Adolescents' exposure to community violence and associations with after-school activities across two samples.

INTRODUCTION: Exposure to community violence (ECV) continues to be a major public health problem among urban adolescents in the United States. We sought to identify subgroups of adolescents' ECV and examine how after-school activities are related to exposure subgroups across two samples. METHODS: In Study 1 there were 1432 adolescents (Cohort 9 n = 717, Mage = 11, and Cohort 12 n = 715, Mage = 14; 52% boys) from the Project on Human Development in Chicago Neighborhoods (1994-2002). Study 2 had a more recent sample of 537 adolescents (Mage = 16 years; 54% girls) from the After-School Activity Study (ASAS; 2015-2017) in Chicago and Detroit. RESULTS: Exploratory latent class analyses yielded a three-class solution for Study 1: a "No ECV" class (44%); a "Low ECV" class (36%); and a "High Exposure" class (14%). In Study 2, a four-class solution was the best fit with a "No ECV" class (33%), a "Moderate Witness/Low Victim" class (36%), a "High Witness/Moderate Victim" class (19%), and a "High ECV" class (11%). Home-based activities appeared to be protective against high ECV for adolescents in Study 2. School-based activities were associated with higher ECV across both samples, but community-based activities were only associated with greater violence exposure in Study 1. Adolescents' unstructured socializing in both studies was associated with higher odds of ECV. CONCLUSIONS: Results indicate that subgroups of adolescents can be identified based on ECV and highlight the complexity of after-school activities as risk and protective factors in both past and more recent contexts.

Risk Factors and Management Outcomes in Pediatric Epistaxis at an Emergency Department.

BACKGROUND: Most cases of pediatric epistaxis are spontaneous and self-resolve. However, a subset of children may experience significant bleeding and require procedural or medical intervention. OBJECTIVE: We aim to identify risk factors associated with moderate and severe epistaxis in the emergency department (ED) and explore management outcomes. METHODS: We retrospectively reviewed all patients under 22 years old with epistaxis who presented to our ED between 2013 and 2022. Epistaxis severity was defined as mild (required nasal compression or intranasal medications), moderate (required cautery or packing), or severe (required factor replacement, transfusion, hospital admission, or surgery). We performed univariable and multinomial regression analyses, with risk factors and outcomes analyzed according to severity. RESULTS: Of 858 visits, 41 (5%) patients had moderate and 67 (8%) had severe epistaxis. Patients with moderate epistaxis were older than those with mild and severe epistaxis (median 15.6 vs. 8.3 vs. 10.7 years, p < 0.001). In regression analysis, moderate epistaxis was associated with older age, prior ED visit within 72 h, and antiplatelet medication use (p < 0.01). Severe epistaxis was associated with bleeding disorders, nasal procedures within 30 days, and anticoagulation medication use (p ≤ 0.001). Bleeding over 30 min prior to arrival was associated with both moderate and severe epistaxis (p < 0.05). Of the 67 patients with severe epistaxis, 10 (15%) required factor replacement, 28 (42%) required transfusion, 52 (77%) required hospital admission, and 5 (7%) underwent surgery. CONCLUSION: Epistaxis severity is associated with certain risk factors. However, most cases of pediatric epistaxis are mild and do not require intervention or ED evaluation.

The Two-Bag Method for Management of Adult Diabetic Ketoacidosis-Experience With 634 Patients.

