Examining the Gender Gap in Emergency Medicine Research Publications.

STUDY OBJECTIVE: The objective of this study was to describe the proportion of female authors on original research articles and editorials across 4 emergency medicine journals from 2013 to 2019. A secondary objective was to examine the gender composition of middle authors in relation to the genders of their respective first and last authors. METHODS: In this observational study, we selected 4 journals in emergency medicine using the Journal of Citation Reports and prior literature to analyze genders of all authors from research articles and editorials published from January 2013 to September 2019. Reviewers identified author genders through web searches with matching academic qualifications or used a gender identification application programming interface to identify likelihood of male or female identity. The primary outcome was the proportion of female authors in each position. RESULTS: Selected publications included 2,980 original research articles with 18,224 authors (median 6, interquartile range [IQR] 4 to 8) and 433 editorials with 986 authors (median 2, IQR 1 to 2). Women occupied 34.9%, 24.3%, and 36.5% of first, last, and middle author positions on original research articles and 23.8%, 20.5%, and 34.2% of first, last, and middle author positions among editorials, respectively. Publications with female first and last authors (n=340 articles) had a larger proportion of female middle authors (49%, 634/1,290) compared to publications with male first and last authors (n=1667 articles, female middle authors 33% [2,215/6,771]). CONCLUSION: Over the 7 years examined, female authorship in these emergency medicine journals increased. A more pronounced gender gap exists in editorial authorship compared to research articles. On publications where the first and last author were women, a higher proportion of middle authors were women.

The Effect of Athletic Chest Protectors on the Performance of Manual and Mechanical CPR: A Simulation Study.

OBJECTIVES: Sudden cardiac arrest is a leading cause of death in athletes. Although athletes wear various athletic chest protectors (ACPs) to prevent commotio cordis (CC), cardiac arrest cases still occur. Although it is established that cardiopulmonary resuscitation (CPR) quality affects outcome, little research has evaluated the effect of ACPs on CPR compressions quality. This study aimed to observe whether: (1) ACPs impact depth, rate, and hand positioning of both bystander and LUCAS CPR. (2) LUCAS devices affect CPR performance compared with traditional compressions. METHODS: An observational, prospective, convenient sample of 26 emergency medicine residents performed CPR on a high-fidelity Laerdal mannequin, which recorded real-time performance data. Baseline CPR for 1- and 2-minute cycles, CPR on a mannequin wearing the ACP, and ACP removal time was recorded. LUCAS CPR performance was measured at baseline and over the ACP. RESULTS: Bystander CPR had a statistically significant difference in both hand placement and compression rate for baseline versus ACP compressions (85% vs 57%, P < 0.05; 138 vs 142, P < 0.05, respectively), but not in compression depth (51.08 vs 50.05 mm, P = 0.39). LUCAS CPR had no significant difference in CPR performance. Bystander versus LUCAS CPR had a significant difference in compression rate (138 vs 101, P < 0.01), but not in depth or hand placement. CONCLUSIONS: Athletic chest protectors significantly impacted hand placement during bystander CPR, which may diminish CPR quality. Considering ACP removal required only 5.4 seconds, removing the ACP before standard CPR may improve quality.

Agreement between actual and synthesized right-sided and posterior electrocardiographic leads in identifying ischemia.

OBJECTIVE: A 12-lead electrocardiogram (ECG) is the standard of care for chest pain patients. However, 12-lead ECGs have difficulty detecting ischemia of the right ventricle or posterior wall of the heart. New technology exists to mathematically synthesize these leads from a 12-lead ECG; however, this technology has not been evaluated in the emergency department (ED). We assessed the level of agreement between synthesized 18-lead ECGs and actual 18-lead ECGs in identifying ST elevations, ST depressions, and T wave inversions in ED patients. METHODS: Actual 12- and 18-lead ECGs were acquired and synthesized 18-lead ECGs were produced based on waveforms from 12-lead ECGs. A blinded cardiologist interpreted the actual and synthesized 18-lead ECGs to identify the presence of abnormalities. Using actual 18-lead ECGs as the reference, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and kappa of synthesized 18-lead ECGs in identifying abnormalities were determined. RESULTS: Data from 295 patients were analyzed. There was 100% agreement between synthesized 18-lead ECGs and actual 18-lead ECGs in identifying ST elevations and ST depressions (sensitivity, specificity, PPV, and NPV of 100%, and kappa of 1.00). Synthesized 18-lead ECGs had 95% sensitivity, 80% specificity, 97% PPV, and 70% NPV in identifying T wave inversions, when compared with actual 18-lead ECGs (kappa: 0.70). CONCLUSION: Synthesized 18-lead ECGs demonstrated 100% agreement with actual 18-lead ECGs in the identification of ST elevations and ST depressions and good agreement in the identification of T wave inversions in a sample of patients ED patients with complaints suspicious of cardiac origin.

The GAP-ED Project: Improving Care for Elderly Patients Presenting to the Emergency Department.

BACKGROUND: Older adults presenting to the emergency department (ED) represent a highly vulnerable patient population with complex conditions and multiple comorbidities. The introduction of a Geriatric and Palliative (GAP)-ED partnership may be an effective strategy to avoid unneeded admissions and improve outcomes for this population. OBJECTIVES: The primary objective was to decrease 30-day revisit and hospitalization rates in this population through identifying patients that could be safely sent home with connection to community resources. Secondary outcomes included achieving high patient and family satisfaction scores assessed through follow-up interviews. METHODS: The GAP-ED intervention included the placement of a Specialist in the ED to coordinate care for older adults presenting to the ED who were likely to be discharged home. Independent t-tests and chi-squared tests were used to assess for changes in outcomes between the intervention group and a blocked matched historical usual-care group. RESULTS: There was no significant difference in 30-day ED revisits between the two groups, but there was a statistically significant reduction in hospital admissions from these 30-day revisits. Patient and family satisfaction with the presence of the GAP-ED Specialist was high. CONCLUSION: The implementation of a GAP-ED partnership and use of a GAP-ED Specialist is an effective means of reducing hospitalization in older adults revisiting the ED.

