Evaluating a species phylogeny using ddRAD SNPs: Cyto-nuclear discordance and introgression in the salmonid genus Thymallus (Salmonidae).

Hybridization and introgression are very common among freshwater fishes due to the dynamic nature of hydrological landscapes. Cyclic patterns of allopatry and secondary contact provide numerous opportunities for interspecific gene flow, which can lead to discordant paths of evolution for mitochondrial and nuclear genomes. Here, we used double digest restriction-site associated DNA sequencing (ddRADseq) to obtain a genome-wide single nucleotide polymorphism (SNP) dataset comprehensive for allThymallus (Salmonidae)species to infer phylogenetic relationships and evaluate potential recent and historical gene flow among species. The newly obtained nuclear phylogeny was largely concordant with a previously published mitogenome-based topology but revealed a few cyto-nuclear discordances. These incongruencies primarily involved the placement of internal nodes rather than the resolution of species, except for one European species where anthropogenic stock transfers are thought to be responsible for the observed pattern. The analysis of four contact zones where multiple species are found revealed a few cases of mitochondrial capture and limited signals of nuclear introgression. Interestingly, the mechanisms restricting interspecific gene flow might be distinct; while in zones of secondary contact, small-scale physical habitat separation appeared as a limiting factor, biologically based reinforcement mechanisms are presumed to be operative in areas where species presumably evolved in sympatry. Signals of historical introgression were largely congruent with the routes of species dispersal previously inferred from mitogenome data. Overall, the ddRADseq dataset provided a robust phylogenetic reconstruction of the genus Thymallus including new insights into historical hybridization and introgression, opening up new questions concerning their evolutionary history.

Assessing the Prevalence and Predictors of Bullying Among Emergency Medical Service Providers.

Background: Bullying as a stressor in the workplace has been evaluated in numerous settings. It has never been evaluated in the emergency medical service (EMS) environment where bullying can occur from many different sources. The Negative Acts Questionnaire-Revised (NAQ-R) is a 22-question validated tool for evaluating bullying. Our hypothesis was that we could identify a shortened version of the NAQ-R that identifies bullying as accurately as the full screening tool. Methods: This was a cross sectional study of EMS providers in our local EMS transport agency. The local EMS agency transports approximately 50,000 patients per year and is a paramedic level response system. Results on the NAQ-R were on a 5-point Likert scale for each of 22 different categories of bullying that were summed by adding each questions 1-5 response for the 22 questions. Respondents were also categorized as victims or non-victims of bullying based on being positive for any of the 22 types of bullying at least once a week. We performed a binomial decision tree analysis and a cross-validation. Results: Data were collected from 153 providers. Mean age was 33 ± 10 years and 50% were male. Total years in EMS were 8 ± 8 years. NAQ-R summed results in our group ranged between 22 and 88, with an average of 40 ± 15. A NAQ-R score of 33 or less was 91% accurate in identifying non-victims and a score of 45 or more was 94% accurate in identifying victims. The majority at 51% (77/152) of respondents were victims of one or more types of bullying. A combination of five questions was 94% accurate in identifying a victim of bullying among EMS providers. Cross validation resulted in a misclassification risk estimate of 0.12 ± .03. Conclusion: NAQ-R bullying scores in EMS are similar or higher than numbers in other fields. Five questions on the NAQ-R were 94% accurate in identifying victims of bullying in EMS providers.

Thyroid stimulating hormone testing in ED evaluation of patients with atrial fibrillation and various psychiatric diagnoses.

BACKGROUND: Previous studies of thyroid stimulating hormone (TSH) levels in Emergency Department (ED) patients largely have centered on patients with atrial fibrillation (AF). In our ED patients with AF as well as patients with Psychiatric diagnoses (psych) are screened. The purpose of the present study was to compare TSH levels in the 2 groups. Our hypotheses were that an abnormal TSH and/or AF predicted the need for hospital admission and that TSH is more likely decreased in AF and increased in psych patients. METHODS: Our goal in the study was to compare the use of TSH testing in two ED populations, AF vs. psych patients. The study was a cross sectional cohort of AF vs. psych patients who had TSH levels drawn in the ED over a two year period. Our laboratory ranges were used to determine high vs. low TSH. Two chart examiners collected data after a training process. Charts were reviewed extracting demographic data, TSH levels, outcome (admit vs. discharge), history of AF, thyroid disease, psych diagnoses, presence of CHF, diabetes, hypertension. We compared AF vs. Psych groups using chi square and t-tests for parametric data. Odds ratios were calculated for comparisons between the 2 groups. For non-parametric data Mann Whitney U was used. A logistic regression was performed with the outcome of admission vs. discharge to find predictors of hospital admission. Kappa was calculated for inter-rater agreement. An a priori power analysis showed 80% power with 2 groups of 100 with an absolute difference of 20% between the 2 groups. RESULTS: 252 patients were included, 101 with AF and 152 Psych. Demographics differed in age only with AF patients being older. Mean TSH for AF vs. 2.4 for AF, 2.9 for psych (NS) with no differences in percentages with high or low TSH in the 2 groups. Fifty-three patients had abnormal TSH levels (21%), 27% of AF and 17% of Psych patients (NS). There were significant differences in incidence of CHF, DM, HTN, and tachycardia with more in the AF group (P < 0.001). Significantly more of the psych patients had a history of hypothyroidism (OR 2.28). Our logistic regression showed that taking into account demographics including age, the only predictors of admission were the presence of CHF (aOR 18.6) and having a diagnosis of AF (aOR 4.0). CONCLUSION: There were no differences in TSH levels between the 2 groups. Twenty-one percent had an abnormal level. CHF and AF predicted hospital admission on regression analysis. Many with these AF or Psych diagnoses had abnormal ED TSH levels that could be useful in diagnosis, maintenance, or continuous treatment for their conditions diagnoses.