PURPOSE: To compare key resource utilization and safety outcomes of adult emergency department (ED) patients in diabetic ketoacidosis (DKA) managed via the Two-Bag or traditional One-Bag method. MATERIALS AND METHODS: This is a retrospective review at an academic medical center ED. Patients were included if >18 years, met diagnostic criteria for DKA (pH ≤ 7.30, bicarbonate ≤ 18 mmol/L, anion gap ≥ 10), and were managed via a standardized order set (either Two-Bag or One-Bag Method). Comparisons used independent-groups t-tests for continuous variables and χ2 tests for binary variables. RESULTS: We identified 634 patients with DKA managed via the Two-Bag method, and 107 managed via the One-Bag method. Cohorts were similar in demographics and presenting laboratories. The Two-Bag Method was associated with 8.1 h shorter to first bicarbonate >18 mmol/L (11.9 vs 20.0, P < .001), and 24 fewer IV fluid bags (5.3 vs 29.7, P < .001). Incidence of hypokalemia (potassium <3.0 mmol/L) was 53% lower in the Two-Bag cohort (6.6 vs 14.0%, P = .03); incidence of hypoglycemia (glucose <70 mg/dL) was 5.8 versus 10.3%, P = .16. CONCLUSIONS: For adult ED patients in DKA, the Two-Bag Method was associated with faster resolution of acidosis, fewer IV fluid bags charged, lower incidence of hypokalemia, and trend toward lower incidence of hypoglycemia compared to the One-Bag Method.

Variability in emergency department management of hypothermic infants ≤90 days of age.

OBJECTIVES: Hypothermic infants are at risk for serious bacterial and herpes simplex virus infections, but there are no evidence-based guidelines for managing these patients. We sought to characterize variations and trends in care for these infants in the emergency department (ED). METHODS: We conducted a retrospective cross-sectional study of infants under 90 days old presenting to 32 pediatric EDs from 2009 through 2019 with an International Classification of Diseases diagnosis code for hypothermia. We characterized variation in diagnostic testing, antimicrobial treatment, and disposition of children in three age groups (≤30 days, 31-60 days, and 61-90 days old) and analyzed care trends. RESULTS: Of 7828 ED encounters meeting inclusion criteria, most (81%) were ≤ 30 days of age. Infants in the 0-30 days old age group, compared to 61-90 days old age group, had a higher proportion of blood (75% vs. 68%), urine (72% vs. 64%), and cerebrospinal fluid (CSF; 35% vs. 22%) cultures obtained (p < 0.01) and greater antimicrobial use (81% vs. 68%; p < 0.01) in the ED. From 2009 to 2019, C-reactive protein (CRP), and procalcitonin usage steadily increased, from 25% to 40% and 0% to 30% respectively, while antibiotic use (83% to 77%), CSF testing (53% to 44%), and chest radiography (47% to 34%) decreased. Considerable interhospital variation was noted in testing and treatment, including CSF testing (14-70%), inflammatory markers (CRP and procalcitonin; 8-88%), and antibiotics (56-92%). CONCLUSION: Substantial hospital-level variation exists for managing hypothermic infants in the ED. Long-term trends are notable for changing practice over time, particularly with increased use of inflammatory markers. Prospective studies are needed to risk stratify and optimize care for this population.

Latino/a adolescents facing neighborhood dangers: An examination of community violence and gender-based harassment.

While ample research examines community violence as a serious public health problem that disproportionately affects minority adolescents, less attention focuses on adolescents' experiences of gender-based harassment in poor, urban neighborhoods. Using data from 416 urban, low-income Latino/a adolescents (53% female; Mage = 15.5), this study examined (a) the relations between community violence exposure (CVE), gender-based harassment, and posttraumatic stress disorder (PTSD) symptoms and (b) the role of parent-child cohesion as a moderator of the relations between CVE/harassment and PTSD symptoms. Whereas both CVE and gender-based harassment were associated with greater PTSD symptoms, the effect of gender-based harassment on PTSD symptoms was far greater than the effect of community violence. Additionally, the association between gender-based harassment and PTSD symptoms was exacerbated when parent-child cohesion was high, compared to when cohesion was low or average. Finally, Latino/a adolescents exposed to high levels of both CVE and gender-based harassment had worse PTSD symptoms compared to those exposed primarily to gender-based harassment, who in turn had worse PTSD symptoms than those exposed primarily to community violence. Findings highlight the importance of including adolescents' experiences with gender-based harassment when studying community violence.

Use of an Electronic Referral Application to Address Post-Injury Needs of Victims of Firearm Injury in a Hospital-Based Violence Intervention Program.

