Anemia in a young Guinean male.

The etiology of anemia in adults is often multifactorial. This case highlights an uncommon combination of causes of anemia and the importance of a diagnostic workup guided by a patient's unique history, risk factors, and laboratory findings.

COVID-19 in a Patient Presenting with Syncope and a Normal Chest X-ray.

SARS-CoV-2 is a novel virus that has now affected hundreds of thousands of individuals across the world. Amidst this global pandemic, maintaining a high index of suspicion, rapid testing capacity, and infection control measures are required to curtail the virus' rapid spread. While fever and respiratory symptoms have been commonly used to identify COVID-19 suspects, we present an elderly female who arrived to the hospital after a syncopal episode. She was afebrile with a normal chest X-ray and there was no suspicion of COVID-19. She then developed a fever and tested positive for COVID-19. Our unique case underscores the increasing diversity of COVID-19 presentations and potential for initial mis- diagnosis and delay in implementing proper precautions.

Co-infection with SARS-CoV-2 and Human Metapneumovirus.

The novel coronavirus (now called SARS-CoV-2) initially discovered in Wuhan, China, has now become a global pandemic. We describe a patient presenting to an Emergency Department in Rhode Island on March 12, 2020 with cough and shortness of breath after a trip to Jamaica. The patient underwent nasopharyngeal swab for a respiratory pathogen panel as well as SARS-CoV-2 RT-PCR. When the respiratory pathogen panel was positive for human metapneumovirus, the patient was treated and discharged. SARS-CoV-2 RT-PCR came back positive 24 hours later. Although respiratory viral co-infection is thought to be relatively uncommon in adults, this case reflects that SARS-CoV-2 testing algorithms that exclude patients who test positive for routine viral pathogens may miss SARS-CoV-2 co-infected patients.

Abortion-related emergency department visits in the United States: An analysis of a national emergency department sample.

BACKGROUND: Media depictions and laws passed in state legislatures regulating abortion suggest abortion-related medical emergencies are common. An accurate understanding of abortion-related emergencies is important for informing policy and practice. We assessed the incidence of abortion-related emergency department (ED) visits in the United States (U.S.). METHODS: We used a retrospective observational study design using 2009-2013 data from the Nationwide Emergency Department Sample, a nationally representative sample of U.S. ED visits from 947 to 964 hospitals across the U.S. per year. All ED visits among women of reproductive age (15-49) were included. We categorized ED visits by abortion relatedness and treatments received, and assessed whether the visit was for a major incident (defined as requiring blood transfusion, surgery, or overnight inpatient stay). We estimated the proportion of visits that were abortion-related and described the characteristics of patients making these visits, the diagnoses and subsequent treatments received by these patients, the sociodemographic and hospital characteristics associated with the incidents and observation care only (defined as receiving no treatments), and the rate of major incidents for all abortion patients in the U.S. RESULTS: Among all ED visits by women aged 15-49 (189,480,685), 0.01% (n = 27,941) were abortion-related. Of these visits, 51% (95% confidence interval, 95% CI 49.3-51.9%) of the women received observation care only. A total of 20% (95% CI 19.3-21.3%) of abortion-related ED visits were for major incidents. One-fifth (22%, 95% CI 20.9-23.0%) of abortion-related visits resulted in admission to the same hospital for abortion-related reasons. Of the visits, 1.4% (n = 390, 95% CI 1.1-1.7%) were potentially due to attempts at self-induced abortion. In multivariable models, women using Medicaid (adjusted odds ratio, AOR 1.28, 95% CI 1.08-1.52) and women with a comorbid condition (AORs 2.47-4.63) had higher odds of having a major incident than women using private insurance and those without comorbid conditions. During the study period, 0.11% of all abortions in the U.S. resulted in major incidents as seen in EDs. CONCLUSIONS: Abortion-related ED visits comprise a small proportion of women's ED visits. Many abortion-related ED visits may not be indicated or could have been managed at a less costly level of care. Given the low rate of major incidents, perceptions that abortion is unsafe are not based on evidence.

"Sometimes You Feel Like the Freak Show": A Qualitative Assessment of Emergency Care Experiences Among Transgender and Gender-Nonconforming Patients.