Sepsis alerts in EMS and the results of pre-hospital ETCO2.

BACKGROUND: Field sepsis alerts have the ability to expedite initial ED sepsis treatment. Our hypothesis is that in patients that meet EMS sepsis alert criteria there is a strong relationship between prehospital end-tidal carbon dioxide (ETCO2) readings and the outcome of diagnosed infection. METHODS: In 2014, our EMS service initiated a protocol requiring hospitals to receive notification of a "sepsis alert" on all suspected sepsis patients. The EMS service transports 70,000 patients/year to a number of urban centers. All patients transported to our major urban teaching hospital by our EMS service in one year in which a sepsis alert was announced were included in this study. The primary outcome variable was diagnosed infection and secondary outcomes were hospital admission, ICU admission and mortality. Positive lactate was defined as >4.0 mmol/L. ROC curve analysis was used to define the best cutoff for ETCO2. RESULTS: 351 patients were announced as EMS sepsis alert patients and transported to our center over a one year period. Positive outcomes were as follows: diagnosed infection in 28% of patients, hospital admission in 63% and ICU admission in 11%. The correlation between lactate and ETCO2 was -0.45. A ROC curve analysis of ETCO2 vs. lactate >4 found that the best cutoff to predict a high lactate was an ETCO2 of 25 or less, which was considered a positive ETCO2 (AUC = 0.73). 27% of patients had a positive ETCO2 and 24% had a positive lactate. A positive ETCO2 predicted a positive lactate with 76% accuracy, 63% sensitivity and 80% specificity. 27% of those with a positive ETCO2 and 44% of those with a positive lactate had a diagnosed infection. 59% of those with a positive ETCO2 and 89% of those with a positive lactate had admission to the hospital. 15% of those with a positive ETCO2 and 18% of those with a positive lactate had admission to the ICU. Neither lactate nor ETCO2 were predictive of an increased risk for diagnosed infection, hospital admission or ICU admission in this patient population. CONCLUSION: While ETCO2 predicted the initial ED lactate levels it did not predict diagnosed infection, admission to the hospital or ICU admission in our patient population but did predict mortality.

Inferring phylogenetic structure, hybridization and divergence times within Salmoninae (Teleostei: Salmonidae) using RAD-sequencing.

Phylogenetic studies focusing on Salmonidae have revealed significant obstacles in trying to clarify some interspecific relationships within the Salmoninae subfamily, due to a limited number of markers typed, conflicting phylogenetic signals and ancient hybridization events. To infer reliable phylogenetic relationships, evaluate several putative scenarios of ancient hybridization, and estimate divergence times within Salmoninae, we applied restriction-site associated DNA sequencing (RAD-seq) to 43 samples, including 26 genetic lineages across 21 species, largely representing the subfamily, with an emphasis on the genus Salvelinus. We identified 28,402 loci and 28,363 putatively unlinked SNPs, which were used in downstream analyses. Using an iterative k-means partitioned dataset and a Maximum Likelihood approach; we generated a well-supported phylogeny, providing clear answers to several previous phylogenetic uncertainties. We detected several significant introgression signals, presumably ancient, in the genus Salvelinus. The most recent common ancestor of Salmonidae dates back to approximately 58.9MY ago (50.8-64 MY) and the crown age of Salmoninae was estimated to be 37.7 MY (35.2-40.8 MY) using a Bayesian molecular dating analysis with a relaxed molecular clock. The divergence among genera of the subfamily occurred between the late Eocene and middle of the Miocene (≈38-11 MY) such as the divergence between the genus Oncorhynchus and Salvelinus, which we estimated to 21.2 MY ago (95% HPD: 19.8-23.0 MY), while species diversification took place mainly during the Neogene (≈22-1.5 MY), with more than half of these events occurring in the last 10 MY.