BACKGROUND: Wraparound referrals are a cornerstone of hospital-based violence intervention programs, which have proven to be an effective public health approach for mitigating violence and recidivism. We hypothesized that replacing a manual referral process with an electronic referral application would increase the number of generated referrals and improve compliance with follow-up visits. STUDY DESIGN: The population for this single center quantitative study was a convenience sample of firearm-injured patients. Data from 74 patients were collected using the electronic health record, the electronic referral application, and the trauma registry before and after the intervention. RESULTS: Post-implementation of the electronic referral application showed an increased number of generated referrals, increased emergency department and inpatient utilization of trauma recovery center services, and an increase in second follow-up visit compliance. CONCLUSION: This study demonstrated an increase in the number of referrals and greater likelihood of completion of post-injury follow-up visits after implementing the electronic referral system.

An emergency department-based intensive care unit is associated with decreased hospital length of stay for upper gastrointestinal bleeding.

INTRODUCTION: Upper gastrointestinal bleeding (UGIB) is associated with substantial morbidity, mortality, and intensive care unit (ICU) utilization. Initial risk stratification and disposition from the Emergency Department (ED) can prove challenging due to limited data points during a short period of observation. An ED-based ICU (ED-ICU) may allow more rapid delivery of ICU-level care, though its impact on patients with UGIB is unknown. METHODS: A retrospective observational study was conducted at a tertiary U.S. academic medical center. An ED-ICU (the Emergency Critical Care Center [EC3]) opened in February 2015. Patients presenting to the ED with UGIB undergoing esophagogastroduodenoscopy within 72 h were identified and analyzed. The Pre- and Post-EC3 cohorts included patients from 9/2/2012-2/15/2015 and 2/16/2015-6/30/2019. RESULTS: We identified 3788 ED visits; 1033 Pre-EC3 and 2755 Post-EC3. Of Pre-EC3 visits, 200 were critically ill and admitted to ICU [Cohort A]. Of Post-EC3 visits, 682 were critically ill and managed in EC3 [Cohort B], whereas 61 were critically ill and admitted directly to ICU without care in EC3 [Cohort C]. The mean interval from ED presentation to ICU level care was shorter in Cohort B than A or C (3.8 vs 6.3 vs 7.7 h, p < 0.05). More patients in Cohort B received ICU level care within six hours of ED arrival (85.3 vs 52.0 vs 57.4%, p < 0.05). Mean hospital length of stay (LOS) was shorter in Cohort B than A or C (6.2 vs 7.3 vs 10.0 days, p < 0.05). In the Post-EC3 cohort, fewer patients were admitted to an ICU (9.3 vs 19.4%, p < 0.001). The rate of floor admission with transfer to ICU within 24 h was similar. No differences in absolute or risk-adjusted mortality were observed. CONCLUSION: For critically ill ED patients with UGIB, implementation of an ED-ICU was associated with reductions in rate of ICU admission and hospital LOS, with no differences in safety outcomes.

Extended dwell and standard ultrasound guided peripheral intravenous catheters: Comparison of durability and reliability.

Background Vascular access is a critical component of emergency department (ED) care. Ultrasound guided placement of peripheral intravenous (USIV) catheters is increasingly common. However, USIV are thought to suffer from reduced durability and higher complication rates. Extended dwell catheters (EDC) are long peripheral IVs placed under combined ultrasound and wire guidance. The goal of this study is to compare dwell times and complication rates of EDC to standard peripheral USIV. Methods We performed a retrospective cohort study at a tertiary care adult ED comparing IV placements during a 17-month period (8/1/2018-12/31/2019), stratified by standard USIV versus EDC. The primary outcome was catheter dwell time and secondary outcomes included need for inpatient vascular access team (VAST) consultation, peripherally inserted central catheter (PICC) insertions, and radiocontrast extravasations. Multivariable Cox regression time-to-event analyses were used to evaluate dwell times, adjusting for age, gender, BMI and end-stage renal disease. Results 359 EDC and 4190 standard USIV were included for analysis. Most USIV (95.6%) and EDC (98.3%) were placed by ED technicians trained in ultrasound vascular access. EDC median dwell time (5.9 days [95%CI: 5.1-6.7]) exceeded standard USIV (3.8 days [95% CI: 3.6-4.0]). Patients with EDC placed in the ED required less VAST consultation (0.84 vs 0.99 charges/encounter), had similar rates of PICC line use (8.0% vs 8.4% of encounters) and had no radiocontrast extravasation events. Multivariable Cox regression demonstrated survival benefit (longer dwell time) favoring EDC (HR 0.70 [95%CI 0.60-0.81]). Conclusion Use of EDC results in longer dwell time and reduces subsequent use of vascular access resources, while maintaining low complication rates. EDC demonstrate superior durability which may justify their selection over standard USIV in some patients.

