Cost variation and revisit rate for adult patients with asthma presenting to the emergency department.

BACKGROUND: Asthma is common, resulting in 53 million emergency department (ED) visits annually. Little is known about variation in cost and quality of ED asthma care. STUDY OBJECTIVE: We sought to describe variation in costs and 7-day ED revisit rates for asthma care across EDs. Our primary objective was to test for an association between ED costs and the likelihood of a 7-day revisit for another asthma exacerbation. METHODS: We used the 2014 Florida State Emergency Department Database to perform an observational study of ED visits by patients ≥18 years old with a primary diagnosis of asthma that were discharged home. We compared patient and hospital characteristics of index ED discharges with and without 7-day revisits, then tested the association between ED revisits and index ED costs. Multilevel regression was performed to account for hospital-level clustering. RESULTS: In 2014, there were 54,060 adult ED visits for asthma resulting in discharge, and 1667 (3%) were associated with an asthma-related ED revisit within 7 days. Median cost for an episode of ED asthma care was $597 with an interquartile range of $371-980. After adjusting for both patient and hospital characteristics, lack of insurance was associated with higher odds of revisit (OR 1.42, 95% CI 1.18-1.71), while private insurance, female gender, and older age were associated with lower odds of revisit. Hospital costs were not associated with ED revisits (OR = 1.00; 95% CI 1.00-1.00). CONCLUSION: Hospital costs associated with ED asthma visits vary but are not associated with odds of ED revisit.

Assessing outcomes after partial and total tonsillectomy for sleep-disordered breathing in children using Clinical Assessment Score-15.

INTRODUCTION: The Clinical Assessment Score-15 (CAS-15) is an office-based tool for assessing the risk of sleep disordered breathing (SDB), a relatively common condition in the pediatric population. Change in CAS-15 following total tonsillectomy (TT) has been shown to have a large effect size, but it is unclear how it varies following partial intracapsular tonsillectomy (PIT). Thus, the objective of the present study is to evaluate the utility of the CAS-15 score in assessing the effectiveness of PIT and how this compares to change after TT. MATERIAL METHODS: Children ages 2-18 undergoing PIT (N = 16) or TT (N = 8) with or without adenoidectomy for SDB completed the CAS-15 before surgery and at their post-operative follow-up visit. Changes in CAS-15 score were assessed by paired t-test. The mean difference in CAS-15 change between PIT and TT was evaluated by unpaired t-test for unequal variances. Differences in participant characteristics were determined via unpaired t-test for unequal variances. RESULTS: Participants undergoing PIT did not differ significantly than those undergoing TT with regard to age, sex, BMI percentile, pre-op CAS-15 score or tonsil size, or admission rates following surgery (p > 0.05). The median follow-up after surgery was 5.2 (PIT) and 4.4 (TT) weeks. CAS-15 score improved significantly following PIT (42.8 ± 12.3 vs. 9.4 ± 5.6, p < 0.0001) and TT (45.5 ± 13.3 vs. 7.9 ± 5.8, p < 0.0002). The decrease in CAS-15 for PIT did not differ from TT (33.3 ± 11.8 vs. 37.6 ± 15.0, p > 0.49). DISCUSSION: CAS-15 decreases drastically following PIT and TT, indicating significant improvement of SDB symptoms. Because the change in CAS-15 after PIT was similar to TT, PIT may be preferred due to the decreased morbidity of the procedure. Given the cost, time required, inconvenience, and other limitations of overnight polysomnography (PSG), which is the gold standard method of diagnosing SDB, CAS-15 may be a suitable replacement or adjunct for the assessment of SDB following PIT in addition to TT.

Predictors of sinonasal disease onset, progression, and severity in pediatric cystic fibrosis patients.

