) areas. CONCLUSION: Urban emergency physicians in 2020 remain substantially younger than rural emergency physicians, with many rural ones near the US retirement age. We did not observe a continued increase in the percentage of female physicians among emergency physicians. Given the ongoing demand for physicians in all US emergency departments, this analysis provides essential information for understanding the current emergency physician workforce and the challenges ahead.

Auditory Icon Alarms Are More Accurately and Quickly Identified than Current Standard Melodic Alarms in a Simulated Clinical Setting.

BACKGROUND: Current standard audible medical alarms are difficult to learn and distinguish from one another. Auditory icons represent a new type of alarm that has been shown to be easier to learn and identify in laboratory settings by lay subjects. In this study, we test the hypothesis that icon alarms are easier to learn and identify than standard alarms by anesthesia providers in a simulated clinical setting. METHODS: Twenty anesthesia providers were assigned to standard or icon groups. Experiments were conducted in a simulated intensive care unit. After a brief group-specific alarm orientation, subjects identified patient-associated alarm sounds during the simulation and logged responses via a tablet computer. Each subject participated in the simulation twice and was exposed to 32 alarm annunciations. Primary outcome measures were response accuracy and response times. Secondary outcomes included assessments of perceived fatigue and task load. RESULTS: Overall accuracy rate in the standard alarm group was 43% (mean) and in the icon group was 88% (mean). Subjects in the icon group were 26.1 (odds ratio [98.75% CI, 8.4 to 81.5; P < 0.001]) times more likely to correctly identify an alarm. Response times in the icon group were shorter than in the standard alarm group (12 vs. 15 s, difference 3 s [98.75% CI ,1 to 5; P < 0.001]). CONCLUSIONS: Under our simulated conditions, anesthesia providers more correctly and quickly identified icon alarms than standard alarms. Subjects were more likely to perceive higher fatigue and task load when using current standard alarms than icon alarms.

The Component Timed-Up-and-Go test: the utility and psychometric properties of using a mobile application to determine prosthetic mobility in people with lower limb amputations.

OBJECTIVE: Using a custom mobile application to evaluate the reliability and validity of the Component Timed-Up-and-Go test to assess prosthetic mobility in people with lower limb amputation. DESIGN: Cross-sectional design. SETTING: National conference for people with limb loss. SUBJECTS: A total of 118 people with non-vascular cause of lower limb amputation participated. Subjects had a mean age of 48 (±13.7) years and were an average of 10 years post amputation. Of them, 54% ( n = 64) of subjects were male. INTERVENTION: None. MAIN MEASURE: The Component Timed-Up-and-Go was administered using a mobile iPad application, generating a total time to complete the test and five component times capturing each subtask (sit to stand transitions, linear gait, turning) of the standard timed-up-and-go test. The outcome underwent test-retest reliability using intraclass correlation coefficients (ICCs) and convergent validity analyses through correlation with self-report measures of balance and mobility. RESULTS: The Component Timed-Up-and-Go exhibited excellent test-retest reliability with ICCs ranging from .98 to .86 for total and component times. Evidence of discriminative validity resulted from significant differences in mean total times between people with transtibial (10.1 (SD: ±2.3)) and transfemoral (12.76 (SD: ±5.1) amputation, as well as significant differences in all five component times ( P < .05). Convergent validity of the Component Timed-Up-and-Go was demonstrated through moderate correlations with the PLUS-M ( rs = -.56). CONCLUSION: The Component Timed-Up-and-Go is a reliable and valid clinical tool for detailed assessment of prosthetic mobility in people with non-vascular lower limb amputation. The iPad application provided a means to easily record data, contributing to clinical utility.

North Carolina Medical Student Views on Abortion.

BACKGROUND Abortion is a controversial yet common procedure within the United States and North Carolina. Although much effort has been directed at understanding the views of physicians and the general public, the views of medical students on abortion are understudied. This study examines the views of medical students at different stages in training on abortion at a public institution, the University of North Carolina at Chapel Hill School of Medicine.METHODS We surveyed incoming, second year, fourth year, and leave-of-absence medical students at the University of North Carolina at Chapel Hill about their views on abortion. We utilized an IRB-approved, anonymous online Qualtrics-based, cross-sectional survey during the spring of 2014.RESULTS We received 315 responses (58% response rate) from 98 incoming (54.5%), 126 second year (70.0%), and 91 fourth year and leave-of-absence (49.2%) students. The majority of students, regardless of stage of training, felt abortion was morally acceptable (incoming 64.3%, second year 74.0%, and fourth year and leave-of-absence 70.0%). Of the students who found abortion to be acceptable, second year (80.9%) and fourth year and leave-of-absence (85.5%) students found second-trimester abortion more acceptable than incoming students (57.15%, P = .002); second year students (42.2%) had greater acceptability of third-trimester abortions compared to incoming (26.2%) and fourth year and leave-of-absence students (22.2%; P = .03). Religiosity and Republican political affiliation were associated with more conservative views on abortion (P = .002); however, gender or intention to enter into an obstetrics/gynecology residency were not.LIMITATIONS Our study reflects views from a single institution, the University of North Carolina at Chapel Hill School of Medicine. This limits the generalizability of our findings to the greater population of medical students across the country.CONCLUSION Despite the controversy surrounding abortion, our work suggests that medical students at the University of North Carolina at Chapel Hill School of Medicine have accepting views of abortion.

