Correlation of Ultraviolet Radiation Levels With the Incidence of Cutaneous Squamous Cell and Merkel Cell Carcinomas in Non-sunbelt Locales in the United States: 2010-2017.

BACKGROUND: Non-melanoma skin cancer (NMSC) is the most common human malignancy worldwide, with increasing incidence in the United States (US). Recent environmental data have shown that ultraviolet radiation (UVR) levels have increased in the US, particularly in the higher latitudes, but the potential impact of this on NMSC incidence is not well known, despite estimates that 90% of NMSC is due to sun exposure. Our exploratory study synthesizes environmental data with demographic and clinical data to determine whether UV indices (UVIs) and non-sunbelt (non-SB) locale (latitudes >40 degrees, which comprises most of the US) might contribute to incidence rates of two types of NMSC: cutaneous squamous cell and Merkel cell carcinomas. METHODS: UVIs from 2010 to 2017 were obtained from the National Oceanic and Atmospheric Administration database and meshed with corresponding locales in the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database (version 8.4.0.1). Four SB and five NSB locales contained sufficient data for analysis. Linear mixed modeling was performed with the outcome variable of the age-adjusted incidence of NMSC cancer (comprised of cutaneous squamous cell carcinoma of the head and neck (CSCCHN) and Merkel cell carcinoma (MCC)), the two most common types of NMSC contained within SEER). Non-SB locale and percent of days with UVI >3 were independent variables. RESULTS: Percent of days with UVI >3 increased during this period, as did the overall NMSC (combined CSCCHN and MCC) skin cancer incidence, though MCC incidence alone did not increase during our study period. Environmental factors that significantly contributed to the age-adjusted overall NMSC (combined CSCCHN and MCC) cancer incidence (per 100,000 individuals) included NSB locale (b=1.227, p=0.0019) and percent of days with UVIs >3 (b=0.028, p<0.0001), as well as clinical factors of percent white race and percent male, by linear mixed modeling. CONCLUSIONS: Our results are limited by the completeness of the NOAA and SEER databases, and do not include basal cell carcinoma. Nevertheless, our data demonstrate that environmental factors, such as latitude in NSB locale and UVI indices, can affect the age-adjusted overall NMSC (defined as CSCCHN and MCC in this study) incidence even in this relatively short period of time. Prospective studies over longer time periods are needed to identify the extent to which these findings are clinically significant so that increased educational efforts to promote sun-safe behaviors can be maximally effective.

Evaluation of a state law on opioid-prescribing behaviour and the void affecting codeine-containing antitussive syrup.

BACKGROUND: Government opioid policies-such as the North Carolina Strengthen Opioid Misuse Prevention (STOP) Act-have aided in lowering the days' supply of opioid prescriptions. However, what effect do these laws have on codeine-containing antitussive syrup? We aimed to assess the effect of the North Carolina STOP Act on ED opioid prescriptions written for >5 days for acute pain/non-pain diagnoses and whether it had an effect on the prescribing of codeine-containing antitussive syrup. METHODS: A retrospective study of two emergency departments, with an average annual census of 70 000 and 22 000 patients, from January to August of 2017 and 2018. We applied logistic regression techniques to calculate the odds of an opioid prescription for >5 days. Opioid medication categories were formed to determine relational proportions. Two-tailed z-tests were used to test the difference in proportions. RESULTS: Our study included 5366 verifiable opioid prescriptions. The percentage of an opioid prescription for >5 days decreased by 3.3% (95% CI -1.8% to -4.7%, p<0.05) after the North Carolina STOP Act (9.8% to 6.5%; 95% CI 5.5% to 7.5%, p<0.05). There was no statistically significant change in the prescribing of codeine syrup for >5 days pre-STOP and post- STOP Act, respectively (91.5% and 90.4%; difference=-1.1%, p=0.83). CONCLUSION: The North Carolina STOP Act was associated with a reduction in the overall percentage of opioid prescriptions for >5 days for acute pain/non-pain diagnoses. However, there was no statistically significant effect on the prescribing of codeine-containing antitussive syrup.

Assessment of the Feasibility of automated, real-time clinical decision support in the emergency department using electronic health record data.

