Using the electronic medical record to increase testing for HIV and hepatitis C virus in an Appalachian emergency department.

BACKGROUND: The ongoing Appalachian opioid epidemic has led to increasing hepatitis C virus (HCV) infections among people who inject drugs (PWID), and Human Immunodeficiency Virus (HIV) outbreaks have been observed. The primary aim of this study was to assess the potential increase in screening for HIV and HCV in an academic central Appalachian emergency department (ED) through the use of Best Practice Alerts (BPAs) in the electronic medical record (EMR). A secondary aim was to assess for an increase in linkage to care using patient navigators. METHODS: EMR algorithms based on current Centers for Disease Control and Prevention HIV and HCV testing recommendations were created that triggered Best Practice Alerts (BPAs), giving providers a one-click acceptance option to order HIV and/or HCV testing. Placards were placed in care areas, informing patients of the availability of routine screening. Patient navigators facilitated linkage to care for seropositive patients. RESULTS: The BPA appeared 58,936 times on 21,098 patients eligible for HIV screening and 24,319 times on 11,989 patients eligible for HCV screening over a one-year period. Of those, 7106 (33.7%) patients were screened for HIV and 3496 (29.2%) patients were screened for HCV, for an overall testing increase of 2269% and 1065% for HIV and HCV, respectively. Linkage to care increased by 15% for HIV to 100, and 14% for HCV to 64%. CONCLUSION: HIV and HCV screening and linkage to care were increased in an academic ED setting in central Appalachia using EMR alerts. This approach could be utilized in multiple ambulatory settings. Increased testing and earlier linkage to care may help combat the current injection drug use-related HCV epidemic and avoid additional HIV outbreaks.

Forget-me-not: Lemierre's syndrome, a case report.

Background: Familiarity breeds complacency. One case of sore throat can start to sound like another. However, even common viral and bacterial infections can lead to serious sequelae. Clinicians cannot make a diagnosis if they do not consider it in their differential.Case: The presentation - and subsequent hospitalization - of a septic 19 year-old male college student is described. Despite brief interval improvement, he became hypoxic one week after developing a sore throat and was ultimately diagnosed with Lemierre's syndrome (septic thrombophlebitis of the internal jugular vein) via blood cultures and advanced imaging.Conclusions: Though rare, Lemierre's syndrome carries a high mortality rate. It should be considered an emergent complication of head and neck infections, particularly in young adults.

Initially concealed concussion lowers in-game performance of NCAA Division I football players: a case series.

Objectives: Many athletes conceal concussion symptoms to continue to play. If athletes and coaches knew that performance drops significantly after a concussion, in turn hurting the team, athletes may be more prone to report concussion symptoms. The objective of our research was to report three cases that support this performance decline after an undisclosed concussion. Methods: This is a case series of three NCAA Division I football players who did not immediately report their concussions. The play in which the concussion occurred was identified via video review then the players' pre and post-injury performance grades, as scored by their position coaches, were recorded. Additional data regarding their performance in other games and their concussion assessments were also recorded. Results: Three injuries were identified and reviewed. Player 1 had a pre-injury performance score of 76/100 with a post-injury score of 47/100. This was a drop of 29 points for a decrease in his in-game performance by 38%. Player 2 had a pre-injury score of 100/100 with a post-injury score of 60/100. This was a drop of 40 points or a 40% decrease in his in-game performance. Player 3 had a pre-injury score of 67/100 and a post-injury score of 43/100 for a drop of 24 points or a 36% decrease in his in-game performance. Conclusions: We reported three college football players who suffered concussions but did not immediately disclose their symptoms. Each had a marked decrease in performance grades after their concussion. If the performance effect of a concussion can be quantified, athletes and coaches may begin to change their mind-set that a concussion can be 'played through.' This case series should serve as a first step in quantifying concussion effects on performance.

Centers for Disease Control and Prevention Recommendations for Hepatitis C Testing: The Need to Adopt Universal Screening in an Appalachian Emergency Department.