STUDY OBJECTIVE: Transgender, gender-variant, and intersex (trans) people have decreased access to care and poorer health outcomes compared with the general population. Little has been studied and documented about such patients' emergency department (ED) experiences and barriers to care. Using survey and qualitative research methods, this study aims to identify specific areas for improvement and generate testable hypotheses about the barriers and challenges for trans individuals needing acute care. METHODS: A survey and 4 focus groups were conducted with trans individuals older than 18 years who had been to an ED in the last 5 years. Participants were recruited by trans e-mail listservs; outreach to local trans organizations; and lesbian, gay, bisexual, and transgender periodical advertisements. The interview guide was reviewed by qualitative research and trans health content experts. Deidentified participant demographic information was collected with a standardized instrument. All discussions were captured on digital audio recorders and professionally transcribed. Interview coding and thematic analysis were conducted with a grounded theory approach. RESULTS: Among 32 participants, 71.9% were male identified and 78.1% were white. Nearly half (43.8%) reported avoiding the ED when they needed acute care. The factors that had the greatest influence on ED avoidance were fear of discrimination, length of wait, and negative previous experiences. There were 4 overarching discussion themes: system structure, care competency, discrimination and trauma, and avoidance of emergency care. Improvement recommendations focused on staff and provider training about gender and trans health, assurance of private gender identity disclosure, and accurate capture of sex, gender, and sexual orientation information in the electronic medical record. CONCLUSION: Efforts to improve trans ED experiences should focus on provider competency and communication training, electronic medical record modifications, and assurance of private means for gender disclosure. Future research directions include quantifying the frequency of care avoidance, the effect of avoidance on trans patient morbidity and mortality, and comparing ED patient outcomes by gender identity. Further research with increased inclusion of transwomen and people of color is needed to identify themes that may not have been raised in this preliminary investigation.

"I need to hear from women who have 'been there'": Developing a woman-focused intervention for drug use and partner violence in the emergency department.

OBJECTIVE: Addressing violence and linking women to community services in parallel with drug change goals is critical for women with coexisting intimate partner violence (IPV) and substance use disorders (SUD). Our objective was to develop a Web-based intervention to address violence and drug use among women patients in the ED. METHODS: The intervention was developed in a five-step process: 1) Initial intervention development based on selected theoretical frameworks; 2) In-depth interviews with the target population; 3) Intervention adaptation, with iterative feedback from further interviews; 4) Beta testing and review by an advisory committee of domestic violence advocates; 5) Acceptability and feasibility testing in a small open trial. RESULTS: Themes supported the selection of MI and empowerment models but also guided major adaptations to the intervention, including the introduction of videos and a more robust booster phone call. Participants in the open trial reported high scores for satisfaction, usability, and consistency with essential elements of motivational interviewing. CONCLUSIONS: This qualitative work with our target population of women in the ED with SUD experiencing IPV underscored the importance of connection to peers and empathetic human contact. We developed an acceptable and feasible intervention distinct from prior ED-based brief interventions for substance-using populations.

"That's Where the Arguments Come in": A Qualitative Analysis of Booster Sessions Following a Brief Intervention for Drug Use and Intimate Partner Violence in the Emergency Department.

Although booster phone calls have been used to enhance the impact of brief interventions in the emergency department, there has been less number of studies describing the content of these boosters. We conducted a qualitative analysis of booster calls occurring two weeks after an initial Web-based intervention for drug use and intimate partner violence (IPV) among women presenting for emergency care, with the objective of identifying the following: progress toward goals set during the initial emergency department visit, barriers to positive change, and additional resources and services needed in order to inform improvements in future booster sessions. The initial thematic framework was developed by summarizing codes by major themes and subthemes; the study team collaboratively decided on a final thematic framework. Eighteen participants completed the booster call. Most of them described a therapeutic purpose for their drug use. Altering the social milieu was the primary means of drug use change; this seemed to increase isolation of women already in abusive relationships. Women described IPV as interwoven with drug use. Participants identified challenges in attending substance use treatment service and domestic violence agencies. Women with substance use disorders and in abusive relationships face specific barriers to reducing drug use and to seeking help after a brief intervention.

Physician Specialty Influences Care of Pelvic Inflammatory Disease.

BACKGROUND: CDC guidelines recommend Neisseria gonorrhoeae, Chlamydia trachomatis, and HIV testing, as well as specific antibiotic regimens in the diagnosis and treatment of pelvic inflammatory disease (PID), although latitude in adhering to these guidelines is common. We hypothesized that adherence to CDC guidelines for antibiotic regimens and laboratory testing, coverage for anaerobic organisms, and the use of diagnostic imaging techniques do not differ significantly between practitioners with emergency medicine (EM) versus obstetrics and gynecology (OB-GYN) training. MATERIALS AND METHODS: We conducted a retrospective medical chart review on patients (N = 351) discharged with a diagnosis of PID over a 20-month period at two neighboring emergency care facilities-one with EM-trained providers and the other with OB-GYN-trained providers. RESULTS: Adjusted for demographic predictors and chief complaint, there was no significant difference in adherence to N. gonorrhoeae and C. trachomatis antibiotic coverage guidelines between the two facilities (adjusted odds ratio [AOR] 1.34; 95% CI 0.66-2.74), using the OB-GYN facility in the numerator of the AOR. Anaerobic coverage was significantly more common at the OB-GYN facility (AOR 9.11; 95% CI 5.36-15.48). Both sites had very low rates of adherence to CDC laboratory testing guidelines with overall rates of adherence at 4.0% (95% CI 1.9%-5.9%). Utilization of diagnostic tests differed greatly between facilities: ultrasound utilization was 66.7% (95% CI 58.2%-75.2%) at the OB-GYN facility and 39.7% (95% CI 33.4%-45.9%) at the EM facility. CONCLUSIONS: The diagnostic pathway for PID and adherence to guidelines differ significantly depending on physician specialty and practice environment, suggesting the need for further standardization, perhaps with cross-disciplinary training.