BACKGROUND: The use of big data and machine learning within clinical decision support systems (CDSSs) has the potential to transform medicine through better prognosis, diagnosis and automation of tasks. Real-time application of machine learning algorithms, however, is dependent on data being present and entered prior to, or at the point of, CDSS deployment. Our aim was to determine the feasibility of automating CDSSs within electronic health records (EHRs) by investigating the timing, data categorization, and completeness of documentation of their individual components of two common Clinical Decision Rules (CDRs) in the Emergency Department. METHODS: The CURB-65 severity score and HEART score were randomly selected from a list of the top emergency medicine CDRs. Emergency department (ED) visits with ICD-9 codes applicable to our CDRs were eligible. The charts were reviewed to determine the categorization components of the CDRs as structured and/or unstructured, median times of documentation, portion of charts with all data components documented as structured data, portion of charts with all structured CDR components documented before ED departure. A kappa score was calculated for interrater reliability. RESULTS: The components of the CDRs were mainly documented as structured data for the CURB-65 severity score and HEART score. In the CURB-65 group, 26.8% of charts had all components documented as structured data, and 67.8% in the HEART score. Documentation of some CDR components often occurred late for both CDRs. Only 21 and 11% of patients had all CDR components documented as structured data prior to ED departure for the CURB-65 and HEART score groups, respectively. The interrater reliability for the CURB-65 score review was 0.75 and 0.65 for the HEART score. CONCLUSION: Our study found that EHRs may be unable to automatically calculate popular CDRs-such as the CURB-65 severity score and HEART score-due to missing components and late data entry.

Health Policy and Shared Decision Making in Emergency Care: A Research Agenda.

Although the Patient Protection and Affordable Care Act and other laws have promoted the use of shared decision making (SDM) in recent years, few specific policies have addressed the opportunities and challenges of utilizing SDM in the emergency department (ED). Policies relating to physician payment, quality measurement, and medical-legal risks each present unique challenges to adoption of SDM in the ED. This article summarizes findings from a health policy breakout session of the 2016 Academic Emergency Medicine Consensus Conference "Shared Decision Making in the Emergency Department: Development of a Policy-relevant, Patient-centered Research Agenda." The objectives were to 1) describe federal and state policies that influence utilization or assessment of SDM; 2) identify policies and policy-focused knowledge gaps that serve as barriers to adoption of ED SDM; and 3) to define a consensus-based, policy-focused research agenda to support adoption of SDM in emergency care.

Time-motion analysis of emergency radiologists and emergency physicians at an urban academic medical center.

Our objective was to characterize the tasks of emergency radiologists and emergency physicians and quantify the proportion of time spent on these tasks to assess their roles in patient evaluation. Our study involved emergency radiologists and emergency physicians at an urban academic level I trauma medical center. Participants were observed for continuous 2-h periods during which all of their activities were timed and categorized into the following tasks: patient history, patient physical findings, assessment/plan, procedures, technical/administration, paperwork, and personal time. We performed multivariate analyses to compare the proportion of time spent on task categories between specialties. Twenty physicians (10 emergency medicine and 10 radiology) were observed for a total of 146,802 s (2,446.7 min). Radiologists spent a significantly larger combined proportion of time on determining physical findings and paperwork than emergency physicians (61.9 vs. 28.3 %, p<0.0001). Emergency physicians spent a significantly larger proportion of time than radiologists on determining patient history (17.5 vs. 2.5 %, p=0.0008) and assessment/plan (42.3 vs. 19.3 %, p<0.0001). Both specialties devoted minimal time toward personal tasks. Radiologists play a major role in the diagnostic evaluation of a subset of acute patients, spending significantly more of their time determining physical findings than their emergency physician counterparts.

Endovascular stent graft repair of left renal artery pseudoaneurysm from malignant fibrous histiosarcoma.

A renal artery pseudoaneurysm is a rare but life-threatening complication. Historically, these vascular abnormalities have been treated using open surgery, but today's endovascular techniques provide less invasive forms of treatment. Though literature supports selective angio-embolization as an effective form of repair, there are little data on covered stent placement for renal artery psuedoaneurysms. The authors report a case of left renal artery pseudoaneurysm repaired with a covered stent that allowed a patient with malignant fibrous histiosarcoma to receive chemotherapy with minimal risk of rupture.