BACKGROUND: The Centers for Disease Control and Prevention recommends screening baby boomers and high-risk patients for hepatitis C virus (HCV); however, the incidence of HCV is rapidly increasing among younger populations, and screening is limited by access to care and risk factor assessment. The purpose of this study was to evaluate characteristics of HCV antibody-positive (Ab+) and ribonucleic acid (RNA)-confirmed-positive patients identified via two screening models in an Appalachian emergency department (ED). METHODS: This was a retrospective cohort study of patients who screened HCV Ab+ in the ED from January 1 to October 31, 2018. Data were extracted, and comparative analyses were conducted between the risk-based and the universal screening models. RESULTS: Overall, 444 patients screened HCV Ab+, with a median age of 39 years. From January to May 2018, the risk factor model identified 126 HCV Ab+ patients out of 3,014 screened (4%), whereas from June to October 2018, the universal model identified 318 HCV Ab+ patients out of 5,407 screened (6%; p < 0.001). A consistently large proportion of diagnoses were new (71%). There was no statistically significant decrease between the RNA-confirmed-positive patients during the risk factor model (76, 60%) and universal model (186, 58%) time periods (p = 0.72). The models had high rates of reported intravenous drug use, and the universal screening adoption was modest at 33%. CONCLUSION: This study was the first to present characteristics of HCV Ab+ and RNA-confirmed-positive patients identified during the transition to a universal screening model in an Appalachian ED. Most diagnoses were new regardless of screening model, but more patients screened HCV Ab+, and a similar proportion were RNA-confirmed-positive, under the universal model. Given that adoption of universal screening was modest, and risk factors remained similar, future research should investigate how to more effectively implement a universal screening model on a wider scale to identify early infections.

Gender Differences in Sexual Health Knowledge Among Emerging Adults in Acute-Care Settings.

CONTEXT: Emerging adults (aged 18-25 years) are increasingly seeking evaluation in acute-care clinics for sexual health-related concerns to receive treatment and education. OBJECTIVE: To assess the sexual health knowledge of emerging adult patients by gender at acute-care health centers. METHODS: A prospective, self-administered survey was distributed from August 2014 through May 2016 to patients aged 18 to 24 years who presented to 1 of 4 acute-care locations in a university town in a mid-Atlantic state. Analyses included descriptive statistics, as well as χ2 and Fisher exact test crosstabulations to determine differences between genders. RESULTS: A total of 388 patients aged 18 to 24 years responded to the survey, with 81% of the sample identifying themselves as students and 64% identifying as female. Women were more likely than men to state that they sought sexual health advice at an urgent-care or walk-in clinic (70.3% vs 52.1%; P<.05). Human papillomavirus knowledge among women was significantly greater than among men (P<.0001). Open-ended responses were widespread and often incorrect, specifically with regard to the human papillomavirus vaccine and routine testing for sexually transmitted infections. CONCLUSION: Women were more knowledgeable about sexual health than men. However, both genders were not as knowledgeable overall on sexual health topics as hypothesized. A stronger emphasis on gender-specific programming for sexual health education via community- and school-based programs throughout adolescence, supplemented with greater emphasis on routine preventive health care during adolescence and emerging adulthood, is encouraged.

Point-of-care Ultrasound Diagnosis of Tennis Leg.

A 38-year-old male presented with left calf pain after a fall while skiing. Physical examination revealed tenderness over the gastrocnemius with a palpable mass and pain with resisted plantar flexion. Point-of care-ultrasound (POCUS) of the gastrocnemius was consistent with a muscle rupture, and we made a diagnosis of tennis leg. The patient was instructed to rest for two weeks, followed by a home rehabilitation program, and he was able to return to his normal activities. Here we present a case of tennis leg quickly and accurately diagnosed with POCUS, negating the need for additional advanced imaging.

Emergency Department Visits for Sexual Assault by Emerging Adults: Is Alcohol a Factor?

INTRODUCTION: Emerging adults (18-25 years of age) are at increased risk for sexual assault. There is little Emergency Department (ED) data on sexual assaults that involve alcohol among this population. The purpose of this study was to analyze ED visits for sexual assault and determine if alcohol consumption by the patient was noted. METHODS: This study was a retrospective chart review of patients aged 18-25 presenting to an ED in a college town over a four-year period. Extracted variables included age, gender, delay in seeking care, sexual assault nurse examiner (SANE) evaluation, and alcohol consumption by the patient. For analysis of alcohol use, cases were categorized as ages < 21 and ≥ 21. RESULTS: There were 118 patients who presented to the ED from 2012 to 2015. The mean age of the cohort was 20 years, and almost 70% of visits were among those < 21. Of those aged < 21, 74% reported alcohol consumption, in contrast to 48% of those ≥ 21 (p = 0.055). Of those reporting alcohol use, 36% were evaluated on the day of the assault compared to 61% of those not reporting alcohol (p=0.035). CONCLUSION: This study found that ED visits for sexual assault in emerging adults were more common in younger patients. Alcohol use occurred more frequently with patients under the legal drinking age, and presentation was also more likely to be delayed. The relationship between sexual assault and alcohol use should underscore primary prevention efforts in emerging adult populations.