Increased access to urgent care centers decreases low acuity diagnoses in a nearby hospital emergency department.

OBJECTIVE: We studied the impact four new urgent care centers (UCCs) had on a hospital emergency department (ED) in terms of overall census and proportion of low acuity diagnoses from 2009 to 2016. We hypothesized that low acuity medical problems frequently seen in UCCs would decrease in the ED population. Since Medicaid was not accepted at these UCCs, we also studied the Medicaid vs non-Medicaid discharged populations to see if there were some differences related to access to urgent care. METHODS: We conducted a retrospective review of computerized billing data. We included all patients from 2009 to 2016 who were seen in the ED. We used the Cochran-Armitage Trend Test to examine trends over time. RESULTS: As hypothesized, the proportion of ED patients with a diagnosis of pharyngitis decreased significantly over this time period from 1% to 0.6% (p < 0.0001). The rate of bronchitis in the total ED population also decreased significantly (0.5% to 0.13%, p < 0.0001).When we looked at the discharged patients with and without Medicaid, we found that significantly more Medicaid than non-Medicaid patients presented with pharyngitis to the ED with an increasing trend from 2009 to 2016: OR = 2.33, p < 0.0001. The overall census of the ED rose over the period 2009 to 2016 (80,478 to 85,278/year). Overall admission rates decreased significantly: 36.9% to 34.5% (p < 0.0001). CONCLUSION: With the introduction of four new urgent care centers (UCCs) within 5 miles of the hospital, the ED diagnoses of pharyngitis and bronchitis, two of the most common diagnoses seen in UCCs, decreased significantly. Significantly more Medicaid discharged patients presented to the ED with pharyngitis than in the non-Medicaid discharged group, likely because Medicaid patients had no access to UCCs.

Increased Emergency Department Hallway Length of Stay is Associated with Development of Delirium.

INTRODUCTION: Our study aimed to determine 1) the association between time spent in the emergency department (ED) hallway and the development of delirium and 2) the hospital location of delirium development. METHODS: This single-center, retrospective chart review included patients 18+ years old admitted to the hospital after presenting, without baseline cognitive impairment, to the ED in 2018. We identified the Delirium group by the following: key words describing delirium; orders for psychotropics, special observation, and restraints; or documented positive Confusion Assessment Method (CAM) screen. The Control group included patients not meeting delirium criteria. We used a multivariable logistic regression model, while adjusting for confounders, to assess the odds of delirium development associated with percentage of ED LOS spent in the hallway. RESULTS: A total of 25,156 patients met inclusion criteria with 1920 (7.6%) meeting delirium criteria. Delirium group vs. Control group patients spent a greater percentage of time in the ED hallway (median 50.5% vs 10.8%, P<0.001); had longer ED LOS (median 11.94 vs 8.12 hours, P<0.001); had more ED room transfers (median 5 vs 4, P<0.001); and had longer hospital LOS (median 5.0 vs 4.6 days, P<0.001). Patients more frequently developed delirium in the ED (77.5%) than on inpatient units (22.5%). The relative odds of a patient developing delirium increased by 3.31 times for each percent increase in ED hallway time (95% confidence interval, 2.85, 3.83). CONCLUSION: Patients with delirium had more ED hallway exposure, longer ED LOS, and more ED room transfers. Understanding delirium in the ED has substantial implications for improving patient safety.

SGK1 Is a Critical Component of an AKT-Independent Pathway Essential for PI3K-Mediated Tumor Development and Maintenance.

Activation of the PI3K-AKT signaling cascade is a common critical event during malignant transformation. In this study, we used thyroid gland epithelial cells and a series of genetically engineered mouse strains as model systems to demonstrate that, although necessary, AKT activation is not sufficient for PI3K-driven transformation. Instead, transformation requires the activity of the PDK1-regulated AGC family of protein kinases. In particular, SGK1 was found to be essential for proliferation and survival of thyroid cancer cells harboring PI3K-activating mutations. Notably, cotargeting SGK1 and AKT resulted in significantly higher growth suppression than inhibiting either PI3K or AKT alone. Overall, these findings underscore the clinical relevance of AKT-independent pathways in tumors driven by genetic lesions targeting the PI3K cascade. Cancer Res; 77(24); 6914-26. ©2017 AACR.

Xenobiotic Receptor-Mediated Regulation of Intestinal Barrier Function and Innate Immunity.

The molecular basis for the regulation of the intestinal barrier is a very fertile research area. A growing body of knowledge supports the targeting of various components of intestinal barrier function as means to treat a variety of diseases, including the inflammatory bowel diseases. Herein, we will summarize the current state of knowledge of key xenobiotic receptor regulators of barrier function, highlighting recent advances, such that the field and its future are succinctly reviewed. We posit that these receptors confer an additional dimension of host-microbe interaction in the gut, by sensing and responding to metabolites released from the symbiotic microbiota, in innate immunity and also in host drug metabolism. The scientific evidence for involvement of the receptors and its molecular basis for the control of barrier function and innate immunity regulation would serve as a rationale towards development of non-toxic probes and ligands as drugs.