Factors Affecting Acoustics and Speech Intelligibility in the Operating Room: Size Matters.

INTRODUCTION: Noise in health care settings has increased since 1960 and represents a significant source of dissatisfaction among staff and patients and risk to patient safety. Operating rooms (ORs) in which effective communication is crucial are particularly noisy. Speech intelligibility is impacted by noise, room architecture, and acoustics. For example, sound reverberation time (RT60) increases with room size, which can negatively impact intelligibility, while room objects are hypothesized to have the opposite effect. We explored these relationships by investigating room construction and acoustics of the surgical suites at our institution. METHODS: We studied our ORs during times of nonuse. Room dimensions were measured to calculate room volumes (VR). Room content was assessed by estimating size and assigning items into 5 volume categories to arrive at an adjusted room content volume (VC) metric. Psychoacoustic analyses were performed by playing sweep tones from a speaker and recording the impulse responses (ie, resulting sound fields) from 3 locations in each room. The recordings were used to calculate 6 psychoacoustic indices of intelligibility. Multiple linear regression was performed using VR and VC as predictor variables and each intelligibility index as an outcome variable. RESULTS: A total of 40 ORs were studied. The surgical suites were characterized by a large degree of construction and surface finish heterogeneity and varied in size from 71.2 to 196.4 m (average VR = 131.1 [34.2] m). An insignificant correlation was observed between VR and VC (Pearson correlation = 0.223, P = .166). Multiple linear regression model fits and ß coefficients for VR were highly significant for each of the intelligibility indices and were best for RT60 (R = 0.666, F(2, 37) = 39.9, P < .0001). For Dmax (maximum distance where there is <15% loss of consonant articulation), both VR and VC ß coefficients were significant. For RT60 and Dmax, after controlling for VC, partial correlations were 0.825 (P < .0001) and 0.718 (P < .0001), respectively, while after controlling for VR, partial correlations were -0.322 (P = .169) and 0.381 (P < .05), respectively. CONCLUSIONS: Our results suggest that the size and contents of an OR can predict a range of psychoacoustic indices of speech intelligibility. Specifically, increasing OR size correlated with worse speech intelligibility, while increasing amounts of OR contents correlated with improved speech intelligibility. This study provides valuable descriptive data and a predictive method for identifying existing ORs that may benefit from acoustic modifiers (eg, sound absorption panels). Additionally, it suggests that room dimensions and projected clinical use should be considered during the design phase of OR suites to optimize acoustic performance.

Classifying Alarms: Seeking Durability, Credibility, Consistency, and Simplicity.

Alongside the development and testing of new audible alarms intended to support International Electrotechnical Commission 60601-1-8, a global standard concerned with alarm safety, the categories of risk that the standard denotes require further thought and possible updating. In this article, we revisit the origins of the categories covered by the standard. These categories were based on the ways that tissue damage can be caused. We consider these categories from the varied professional perspectives of the authors: human factors, semiotics, clinical practice, and the patient or family (layperson). We conclude that while the categories possess many clinically applicable and defensible features from our range of perspectives, the advances in alarm design now available may allow a more flexible approach. We present a three-tier system with superordinate, basic, and subordinate levels that fit both within the thinking embodied in the current standard and possible new developments.

Kaposi's Sarcoma-Associated Herpesvirus Viral Interferon Regulatory Factor 1 Interacts with a Member of the Interferon-Stimulated Gene 15 Pathway.

UNLABELLED: Kaposi's sarcoma-associated herpesvirus (KSHV) is a gammaherpesvirus known to establish lifelong latency in the human host. We and others have previously shown that three KSHV homologs of cellular interferon regulatory factors (IRFs), known as viral IRFs (vIRFs), participate in evasion of the host interferon (IFN) response. We report that vIRF1 interacts with the cellular interferon-stimulated gene 15 (ISG15) E3 ligase, HERC5, in the context of Toll-like receptor 3 (TLR3) activation and IFN induction. The ISG15 protein is covalently conjugated to target proteins upon activation of the interferon response. Interaction between vIRF1 and HERC5 was confirmed by immunoprecipitation, and the region between amino acids 224 and 349 of vIRF1 was required for interaction with HERC5. We further report that expression of vIRF1 in the context of TLR3 activation results in decreased ISG15 conjugation of proteins. Specifically, TLR3-induced ISG15 conjugation and protein levels of cellular IRF3, a known ISG15 target, were decreased in the presence of vIRF1 compared to the control. vIRF1 itself was also identified as a target of ISG15 conjugation. KSHV-infected cells exhibited increased ISG15 conjugation upon reactivation from latency in coordination with increased IFN. Furthermore, knockdown of ISG15 in latently infected cells resulted in a higher level of KSHV reactivation and an increase in infectious virus. These data suggest that the KSHV vIRF1 protein affects ISG15 conjugation and interferon responses and may contribute to effective KSHV replication. IMPORTANCE: The KSHV vIRF1 protein can inhibit interferon activation in response to viral infection. We identified a cellular protein named HERC5, which is the major ligase for ISG15, as a vIRF1 binding partner. vIRF1 association with HERC5 altered ISG15 modification of cellular proteins, and knockdown of ISG15 augmented reactivation of KSHV from latency.