Can Comprehensive Respiratory Pathogen Panels be Used to Exclude Pertussis Infection?

BACKGROUND: Pertussis is a serious public health concern and accurate diagnosis is imperative. Comprehensive, multiplex respiratory pathogen polymerase chain reaction (PCR) panels (RPPs) have recently become popular, but their utility in excluding pertussis infection has not been fully explored. OBJECTIVES: To determine RPP testing results for pertussis using frozen banked samples that previously tested positive on dedicated Bordetella pertussis PCR testing, and to describe positive test rates for other respiratory pathogens on these samples via RPP. METHODS: Our microbiology laboratory retrieved banked nasopharyngeal samples from inpatient, ambulatory, and emergency department sources that were positive for pertussis using B. pertussis PCR testing from March 2015 to October 2017. RPP was performed on thawed, archived samples. Rate of pertussis identification on RPP was determined, and positive tests for other pathogens were tabulated. RESULTS: A total of 3482 specimens were submitted for pertussis PCR testing during the study period. Of those, 138 (4%) were positive for B. pertussis, and 102 (74%) samples were banked and available for RPP testing. Fifty-seven of 102 (56%) of the banked samples had positive RPP testing for pertussis. Of the 45 samples negative for pertussis on RPP testing, 20 (44%) tested positive for other respiratory pathogens. CONCLUSION: Negative testing for B. pertussis and positive testing for other respiratory pathogens on RPP was common in samples that previously tested positive on dedicated B. pertussis PCR testing, both of which could lead to missed diagnoses of pertussis infection. Clinicians should consider using dedicated pertussis PCR testing if pertussis infection is suspected.

Undifferentiated Dyspnea with Point-of-Care Ultrasound, Primary Emergency Physician Compared with a Dedicated Emergency Department Ultrasound Team.

BACKGROUND: Emergency physicians (EPs) perform critical actions while operating with diagnostic uncertainty. Point-of-care ultrasound (POCUS) is useful in evaluation of dyspneic patients. In prior studies, POCUS is often performed by ultrasound (US) teams without patient care responsibilities. OBJECTIVES: This study evaluates the effectiveness of POCUS in narrowing diagnostic uncertainty in dyspneic patients when performed by treating EPs vs. separate US teams. METHODS: This multicenter, prospective noninferiority cohort study investigated the effect of a POCUS performing team in patient encounters for dyspnea. Before-and-after surveys assessing medical decision-making were administered to attending physicians. Primary outcome was change in most likely diagnosis after POCUS. This was assessed for noninferiority between encounters where the primary or US team performed POCUS. Secondary outcomes included change in differential diagnosis, confidence in diagnosis, interventions considered, and image quality. RESULTS: There were 156 patient encounters analyzed. In the primary team group, most likely diagnosis changed in 40% (95% confidence interval 28-52%) of encounters vs. 32% (95% confidence interval 22-41%) in the US team group. This was noninferior using an a priori specified margin of 20% (p < .0001). Post-POCUS differential decreased by a mean 1.8 diagnoses and was equivalent within a margin of 0.5 diagnoses between performing teams (p = 0.034). Other outcomes were similar between groups. CONCLUSION: POCUS performed by primary teams was noninferior to POCUS performed by US teams for changing the most likely diagnosis, and equivalent when considering mean reduction in number of diagnoses. POCUS performed by treating EPs reduces cognitive burden in dyspneic patients.