Explaining negative refraction without negative refractive indices.

Negative refraction through a triangular prism may be explained without assigning a negative refractive index to the prism by using array theory. For the case of a beam incident upon the wedge, the array theory accurately predicts the beam transmission angle through the prism and provides an estimate of the frequency interval at which negative refraction occurs. The hypotenuse of the prism has a staircase shape because it is built of cubic unit cells. The large phase delay imparted by each unit cell, combined with the staircase shape of the hypotenuse, creates the necessary conditions for negative refraction. Full-wave simulations using the finite-difference time-domain method show that array theory accurately predicts the beam transmission angle.

Bathing Habits in Emergency Department Patients with Cellulitis or Abscess Versus Controls.

OBJECTIVE: Cellulitis is a leading cause of emergency department (ED) visits, with more than 200 cases per 100,000 people per year. Although many risk factors have been identified, including edema, skin breakdown, and penetrance of the skin, there are few data available on whether personal hygiene habits (bathing and clean clothes) are associated with increased risk for soft tissue infection. Studies looking at chlorhexidine baths in the intensive care unit to prevent soft tissue infections have shown conflicting and limited efficacy. Our objective was to determine whether poor personal hygiene, as manifested in poor bathing habits, a lack of access to clean clothes, or frequent needle self-injections, are associated with cellulitis or abscesses. METHODS: The research is a cross-sectional cohort study of patients with either cellulitis, soft tissue abscess, or both (cases) versus a control group of patients with abdominal pain without prior surgeries in a large, urban ED in a convenience sampling. We asked about bathing habits, access to clean clothing, and skin breaks from intravenous (IV) drug use as risk factors. The two groups were compared using descriptive statistics, and a regression analysis was performed to determine the characteristics that are predictive of soft tissue infections. The study was powered at 0.8 to detect a 20% difference in adequate bathing habits with 100 per group. RESULTS: In an approximate 1-year study period, 108 cases were identified and compared with 104 abdominal pain controls selected at random from patients presenting to the same ED. In the cellulitis/abscess group the mean age was 47 and 81% were men, and in the control group the mean age was 45 and 39% were men. There were significantly more men in the cellulitis/abscess group (Diff 22%, 95% confidence interval [CI] 8-34, P < 0.01). Seventy percent (76 of 108) of cases versus 58% (80 of 104) of controls bathed daily (odds ratio [OR] 1.7, 95% CI 0.98-3.1, not significant). There was a significant difference between the two groups in laundry habits: 66% (71 of 108) of cases versus 42% (44 of 104) of controls did not have access to clean laundry daily (adjusted OR [AOR] 2.5, 95% CI 1.4-5.0, P < 0.01). The most profound and significant difference was noted between cases and controls regarding the use of IV drugs, in which 20 of 108 cases (19%) used IV drugs versus 3 of 104 controls (3%, P < 0.01). Finally, 35 of 108 (32%) of our cases had a history of infections, whereas only 5 of 104 (5%) of the controls had cellulitis or an abscess previously (P < 0.01). On regression analysis significant predictors of soft tissue infection were history of skin infection (AOR 7.0) and not cleaning clothes daily (AOR 2.5). CONCLUSIONS: There was no significant difference in bathing habits, but there was a significant difference in laundry habits between the case and control groups. Our study further confirms that IV drug use is a risk factor for cellulitis and no access to clean clothes daily was significantly related to the development of cellulitis. Failing to obtain daily showers was not associated with an increase in infection.

A Comparison of QTc Intervals in Alcohol Withdrawal Patients Versus Acute Coronary Syndrome Patients.