Emergency department visits by pediatric patients sustained as a passenger on a motorcycle.

OBJECTIVE: Currently only 5 out of the 50 states in the United States have laws restricting the age of passengers permitted to ride on a motorcycle. This study sought to characterize the visits by patients under the age of 16 to U.S. emergency departments (EDs) for injuries sustained as a passenger on a motorcycle. METHODS: In this retrospective cohort study, data were obtained from the Nationwide Emergency Department Sample (NEDS) for the years 2006 to 2011. Pediatric patients who were passengers on a motorcycle that was involved in a crash were identified using International Classification of Diseases, Ninth Revision (ICD-9) External Cause of Injury codes. We also examined gender, age, disposition, regional differences, common injuries, and charges. RESULTS: Between 2006 and 2011 there were an estimated 9,689 visits to U.S. EDs by patients under the age of 16 who were passengers on a motorcycle involved in a crash. The overall average patient age was 9.4 years, and they were predominately male (54.5%). The majority (85%) of these patients were treated and released. The average charges for discharged patients were $2,116.50 and amounted to roughly $17,500,000 during the 6 years. The average cost for admission was $51,446 per patient and totaled over $54 million. The most common primary injuries included superficial contusions; sprains and strains; upper limb fractures; open wounds of head, neck, and trunk; and intracranial injuries. CONCLUSION: Although there were only about 9,700 visits to U.S. EDs for motorcycle crashes involving passengers less than 16 years old for 2006 to 2011, the total cost of visits that resulted in either ED discharge or hospital admission amounted to over $71 million.

Implementation of a Collaborative HIV and Hepatitis C Screening Program in Appalachian Urgent Care Settings.

INTRODUCTION: With the current hepatitis C (HCV) epidemic in the Appalachian region and the risk of human immunodeficiency virus (HIV) co-infection, there is a need for increased secondary prevention efforts. The purpose of this study was to implement routine HIV and HCV screenings in the urgent care setting through the use of an electronic medical record (EMR) to increase a provider's likelihood of testing eligible patients. METHODS: From June 2017 through May 2018, EMR-based HIV and HCV screenings were implemented in three emergency department-affiliated urgent care settings: a local urgent care walk-in clinic; a university-based student health services center; and an urgent care setting located within a multi-specialty clinic. EMR best practice alerts (BPA) were developed based on Centers for Disease Control and Prevention (CDC) guidelines and populated on registered patients who qualified to receive HIV and/or HCV testing. Patients were excluded from the study if they chose to opt out from testing or the provider deemed it clinically inappropriate. Upon notification of a positive HIV and/or HCV test result through the EMR, patient navigators (PNs) were responsible for linking patients to their first medical appointment. RESULTS: From June 2017 through May 2018, 48,531 patients presented to the three urgent care clinics. Out of 27,230 eligible patients, 1,972 patients (7.2%) agreed to be screened for HIV; for HCV, out of 6,509 eligible patients, 1,895 (29.1%) agreed to be screened. Thirty-one patients (1.6%) screened antibody-positive for HCV, with three being ribonucleic acid confirmed positives. No patients in either setting were confirmed positive for HIV; however, two initially screened HIV-positive. PNs were able to link 17 HCV antibody-positive patients (55%) to their first appointment, with the remainder having a scheduled future appointment. CONCLUSION: Introducing an EMR-based screening program is an effective method to identify and screen eligible patients for HIV and HCV in Appalachian urgent care settings where universal screenings are not routinely implemented.

Testicular Rupture: A Tough Nut to Crack.

Blunt scrotal injury represents a diagnostic dilemma for emergency physicians (EP). Consequently, point-of-care ultrasound (POCUS) has emerged as a tool for early investigation of the acute scrotum in the emergency department. We describe a case where an EP used scrotal POCUS to immediately visualize the loss of testicular contour and underlying heterogeneous parenchyma to rapidly make the diagnosis of testicular rupture in a young male presenting with scrotal trauma. The use of POCUS in this case expedited therapy, likely improving the patient's outcome. To our knowledge, this is the first detailed description of testicular rupture diagnosed with POCUS by an EP.