The Feasibility of Using Comic-Based Concussion Discharge Instructions: Gauging Likeability and Knowledge Improvement Among Adolescents and Parents.

OBJECTIVE: The objective of this study was to evaluate feasibility of supplementing emergency department (ED) concussion discharge instructions for adolescents and parents with a newly created educational comic and a publicly available comic-based video at an outpatient sports neurology clinic. METHODS: We created a gender-neutral, 2-page comic to augment text-only ED concussion discharge instructions. A sample of patients evaluated at a sports neurology clinic and their parents/guardians participated. Patients and their parents were randomized to view either the comic only or both the comic and publicly available comic-based video. Patients and parents completed preintervention and postintervention surveys to assess likeability and concussion knowledge including concussion definition, symptoms, return-to-ED criteria, and resuming normal activity. Data were analyzed using descriptive and comparative statistics. RESULTS: A total of 57 patients (47.4% female; mean age, 15 years) and 37 guardians were enrolled. Most (73%) concussions were sports related, with the majority having sought care within 24 hours in an ED (80%). Over half (51%) had experienced 2 or more prior concussions. Overall, 31 adolescents and 20 guardians viewed both comic and video, whereas 26 adolescents and 17 guardians viewed the comic only. Both comic and video were favorably reviewed, but a higher proportion of respondents rated the video more positively than the comic for likability (P < 0.01), comprehensibility (P < 0.05), and increasing understanding (P < 0.05). Patients' knowledge of some concussion symptoms emphasized in the comic increased after reading (emotional changes, P = 0.02; vomiting, P = 0.04). CONCLUSIONS: Patients showed increased concussion knowledge using the favorably endorsed comic-based discharge instructions. Using comic-based supplemental discharge tools may optimize concussion education for adolescents.

What Happens After School? Linking Latino Adolescents' Activities and Exposure to Community Violence.

Although community violence and the deleterious behavioral and psychological consequences that are associated with exposure to community violence persist as serious public health concerns, identifying malleable factors that increase or decrease adolescents' risk of exposure to community violence remains a significant gap in our knowledge base. This longitudinal study addresses this research gap by investigating adolescents' endorsement of familismo values and participation in three types of after-school activities, specifically home-, school-, and community-based activities, as potential precursors to adolescents' risk for experiencing community violence. The sample consists of 416 Latino high school students (53% female) with a mean age of 15.5 years (SD = 1.0) and with 85% qualifying for free and reduced school lunch. Cross-sectional results demonstrated that adolescents' endorsement of the Latino cultural value of familismo was associated with lower rates of personal victimization. The frequency of non-structured community-based activities and part-time work were concurrently associated with higher rates of witnessing community violence and being personally victimized by violence. Only the frequency of non-structured community-based activities was related to witnessing more community violence and greater victimization one year later while controlling for prior exposure to violence. These findings underscore the importance of providing structured, well supervised after-school activities for low-income youth in high-risk neighborhoods.

An Emergency Department-Based Intensive Care Unit is Associated with Decreased Hospital and Intensive Care Unit Utilization for Diabetic Ketoacidosis.