OBJECTIVES: Patients with an alcohol use disorder experiencing acute intoxication or withdrawal may be at risk for electrocardiograph (ECG) abnormalities, including prolongation of repolarization (long QTc [corrected QT]) that may contribute to arrhythmias and may be associated with a threefold increase in the likelihood of sudden cardiac events. Patients with acute coronary syndrome may have prolonged QTc as well. To our knowledge, no previous studies have compared the QTc of ACS with acute ethanol (EtOH) withdrawal syndromes in the emergency department (ED). The purpose of our study was to compare the QTc of those with EtOH withdrawal emergencies with patients with ACS in our ED. Our hypothesis was that the QTc would be similarly prolonged in the two cohorts. METHODS: The study compared two cohort groups, those with ACS and those with EtOH withdrawal-related ED visits over a 1-year period. We compared ECG QTc, cardiac medication use, and electrolyte differences. We considered a QTc of >450 ms elevated for men and >470 ms elevated for women based on the literature. Fifty subjects in whom an ECG, serum osmolality, and EtOH level were recorded within 2 hours of one another and who were administered a Clinical Institute Withdrawal Assessment protocol were compared with 203 patients with ACS during the same period. We excluded patients with incomplete data. Medications compared included clopidogrel, acetylsalicylic acid, ß-blockers, angiotensin-converting enzyme inhibitors, and statins. ECG QT and QTc, as well as electrolytes, were recorded and compared. Data were extracted by two investigators with a 20% sample re-evaluated by the other extractor as a reliability measure. Descriptive statistics including medians and interquartile ranges were measured for continuous variables. Comparisons were made using two-tailed t tests for parametric data and the Mann-Whitney U test for nonparametric data. RESULTS: Agreement in the 20% sampling between investigators was high (96%). The mean QTc in the ACS group was 457 ms and the mean QTc in the EtOH withdrawal-related group was 468 ms (diff 11, not significant). Significantly more patients had a prolonged QTc in the EtOH withdrawal group than in the ACS group 62% vs 46%; diff 16; 95% CI (0.1, 30). There was significantly more use of clopidogrel, acetylsalicylic acid, angiotensin-converting enzyme inhibitors, and statins (P < 0.05 for all) in the ACS group compared with the EtOH withdrawal group; however, there was no difference in ß-blocker usage. There was a significantly higher admission rate: 100% of ACS compared with 76% of the EtOH withdrawal group (P < 0.01, diff 24, 95% confidence interval 18-29). Electrolytes were not significantly different in the two groups. CONCLUSIONS: More patients with EtOH withdrawal-related ED visits had a long QTc than patients presenting with ACS. ED physicians should carefully monitor patients experiencing EtOH withdrawal for cardiac arrhythmias and obtain an ECG. If any medications that prolong the QTc are considered, then an ECG should be obtained before administering medications that may affect the myocardium to make medication safer for the patient.

Comparison of QTc and Troponin Levels in ST Elevation MIs Compared with Non-ST Elevation MIs.

OBJECTIVES: ST elevation myocardial infarctions (STEMIs) and non-ST elevation myocardial infarctions (NSTEMIs) have differences that can be important to differentiate. Our primary hypothesis was that corrected QT (QTc) duration and troponin I levels were higher in STEMIs compared with NSTEMIs. The objective of our study was to compare STEMIs with NSTEMIs for QTc duration and troponin levels. METHODS: This was a retrospective case-control study of all STEMIs and a random sample of NSTEMIs during a 1-year period. STEMIs were retrieved by searching our electrocardiogram database for all of the cardiology-diagnosed STEMIs. NSTEMIs were found by selecting a randomized sample of all of the patients with a final discharge diagnosis of NSTEMI. Records and electrocardiograms were reviewed for initial troponin I levels and QTc duration. Data extractors were educated formally and a 5% sample was reevaluated by the other extractor as a reliability measure. Data analysis included χ2 tests and parametric or nonparametric analysis, where appropriate. A logistic regression model was created with variables selected a priori for predictors of STEMIs compared with NSTEMIs. RESULTS: A total of 92 STEMIs and 111 NSTEMIs were evaluated, and interrater reliability showed 90% agreement. Patients with NSTEMIs had significantly longer QTc. Troponin I did not differ on univariate analysis. In a logistic model, Hispanics were more likely than whites to have a STEMI (adjusted odds ratio [AOR] 2.2, 95% confidence interval [CI] 1.09-4.5). An increase in troponin I of 1 was associated with a 7% increase in the AOR of a STEMI (AOR 1.7, 95% CI 1.03-1.12) and an increase in QTc by 10 was associated with a 13% decrease in the AOR of a STEMI (AOR 0.87, 95% CI 0.78-0.93). CONCLUSIONS: Patients with NSTEMIs had longer QTc intervals and lower troponin I levels than those with STEMIs.

Cross-Sectional Study of the Relation of Health Literacy to Primary Language and Emergency Department Length of Stay.

OBJECTIVES: The primary aim of this study was to determine whether emergency department (ED) length of stay (LOS) or primary language was related to the degree of health literacy of patients. METHODS: Adult English-speaking and Spanish-speaking patients were recruited for the study. Participants completed the Newest Vital Sign (NVS) tool (English and Spanish versions), a 6-question validated scale. Patients with NVS scores of 0 to 3 were considered to be at risk for limited health literacy, whereas those with adequate health literacy were defined as scoring a 4 to 6. After completion of their ED visit, a retrospective chart review was performed to identify the patient's ED LOS (time from registration to time of disposition) and ED disposition. In addition, 2 single-item questions were compared with the NVS for validity. RESULTS: Participants included 250 English-speaking and 257 Spanish-speaking subjects. Per the NVS, 71% (359 of 507) of all patients had limited health literacy. By language group, significantly more Spanish-speaking than English-speaking patients had limited health literacy (93% vs 48%, diff 45%, 95% confidence interval 37-51). There was no significant difference in LOS between the limited health literacy group and adequate health literacy group (medians 440 vs 461 min). The 2 single-item questions had fair validity in comparison to the NVS scale (κ 0.2-0.3). CONCLUSIONS: There was a significant difference in health literacy based on language, with 93% of all Spanish-speaking patients in our sample having limited health literacy. We found no significant difference in ED LOS between patients with limited health and adequate health literacy in an academic urban ED setting.