BSAFER: A Web-based intervention for drug use and intimate partner violence demonstrates feasibility and acceptability among women in the emergency department.

BACKGROUND: Addressing violence along with drug use change goals is critical for women with coexisting intimate partner violence (IPV) and substance use disorders (SUDs). METHODS: This was an acceptability and feasibility study of BSAFER, a brief Web-based program and booster phone call addressing violence and drug use. A screening survey identified women with recent drug use and IPV in the emergency department (ED). Participants were randomized to BSAFER or a Web-based control program and booster call providing education about home fire safety. Program completion, usability, satisfaction, and motivational interviewing (MI) adherence were primary outcomes. Drug use and IPV outcomes were measured at baseline, 1 month, and 3 months. RESULTS: Forty women were enrolled (21 BSAFER, 19 control); 50% were nonwhite and mean age was 30 years. The most commonly used drugs were marijuana (88%) and cocaine (30%); 45% reported physical abuse, and 33% reported severe combined physical and sexual abuse. Thirty-nine (98%) completed the Web program, 30 (75%) completed the booster, and 29 (73%) completed the 3-month follow-up. Mean System Usability Scale (SUS) for the BSAFER Web program was 84 (95% confidence interval [CI]: 78-89) of 100; mean Client Satisfaction Questionnaire (CSQ-8) was 28 (95% CI: 26-29) of 32. MI adherence scores were high and similar for both the Web program and the booster. Both intervention and control groups had small mean decreases in weekly drug use days (0.7 vs. 1.5 days); participants using drugs other than marijuana demonstrated greater average reductions in drug use than those using marijuana only. CONCLUSIONS: An ED Web-based intervention for SUDs and IPV in women demonstrated feasibility and acceptability. Future studies will examine efficacy of the BSAFER program and investigate whether specific subgroups of drug using women may be most responsive to ED-based Web interventions.

Attitudes Toward Computer Interventions for Partner Abuse and Drug Use Among Women in the Emergency Department.

BACKGROUND: Drug use and partner abuse often coexist among women presenting to the emergency department (ED). Technology offers one solution to the limited time and expertise available to address these problems. AIMS: The aims of this study were to explore womens' attitudes about use of computers for screening and intervening in drug use and partner abuse. METHODS: Seventeen adult women with recent histories of partner abuse and drug use were recruited from an urban ED to participate in one-on-one semi-structured interviews. A coding classification scheme was developed and applied to the transcripts by two independent coders. The research team collaboratively decided upon a thematic framework and selected illustrative quotes. RESULTS: Most participants used computers and/or mobile phones frequently and reported high self-efficacy with them. Women described emotional difficulty and shame around partner abuse experiences and drug use; however, they felt that reporting drug use and partner abuse was easier and safer through a computer than face-to-face with a person, and that advice from a computer about drug use or partner abuse was acceptable and accessible. Some had very positive experiences completing screening assessments. However, participants were skeptical of a computer's ability to give empathy, emotional support or meaningful feedback. The ED was felt to be an appropriate venue for such programs, as long as they were private and did not supersede clinical care. CONCLUSIONS: Women with partner abuse and drug use histories were receptive to computerized screening and advice, while still expressing a need for the empathy and compassion of a human interaction within an intervention.

Systematic Review of ED-based Intimate Partner Violence Intervention Research.

INTRODUCTION: Assessment reactivity may be a factor in the modest results of brief interventions for substance use in the emergency department (ED). The presence of assessment reactivity in studies of interventions for intimate partner violence (IPV) has not been studied. Our objectives were to identify ED IPV intervention studies and evaluate the presence of a consistently positive effect on the control groups. METHODS: We performed a systematic search of electronic databases for English=language intervention studies addressing IPV in the ED published since 1990. Study selection and assessment of methodologic quality were performed by two independent reviewers. Data extraction was performed by one reviewer and then independently checked for completeness and accuracy by a second reviewer. RESULTS: Of 3,620 unique manuscripts identified by database search, 667 underwent abstract review and 12 underwent full-text review. Only three met full eligibility criteria; data on the control arm were available for two studies. In these two studies, IPV-related outcomes improved for both the experimental and control condition. CONCLUSION: The paucity of controlled trials of IPV precluded a robust evaluation for assessment reactivity. This study highlighted a critical gap in ED research on IPV.