BACKGROUND: Many emergency department (ED) patients in diabetic ketoacidosis (DKA) are admitted to an inpatient intensive care unit (ICU), while ICU capacity is under increasing strain. The Emergency Critical Care Center (EC3), a hybrid ED-ICU setting, opened with the goal of providing rapid initiation of ICU care in the ED. OBJECTIVE: We sought to evaluate the impact of an ED-ICU on disposition and safety outcomes for adult ED patients in DKA. METHODS: This was a retrospective pre-post cohort of ED visits from 2012-2018 at a single academic medical center. Adult ED patients in DKA (pH < 7.30, HCO3 < 18 mEq/L, anion gap > 14, and glucose > 250 mg/dL) immediately before (pre-EC3) and after (post-EC3) opening of an ED-ICU were identified. ED disposition and safety data were collected and analyzed. RESULTS: We identified 631 patient encounters: 217 pre-EC3 and 414 post-EC3. Baseline demographics were similar between cohorts. Fewer patients in the post-EC3 cohort were admitted to an ICU (11.6% vs. 23.5%, p < 0.001, number needed to treat [NNT] = 8) or general floor bed (58.0% vs. 73.3%, p < 0.001, NNT = 6), and more were discharged from the ED (27.1% vs. 1.4%, p < 0.001, NNT = 4). Rates of hypokalemia (10.1% vs. 6.0%, p = 0.08) and admission to non-ICU with transfer to ICU within 24 h (0.5% vs. 0%, p = 0.30) did not differ. CONCLUSION: Management of patients with DKA in an ED-ICU was associated with decreased ICU and hospital utilization with similar safety outcomes. Managing rapidly reversible critical illnesses in an ED-ICU may help obviate increasing strain facing many health care systems.

Sonogram of safety: Ultrasound outperforms the fifth intercostal space landmark for tube thoracostomy site selection.

PURPOSE: Identification of tube thoracostomy insertion location is currently performed using a blind, landmark based approach at either the fifth intercostal space (ICS) or inframammary crease in the midaxillary line. A significant percentage of thoracostomies at this site result in complications. This pilot study aimed to assess whether bedside ultrasound could aid in identifying safer tube thoracostomy insertion sites in emergency department patients. METHODS: Fifty emergency department patients were enrolled in this study. Right and left hemidiaphragms were evaluated with ultrasound at the fifth ICS. Observations were made on if the diaphragm was below, above, or crossed the fifth ICS during an entire respiratory cycle. RESULTS: Eighty-one (95% confidence interval 72-82) of the diaphragms were below, 13 (95% confidence interval 8-21) of the diaphragms were at, and 6 (95% confidence interval 3-12) of the diaphragms were above the location marked using traditional landmark techniques. On the right and left hemidiaphragms, 20% (95% confidence interval 19.9%-20.1%) and 18% (95% confidence interval 17.9%-18.1%) of diaphragms were above or crossing the fifth ICS, respectively CONCLUSIONS: Ultrasound identified a significant number of potential chest tube insertion sites at the fifth ICS that would result in subdiaphragmatic insertion or diaphragmatic injury. Based on this data ultrasound can be used to identify safer insertion sites and reduce thoracostomy complications.

Point-of-Care Ultrasound for Pediatric Endotracheal Tube Placement Confirmation by Advanced Practice Transport Nurses.

OBJECTIVE: This study aimed to identify which point-of-care ultrasound (POCUS) techniques and sonographic signs were reliably acquired and interpreted by transport nurses for the confirmation of endotracheal tube placement in children. METHODS: We developed and assessed a multimodal POCUS training curriculum for transport nurses that evaluated 5 sonographic signs using 3 scanning techniques. RESULTS: Twenty-one transport nurses were enrolled in the curriculum. The mean scores (95% confidence interval [CI]) of the knowledge test were 82% (95% CI, 63%-93%), 88% (95% CI, 68%-95%), and 74% (95% CI, 53%-87%) for tracheal, lung, and hemidiaphragmatic scans, respectively. For the simulation image evaluation, 94% (95% CI, 77%-99%) of tracheal scan images, 97% (95% CI, 81%-99%) of lung scan images, and 88% (95% CI, 69%-96%) of hemidiaphragmatic scan images were determined clinically useful. For the pediatric intensive care unit image evaluation, 100% (95% CI, 86%-100%) of tracheal scan images, 100% (95% CI, 86%-100%) of lung scan images, and 79% (95% CI, 59%-91%) of hemidiaphragmatic scan images were determined clinically useful. A tracheal dilation sign was rarely captured by POCUS. CONCLUSION: Transport nurses can acquire POCUS skills to confirm endotracheal tube placement in children. A combination of a double trachea sign, a lung sliding sign, and a lung pulse sign could be a feasible POCUS approach.