Impact of an emergency medicine pharmacist on antibiotic dosing adjustment.

OBJECTIVE: Overall medication-related errors in the emergency department (ED) are 13.5 times more likely to occur in the absence of an emergency medicine pharmacist (EMP). Although the effectiveness of pharmacist-driven renal dosing adjustment has been studied in the intensive care unit, data are lacking in the ED setting. The aim of our study was to evaluate the appropriateness of antibiotic dosing when an EMP is physically present in the ED compared to when absent. METHODS: This was a retrospective cohort study of patients treated in a level I trauma center with 75 adult and 12 pediatric beds and an annual census of 90000 patients. The study period was from March 1 to September 30, 2014. An EMP was physically present in the ED from 11:00 to 01:30 and absent from 01:31 to 10:59. Male and female patients 18years and older were considered for inclusion if cefazolin, cefepime, ciprofloxacin, piperacillin-tazobactam, or vancomycin was ordered. The primary outcome was the composite rate of correct antibiotic dose and frequency. Statistics included a multivariable logistic regression using age, sex, presence of EMP, and creatinine clearance as independent predictors of correct antibiotic use. RESULTS: A total 210 cases were randomly chosen for evaluation, half during times when EMPs were present and half when they were absent. There were 130 males (62%) with an overall mean age of 54±18years. Overall, 178 (85%) of 210 of the antibiotic orders were appropriate, with 95% appropriate when an EMP was present compared to 74% when an EMP was absent (odds ratio, 6.9; 95% confidence interval, 2.5-18.8). In a logistic regression model, antibiotic appropriateness was independently associated with the presence of the EMP and creatinine clearance. CONCLUSION: Antibiotics that require renal and/or weight dosing adjustment are 6.5 times more likely to be appropriate in the ED when an EMP is present. Prevalence of antibiotic dosing error is related to both the presence of EMPs and the degree of renal impairment.

The meaning of elevated troponin I levels: not always acute coronary syndromes.

BACKGROUND: Troponin elevation can be caused by etiologies other than acute coronary syndromes (ACS). Our hypothesis was that elevated troponins occur more frequently in non-ACS cases but that ACS cases (type 1 ST-elevation myocardial infarction [STEMI] and type 1 non-STEMI [NSTEMI]) have significantly higher troponin elevations. METHODS: This was a cross-sectional cohort analysis of a random subset of all patients with elevated troponins (defined as ≥0.06 ng/mL) over a 1-year period from July 2013 to June 2014. The first positive troponin I and the peak were used in this study. All included patients had medical record reviews looking for whether our cardiologists or hospitalists attributed the elevated troponin to an ACS (NSTEMI or STEMI) or non-ACS cause. Non-ACS causes were categorized as infection, cancer, renal diseases, cardiovascular disease, pulmonary disease, trauma, cardiac arrest, neurologic disease, hypertension, or other. Data were extracted by 2 investigators on the cause of the elevated troponin. Three sessions to educate data extractors were arranged and methods of data extraction discussed, then a 5% sample was reevaluated by the other extractor to determine interrater agreement measures. Parametric data were evaluated with t test and analysis of variance. Dichotomous variables were compared using χ(2) test. Troponin data were evaluated using nonparametric Kruskal-Wallis or Mann-Whitney U. A logistic regression model was created with variables selected a priori to evaluate the predictive ability of these variables in differentiating ACS vs non-ACS causes of elevated troponin. RESULTS: We evaluated 458 randomly selected patients from 1317 unique cases of all patients with initial elevated troponins at least 0.06 mg/mL during the study period. There was 84% interrater agreement in the 5% sampling. Seventy-nine percent had a non-ACS cause of elevated troponin, and the average initial positive troponin I level was significantly lower in the non-ACS cases (0.14; 95% confidence interval [CI], 0.08-0.37) than those with documented STEMI (10.2; 95% CI, 0.75-20.1) or NSTEMIs (0.4; 95% CI, 0.13-1.7). In the non-ACS group, the median initial troponin was 0.14 ng/mL (0.08-0.37 ng/mL). Peak troponin levels were highest in STEMI, next NSTEMI, and lowest in non ACS causes. The most frequent subgroups in the non-ACS group were non-ACS cardiovascular, infectious, renal, or hypertensive causes. In a linear regression model adjusting for age and sex, higher troponin levels had higher odds of being related to ACS causes (adjusted odds ratio, 1.4; 95% CI, 1.2-1.6) than non-ACS causes. CONCLUSION: The etiology for most initial elevated troponin I levels in a randomly selected population is the result of non-ACS causes. As initial + troponin levels increased, they were more likely associated with ACS causes than with non-ACS causes. Average initial + and peak troponin values were highest in STEMIs, next highest in NSTEMIs, and lowest overall in non-ACS causes.