Massive hemoptysis in Loeys-Dietz syndrome.

We describe four unrelated individuals with Loeys-Dietz syndrome (LDS) who presented with massive hemoptysis of unknown etiology. LDS is an autosomal dominant connective-tissue disorder characterized by altered cardiovascular, craniofacial, and skeletal development that is attributed to mutations in the TGFBR1, TGFBR2, SMAD3, or TGFB2 genes. Massive hemoptysis (MH) is a rare and often fatal pulmonary medical emergency. This is the first report of MH in individuals with LDS and establishes it as part of the LDS spectrum. It compels providers to educate their LDS patients on MH, although much investigation needs to be done to determine etiology and appropriate treatment for this newly described LDS feature.

Intraoperative Noise Increases Perceived Task Load and Fatigue in Anesthesiology Residents: A Simulation-Based Study.

BACKGROUND: Operating rooms are identified as being one of the noisiest of clinical environments, and intraoperative noise is associated with adverse effects on staff and patient safety. Simulation-based experiments would offer controllable and safe venues for investigating this noise problem. However, realistic simulation of the clinical auditory environment is rare in current simulators. Therefore, we retrofitted our operating room simulator to be able to produce immersive auditory simulations with the use of typical sound sources encountered during surgeries. Then, we tested the hypothesis that anesthesia residents would perceive greater task load and fatigue while being given simulated lunch breaks in noisy environments rather than in quiet ones. As a secondary objective, we proposed and tested the plausibility of a novel psychometric instrument for the assessment of stress. METHODS: In this simulation-based, randomized, repeated-measures, crossover study, 2 validated psychometric survey instruments, the NASA Task Load Index (NASA-TLX), composed of 6 items, and the Swedish Occupational Fatigue Inventory (SOFI), composed of 5 items, were used to assess perceived task load and fatigue, respectively, in first-year anesthesia residents. Residents completed the psychometric instruments after being given lunch breaks in quiet and noisy intraoperative environments (soundscapes). The effects of soundscape grouping on the psychometric instruments and their comprising items were analyzed with a split-plot analysis. A model for a new psychometric instrument for measuring stress that combines the NASA-TLX and SOFI instruments was proposed, and a factor analysis was performed on the collected data to determine the model's plausibility. RESULTS: Twenty residents participated in this study. Multivariate analysis of variance showed an effect of soundscape grouping on the combined NASA-TLX and SOFI instrument items (P = 0.003) and the comparisons of univariate item reached significance for the NASA Temporal Demand item (P = 0.0004) and the SOFI Lack of Energy item (P = 0.001). Factor analysis extracted 4 factors, which were assigned the following construct names for model development: Psychological Task Load, Psychological Fatigue, Acute Physical Load, and Performance-Chronic Physical Load. Six of the 7 fit tests used in the partial confirmatory factor analysis were positive when we fitted the data to the proposed model, suggesting that further validation is warranted. CONCLUSIONS: This study provides evidence that noise during surgery can increase feelings of stress, as measured by perceived task load and fatigue levels, in anesthesiologists and adds to the growing literature pointing to an overall adverse impact of clinical noise on caregivers and patient safety. The psychometric model proposed in this study for assessing perceived stress is plausible based on factor analysis and will be useful for characterizing the impact of the clinical environment on subject stress levels in future investigations.

Simulating environmental and psychological acoustic factors of the operating room.

In this study, an operating room simulation environment was adapted to include quadraphonic speakers, which were used to recreate a composed clinical soundscape. To assess validity of the composed soundscape, several acoustic parameters of this simulated environment were acquired in the presence of alarms only, background noise only, or both. These parameters were also measured for comparison from size-matched operating rooms at Jackson Memorial Hospital. The parameters examined included sound level, reverberation time, and predictive metrics of speech intelligibility in quiet and noise. It was found that the sound levels and acoustic parameters were comparable between the simulated environment and the actual operating rooms. The impact of the background noise on the perception of medical alarms was then examined, and was found to have little impact on the audibility of the alarms. This study is a first in kind report of a comparison between the environmental and psychological acoustical parameters of a hospital simulation environment and actual operating rooms.