Restrictive versus liberal red blood cell transfusion for cardiac surgery: a systematic review and meta-analysis of randomized controlled trials.

Patients undergoing cardiac surgery are among the most common recipients of allogeneic red blood cell (RBC) transfusions. However, whether restrictive RBC transfusion strategies for cardiac surgery achieve a similar clinical outcome in comparison with liberal strategies remains unclear. We searched electronic databases from inception to December 2017 for randomized controlled trials (RCTs). We calculated the risk ratios (RRs) and weighted-mean difference (MD) using a random-effects model. We included 9 RCTs with a total of 9005 patients. There was no significant difference in mortality between groups [RR 1.03; 95% confidence interval (CI) 0.74-1.45; P = 0.86]. In addition, there were no significant differences between groups in the clinical outcomes of infections (RR 1.09; 95% CI 0.94-1.26; P = 0.26), stroke (RR 0.98; 95% CI 0.72-1.35; P = 0.91), respiratory morbidity (RR 1.05; 95% CI 0.89-1.24; P = 0.58), renal morbidity (RR 1.02; 95% CI 0.94-1.09; P = 0.68), myocardial infarction (RR 1.00; 95% CI 0.80-1.24; P = 0.99), cardiac arrhythmia (RR 1.05; 95% CI 0.88-1.26; P = 0.56), gastrointestinal morbidity (RR 1.93; 95% CI 0.81-4.63; P = 0.14), or reoperation (RR 0.90; 95% CI 0.67-1.20; P = 0.46). There was a significant difference in the intensive care unit length of stay (h) (MD 4.29; 95% CI 2.19-6.39, P < 0.01) favoring the liberal group. However, there was no significant difference in the hospital length of stay (days) (MD 0.15; 95% CI - 0.18 to 0.48; P = 0.38). In conclusion, this meta-analysis showed that restrictive strategies for RBC transfusion are as safe as liberal strategies in patients undergoing cardiac surgery with regards to short-term clinical outcomes.

Creation of a Flight Nurse Critical Care Ultrasound Program.

OBJECTIVE: Our objectives were 2-fold: to describe the creation of a flight nurse (FN) ultrasound (US) program and to evaluate whether critical care US performed by nonphysician providers in the prehospital setting can clarify patient assessment. METHODS: Twenty FNs completed a didactic and hands-on US curriculum focusing on critical care modalities. FNs displayed competency by successful completion of an objective-structured clinical examination. Portable US devices were used during patient transports when deemed clinically indicated by the FN. If US was subsequently performed, the FN was asked if US use prompted a change in assessment. Associations were evaluated with chi-square and bivariate logistic regression analyses. RESULTS: FNs reported US use during 102 (12.3%) patient transports, of which intensive care unit (ICU) to ICU (58.8%) constituted the majority of cases followed by emergency department (ED) to ED (28.4%), ED to ICU (4.9%), and scene to ED (2.9%). FNs agreed or strongly agreed that US use clarified the cause of patient symptoms in 67.4% of transports. CONCLUSION: FNs were more likely to perform US when they expressed lower confidence in their initial patient assessment. FNs reported that US helped to clarify patient assessments.

Oxytocin Genotype Moderates the Impact of Social Support on Psychiatric Distress in Alcohol-Dependent Patients.