Randomized single-blinded clinical trial on effects of nursery songs for infants and young children's anxiety before and during head computed tomography.

OBJECTIVE: The objective of this clinical trial was to determine if an intervention of listening to nursery songs with integrated heartbeat sounds resulted in changes in anxiety levels in infants and children younger than 4 years in an emergent setting. METHODS: This is a randomized single-blinded controlled trial. The study included 62 children younger than 4 years who were deemed by the emergency physician to need a computed tomographic (CT) scan. The experimental group (Exp) (n=30) listened to recorded children's songs with integrated heartbeat sounds (Baby Go To Sleep compact disc) before and during the head CT. The controls (Con) (n=32) had no music. Two scales to measure agitation were completed by a trained research associate: (1) a 10-cm visual analog scale (VAS) and (2) the Modified Ramsay Sedation Scale (MRSS). The research associate wore headphones blocking out all music. The research associate recorded agitation levels preintervention and postintervention on the 2 scales, whether there was successful completion of the head CT without pharmacologic intervention, and the frequency of medication use. Mann-Whitney U, t test, and logistic regression were used for analysis, and P<.05 was considered significant. RESULTS: There were no differences between groups in the age, sex, initial vital signs, diagnostic category, ethnicity, insurance status, rate of completion of head CT, rate of medication use, hospital admissions, or initial VAS or MRSS score. There was improvement on the VAS score in 53% of the Exp group subjects and 25% of the Con group subjects. The VAS score in the Exp group improved by 1.6 cm, whereas the Con group worsened by 0.8 cm after the intervention (difference=2.4 cm, P=.03). There were no significant changes in MRSS scores. Accounting for age, sex, and admission status, the adjusted odds of having an improved sedation score were 3.2 (1.0-9.7) in the Exp group. CONCLUSION: Measured on a VAS, there was a significant decrease in agitation in children undergoing a head CT when children's songs with integrated heartbeat sounds were played before and during the procedure.

Disparity in Patients' Self-Reported and Charted Medication Allergy Information.

OBJECTIVES: The objective of this study was to compare current adverse drug/allergy reaction reporting in patient electronic medical records/charts against information gathered during patient interviews in the emergency department. Our hypothesis was that current methods for allergy reporting results in significant discrepancy between what is documented and the actual allergy history upon interviewing the patient. METHODS: The study was conducted between December 2011 and April 2012 in an academic emergency department. This was a convenience sample study comparing a prospective patient interview with previously documented allergy histories. Demographics for sex, age, and race were recorded. Patients to be interviewed were adults with at least one documented allergy in their chart. Descriptive statistics and percentages were used for demographic and prevalence data. Agreement between interviews and charts was assessed for both the reaction type and the reaction descriptor. RESULTS: There were 101 patients interviewed during this 4-month period, and a total of 235 adverse drug reactions were recorded. There were 66 women and 35 men included in this study. The mean age was 51 ± 17 years. The median number of allergy instances for women was 2 (interquartile range 1-3) and for men the median number of allergy instances was 1 (interquartile range 1-2). The percentage of agreements for overall allergies was 85% and 50% for the type of reaction. Total profile agreement occurred in nine patients. CONCLUSIONS: The percentage of agreement between interviews and charting for reaction type was 50%. Even with the use of electronic medical records, better methods are needed to properly record allergies to ensure patient safety and care.

Evaluating community ED crowding: the Community ED Overcrowding Scale study.

OBJECTIVES: The goals of this study were to (1) identify valid variables that correlate with emergency department (ED) crowding and (2) determine a model that could be used to accurately reflect the degree of ED crowding. METHODS: A site sampling form was applied to convenience sampling of 13 community hospitals in California between April 6, 2011, and May 1, 2011. The outcome variable was average perception of crowding by the ED physician and charge nurse on a 100-mm visual analog scale. We focused on 20 candidate predictor variables that represented counts and times in the ED that were collected every 4 hours. A prediction model was developed using multivariable linear regression to determine the measures that predicted ED crowding. A parsimonious model was developed to allow for a clinical useful tool that that explained a significant amount of variability predicted by the full ED crowding model. RESULTS: A total of 2006 data sets were collected for each of the participating hospitals. A total of 1628 time entries for the hospitals were included in the study. Hospital EDs had censuses ranging from 18 000 to 98 000. Full evaluation was completed on 1489 data sets. Twenty variables were considered for the full model with 7 removed due to multicollinearity. The remaining 13 variables constituted the full model and explained 50.5% of the variability in the outcome variable. Five predictors were found to represent 92% of the variability represented by the full model. CONCLUSIONS: Five variables were highly correlated with community ED crowding and could be used to model the full set of all variables in explaining ED crowding.