PURPOSE: Pediatric cystic fibrosis (CF) patients have a variable onset, severity, and progression of sinonasal disease. The objective of this study was to identify genotypic and phenotypic factors associated with CF that are predictive of sinonasal disease, recurrent nasal polyposis, and failure to respond to standard treatment. METHODS: A retrospective case series was conducted of 30 pediatric patients with CF chronic rhinosinusitis with and without polyps. Patient specific mutations were divided by class and categorized into high risk (Class I-III) and low risk (Class IV-V). Severity of pulmonary and pancreatic manifestations of CF, number of sinus surgeries, nasal polyposis and recurrence, age at presentation to Otolaryngology, and Pediatric Sinonasal Symptom Survey (SN-5)/Sinonasal Outcome Test (SNOT-22) scores were examined. RESULTS: 27/30 patients (90%) had high risk mutations (Class I-III). 21/30 (70.0%) patients had nasal polyposis and 10/30 (33.3%) had recurrent nasal polyposis. Dependence on pancreatic enzymes (23/27, 85.2% vs 0/3, 0.0%, p = 0.009) and worse forced expiratory volumes (FEV1%) (mean 79, SD 15 vs mean 105, SD 12, p = 0.009) were more common in patients with high risk mutations. Insulin-dependence was more common in those with recurrent polyposis (5/10, 50% vs 2/20, 10%, p = 0.026). There was no statistical difference in ages at presentation, first polyps, or sinus surgery, or in polyposis presence, recurrence, or extent of sinus surgery based on high risk vs. low risk classification. CONCLUSION: CF-related diabetes was associated with nasal polyposis recurrence. Patients with more severe extra-pulmonary manifestations of CF may also be at increased risk of sinonasal disease.

Effect of Interpolated Questions on Podcast Knowledge Acquisition and Retention: A Double-Blind, Multicenter, Randomized Controlled Trial.

STUDY OBJECTIVE: We determine whether interpolated questions in a podcast improve knowledge acquisition and retention. METHODS: This double-blinded controlled trial randomized trainees from 6 emergency medicine programs to listen to 1 of 2 versions of a podcast, produced de novo on the history of hypertension. The versions were identical except that 1 included 5 interpolated questions to highlight educational points (intervention). There were 2 postpodcast assessments, 1 within 48 hours of listening (immediate posttest) and a second 2 to 3 weeks later (retention test), consisting of the same 15 multiple-choice questions, 5 directly related to the interpolated questions and 10 unrelated. The primary outcome was the difference in intergroup mean assessment scores at each point. A sample size was calculated a priori to identify a significant interarm difference. RESULTS: One hundred thirty-seven emergency medicine trainees were randomized to listen to a podcast, 69 without interpolated questions (control) and 68 with them (intervention). Although no significant difference was detected at the immediate posttest, trainees randomized to the interpolated arm had a significantly higher mean score on the retention test, with a 5.6% absolute difference (95% confidence interval 0.2% to 10.9%). For the material covered by the interpolated questions, the intervention arm had significantly higher mean scores on both the immediate posttest and retention tests, with absolute differences of 8.7% (95% confidence interval 1.6% to 15.8%) and 10.1% (95% confidence interval 2.8% to 17.4%), respectively. There was no significant intergroup difference for noninterpolated questions. CONCLUSION: Podcasts containing interpolated questions improved knowledge retention at 2 to 3 weeks, driven by the retention of material covered by the interpolated questions. Although the gains may be modest, educational podcasters may improve knowledge retention by using interpolating questions.

Syncope on presentation is a surrogate for submassive and massive acute pulmonary embolism.