AIMS: The social environment strongly influences individual mental health. Individuals with strong social support systems tend to experience higher levels of well-being, lower levels of psychological distress and exhibit fewer psychiatric symptoms. However, there is a significant degree of individual variability as to the extent to which social support is beneficial to overall mental health. From a neurobiological perspective, it is suggested that the social hormone, oxytocin, may moderate the favorable effects of social interaction. To explore this possibility, we evaluated oxytocin genotype, social support and psychological health in a group of individuals diagnosed with DSM-IV alcohol dependence. METHODS: The associations between OXT genotype, social support and psychological health were analyzed in data from 269 adults diagnosed with DSM-IV alcohol dependence (25% female) admitted into residential treatment programs and outpatient centers in Warsaw, Poland. RESULTS: In line with past observations, we noted that psychiatric distress scores were negatively correlated with social support. Extending these observations, we uncovered a significant moderating effect of OXT genotype (rs2740210) on the relationship between social support and psychiatric distress. While G carriers displayed the predicted negative relationship between social support and psychiatric distress, T homozygotes failed to exhibit such a relationship. CONCLUSION: Genetically driven variation in oxytocin system functioning may influence the degree to which the beneficial effects of social support are felt in this population. These results have direct clinical relevance as enhancing social engagement to improve mental health may prove to be a less effective strategy in some patients owing to intrinsic factors. SHORT SUMMARY: The associations between oxytocin genotype, social support, and psychological health were analyzed in data from 269 adults diagnosed with DSM-IV alcohol dependence. A significant moderating effect of OXT genotype (rs2740210) on the relationship between social support and psychiatric distress was detected.

Intrastate Variation in Treatment and Outcomes of Out-of-Hospital Cardiac Arrest.

OBJECTIVE: Our objective was to analyze and compare out-of-hospital cardiac arrest (OHCA) system of care performance and outcomes at the Medical Control Authority (MCA) level in the state of Michigan. We hypothesized that clinically and statistically significant variations in treatment and outcomes of OHCA exists within a single U.S. state. METHODS: We performed a retrospective, observational study of all non-traumatic EMS-treated OHCA from the state of Michigan CARES registry for 2014-2015. Geocoding of the OHCA incident address was used to assign records to individual MCAs. MCA-based demographics, arrest characteristics, system of care performance and outcomes were quantified and compared. Associations between demographics, system of care parameters, and outcomes were examined at the MCA level. RESULTS: A total of 8,115 records with complete data were available for analysis. Eleven MCAs met study inclusion criteria of >100 cases, producing a final sample size of 7,788 records (96%). Statistically significant variations in survival to hospital discharge ranged from 4.5% to 15% (p < 0.001) (Adjusted odds ratio [AOR] range 0.6-2.0) and survival with good neurologic outcome 2.7-12.5% (p < 0.001; AOR range 0.5-2.2,) were observed across MCAs. Bystander CPR ranged from 32% to 53% (p < 0.001) and bystander AED application ranged from 3.5% 11.5% (p < 0.05). Of patients admitted to the hospital alive, 29-68% received targeted temperature management. In hospital mortality ranged from 53.1% to 73.9% (p < 0.05). CONCLUSION: Significant intrastate variability in OHCA system of care performance and outcomes currently exist and are similar to what has been previously reported across North America almost a decade ago. This degree of variability highlights the opportunity to optimize modifiable factors within local systems of care to improve OHCA outcomes.

The impact of informed self-assessment on the development of medical students' learning goals.

PURPOSE: This study investigates the contributions of self-assessment (SA) and external feedback on the development of learning goals (LG) and the influence on LG recall and implementation in medical students. METHODS: Following a standardized patient (SP) assessment, 168 pre-clinical medical students completed a SA, received SP feedback and created a LG. LG were categorized by source. Two weeks later, students recalled LG and described implementation. Chi-squared analyses were used to test the associations. RESULTS: SA influenced LG for 82.8% of students whereas SP feedback influenced LG for 45.9%. Students rarely generated LG based on SA when they received discordant feedback (5.4%), but sometimes incorporated feedback discordant from their SA into LG (14.9%). Students who created LG based on SP feedback were more likely to recall LG than those who created LG based on SA, 89.7 versus 67.6%, p < 0.05 and implement their LG, 72.4 versus 48.9%, χ2(1) = 5.3, p = 0.017. Students who reported receiving effective feedback were more likely to implement their LG than those reporting adequate feedback, 60.9 versus 37.9%, χ2(1) = 8.0, p = 0.01. CONCLUSIONS: SA is an essential part of goal setting and subsequent action. Perception of feedback plays a crucial role in LG implementation.