Emergency department orthopedics observation unit as an alternative to admission.

OBJECTIVES: Inclusion of select orthopedic problems in the orthopedics observation unit (OOU) may reduce hospital admissions. Our system allows OOU status for 24 hours, but the effect on admissions is unknown. Our primary hypothesis was that we could predict which OOU patients required admission based on the presence of uncontrolled pain. METHODS: Data were prospectively collected for all OOU patients in this prospective observational study, including data on extremity cellulitis, fractures, and spine injuries awaiting brace placement.The primary outcome variable was admission to the hospital versus discharge home. The a priori hypotheses were that patients with more persistent or worsening pain would require admission more often and that the OOU would result in fewer patients needing a costlier inpatient admission to the hospital. An a priori power analysis showed adequate power of 80% to detect a difference between admitted and discharged patients. RESULTS: Data were prospectively collected from August 2011 to August 2012 for 199 consecutive OOU patients, 62% of whom were men. Diagnoses included infection (cellulitis or abscess of extremity) in 76%, fracture in 15% and other in 9% of the patients. Sixty-two patients (31%) were admitted and 7 patients (4%) made return visits for the same problem within a 30-day period. No significant relations existed between any of the independent variables and admission on bivariate analysis. Multivariable logistic regression found no significant predictors of hospital admission. Logistic regression was not performed on 30-day returns because of the low event rate (4%). CONCLUSIONS: An OOU prevented 138 of 199 (69%) patients from being admitted to a hospital. There were no significant predictors of which patients would require admission. Pain was not a predictor of need for admission. The lack of significant predictors is important in suggesting that without the ability to predict which patients require admission, a system using an OOU can reduce admissions by more than two-thirds.

No difference in emergency department length of stay for patients with limited proficiency in English.

OBJECTIVES: The population of the United States continues to diversify, with an increasing percentage of individuals who have limited English proficiency (LEP). A major concern facing emergency departments (EDs) around the country is increasing length of stay (LOS). Although multiple studies have shown racial and ethnic disparities in waiting time and LOS, no studies have examined specifically whether patients with LEP have a different LOS than English-speaking (ES) patients. In addition, no studies have examined whether the use of interpreters by patients with LEP has a significant impact on LOS. We hypothesized that there was a significant difference in LOS when comparing patients with LEP and ES patients and patients with LEP who used interpreters versus patients with LEP who did not. METHODS: This was a prospective cohort study with LOS data collected from a level I ED patient tracking software program from October 2011 to December 2011. The primary language preferred by the patient was indicated at the time of triage and registration and the patient's use of an interpreter also was recorded. The patient's demographic data, ED visit information, and LOS were prospectively entered into an Excel spreadsheet. Percentages were compared using 95% confidence intervals and LOS was analyzed using the Student t test. With >100 subjects per group, our study had 80% power (ie, a power of 0.8) to determine a 15% difference in proportions between groups or a difference of 120 minutes (assuming a standard deviation of 300 minutes on both means). RESULTS: Data were collected from a total of 121 ES patients and 124 patients with LEP. In the LEP group were the languages of Spanish, Navajo, Vietnamese, Chinese, Arabic, and American Sign Language. Fifty-eight percent of patients with LEP used an interpreter. There were no differences between ES patients and patients with LEP in age, sex, mode of arrival, chief complaints, acuity, percentage admitted, percentage pediatric patients, or percentage of Medicaid/Medicare recipients. More patients with LEP were self-pay (36% vs 20%, diff 16, 95% confidence interval 2-31). There were no differences in mean LOS from time of arrival to time to being seen by a provider when comparing ES patients with patients with LEP or time of arrival to time to discharge or admission request. Comparing the patients with LEP who used interpreters with those who did not use interpreters, there was a significantly different LOS from time of arrival to time of discharge or admission request (958 ± 644 vs 628 ± 595 minutes, diff 330, 95% confidence interval 84-576). CONCLUSIONS: There was no difference in LOS for patients with LEP; however, patients with LEP who used interpreters had a significant increase in LOS compared with those who did not use interpreters.

Does the addition of Vocera hands-free communication device improve interruptions in an academic emergency department?

OBJECTIVE: Emergency department (ED) interruptions occur frequently. Recently, a hands-free communication device (HCD; Vocera) was added to the population of communications devices (a cellular telephone and a pager) in our ED. The research purpose was to determine whether this addition improved interruption times and our hypothesis was the device would decrease length of interruptions. METHODS: This was a prospective cohort study of interruptions in an academic ED level 1 trauma center before and after introduction of an HCD. Interruptions were defined a priori and based on previous literature. We studied a convenience sampling of shifts. Length of interruption time was recorded. Three investigators collected interruption data, including nine different ED attendings. RESULTS: Of 511 interruptions, there were no significant differences in types of interruptions pre- versus post-HCD. Before HCD use, we collected 40 hours of data with 65 interruptions (mean 1.6/hour). Post-HCD, 180 hours of data were collected with 446 interruptions (mean 2.5/hour). There was a significant difference in length of time of interruptions, with an average of 9 minutes pre-HCD versus 4 minutes post-HCD (P = 0.012 diff 4.9; 95% confidence interval 1.8-8.1). HCD calls were significantly shorter than non-HCD calls (1 vs 5 minutes; P < 0.001). Comparing data collectors for type of interruption during the same 4-hour shift resulted in κ = 0.73. CONCLUSIONS: The addition of Vocera HCD may improve interruptions by shortening call length.

Applying molecular genetic data at different scales to support conservation assessment of European Habitats Directive listed species: A case study of Eurasian otter in Austria.

Evaluating intraspecific genetic structure and diversity is fundamental to assessing a species' conservation status, but direct incorporation of such information into legal frameworks such as the EU's Habitats Directive is surprisingly rare. How genetic structure aligns with EU member state boundaries or biogeographic regions may be very important in designing management plans or achieving legislative goals. The Eurasian fish otter experienced a sharp population decline during the 20th century but is currently re-expanding in several countries. The species is listed under Annex II and IV of the European Habitats Directive, and member states are obliged to assess the species separately across different biogeographic regions. We genotyped 2492 otter spraints across four provinces in Austria, collected between 2017 and 2021. A total of 384 different genotypes were identified, supporting densities along river habitats from 0.1 to 0.47 otters per river km (mean: 0.306), with a resampling-based simulation supporting limited density overestimation at survey lengths of 20 km or more. Three distinct genetic clusters were revealed, two of them presumably reflecting two relict populations whereas the source of the third cluster is unknown. The geographic extent of the three clusters does not coincide with provincial or biogeographic boundaries, both relevant for assessment and management within existing national or European legislative frameworks. We advocate more consideration of genetic structure in the assessment and conservation management planning of species listed in the European Habitats Directive.

Ondansetron oral dissolving tablets are superior to normal saline alone for prehospital nausea.

BACKGROUND: Antiemetics have been shown to be effective in multiple hospital settings, but few studies have been done in the prehospital environment. OBJECTIVES: Our hypotheses were 1) that the amount of normal saline administered during an emergency medical services (EMS) transport was not related to a change in nausea and vomiting and 2) that the addition of the ondansetron orally disintegrating tablet (ODT) would decrease the degree of nausea. METHODS: This was a pre-post study of two cohorts of consecutive patients with nausea in the prehospital setting. During phase 1 of the study, our local EMS agency adopted a protocol form to complete whenever a patient with nausea and/or vomiting was assessed and transported to one of the area hospitals. Patients were asked to rate their nausea on a visual analog scale (VAS) and a Likert scale, and saline administration and active vomiting were documented. During phase 2, our EMS system adopted the use of ondansetron ODT for nausea and continued to complete the same forms. The nausea forms completed by EMS during phase 1 (saline only) and phase 2 (ondansetron ODT) were evaluated and compared. For both phases, the primary outcome measures were the change in VAS nausea rating (0 = no nausea, 100 = most nausea imaginable) from beginning to end of the transport and the results on the Likert scale completed at the end of the transport. Relationships were considered significant if p < 0.01. RESULTS: Data were collected from 274 transports in phase 1 and 372 transports in phase 2. The average patient age was 50 ± 12 years. In phase 1 of the study, 178 of 274 patients (65%) received normal saline (mean volume ± standard deviation = 265 ± 192 mL). There was no significant correlation between the VAS change and the amount of fluid administration in either phase of the study. Conversely, during phase 2, patients receiving ondansetron ODT showed significant improvement in both measures of nausea. The difference in nausea improvement between phase 1 and phase 2 was significant (difference in VAS change: 24.6; 95% confidence interval 20.9, 28.3). CONCLUSION: There was no improvement in patient nausea related to quantity of saline alone during an EMS transport. The addition of ondansetron ODT resulted in a significant improvement in degree of nausea.