INTRODUCTION: There are conflicting data regarding the prognostic value of syncope in patients with acute pulmonary embolism (APE). METHODS: We retrospectively reviewed data of 552 consecutive adults with computed tomography pulmonary angiogram-confirmed APE to determine the correlates and outcome of the occurrence of syncope at the time of presentation. RESULTS: Among 552 subjects with APE (mean age 54years, 47% men), syncope occurred in 12.3% (68/552). Compared with subjects without syncope, those with syncope were more likely to have admission systolic blood pressure<90mmHg (odds ratio (OR) 5.788, P<0.001), and an oxygen saturation<88% on room air (OR 5.560, P<0.001), right ventricular dilation (OR 2.480, P=0.006), right ventricular hypokinesis (OR 2.288, P=0.018), require mechanical ventilation for respiratory failure (OR 3.152, P=0.014), and more likely to receive systemic thrombolysis (OR 4.722, P=0.008). On multivariate analysis, syncope on presentation was an independent predictor of a massive APE (OR 2.454, 95% CI 1.109-5.525, P=0.03) after adjusting for patients' age, sex, requirement of antibiotics throughout hospitalization, peak serum creatinine, admission oxygen saturation<88% and admission heart rate>100bpm. There was no difference in mortality in cases with APE with or without syncope (P=0.412). CONCLUSION: Syncope at the onset of pulmonary embolization is a surrogate for submassive and massive APE but is not associated with higher in-hospital mortality.

Pediatric Cervical Lymphadenopathy.

Cervical lymphadenopathy affects as many as 90% of children aged 4 to 8 years. With so many children presenting to doctors' offices and emergency departments, a systematic approach to diagnosis and evaluation must be considered. In the following review, we aim to provide the pediatric clinician with a general framework for an appropriate history and physical examination, while giving guidance on initial diagnostic laboratory testing, imaging, and potential need for biopsy. The most common cause of cervical lymphadenopathy in the pediatric population is reactivity to known and unknown viral agents. The second most common cause includes bacterial infections ranging from aerobic to anaerobic to mycobacterial infections. Malignancies are the most concerning cause of cervical lymphadenopathy.The explosion in the use of ultrasonography as a nonradiating imaging modality in the pediatric population has changed the diagnostic algorithm for many clinicians. We aim to provide some clarity on the utility and shortcomings of the imaging modalities available, including ultrasonography, computed tomography, and magnetic resonance imaging.

How Do We Balance the Long-Term Health of a Patient With the Short-Term Risk to the Physician?

BACKGROUND: There is a wide variation in practice patterns among emergency medicine physicians; many factors weigh into the medical decision-making process including the health of the patient as well as short-term risk to the physician. OBJECTIVE: The objective of our discussion is to illustrate specific scenarios where medical decisions are focused on the physician's short-term risk, then to propose an approach to shifting the balance to the patient's long-term health. METHODS: Using recent data on the evaluation, disposition, and outcomes of patients with low-risk chest pain in the emergency department, we calculate the risk of outpatient evaluation compared to the common practice of admission or observation. RESULTS: Patients with low-risk chest pain and negative initial evaluation in the emergency department with 2 normal cardiac biomarkers, normal vital signs, and non-ischemic, interpretable ECGs, have an extremely low-risk of a short term clinically relevant adverse cardiac event. There is a suggestion of a higher patient risk from admission, prompting consideration that continued evaluation of the chest pain as an outpatient may be safer than admission or observation. CONCLUSION: A test/intervention should be done if the risk of a missed diagnosis or adverse outcome is greater that the risk of the test/intervention. Involving the patient in the decision-making process may help to shift the management balance from the physician's short-term concern of their own risk, to the patient's long-term health.

Changing epistemologies under conditions of social change in two Arab communities in Israel.

The study of epistemic thinking focuses on how people understand and coordinate objective and subjective aspects of knowing and make sense of multiple and discrepant knowledge claims. Typically described in terms of normative development, cross-cultural studies show differences in epistemic development and characteristics of epistemic thinking. This study focuses on within-culture variations of epistemic thinking, with the assumption that social change will produce changes in development. Arab society in Israel has undergone notable change over the last half century. In this cross-sectional research design, cross-generational comparison and rural-urban comparison were used as proxies for longitudinal social change. Three generations of Muslim Arab women in a village in Israel (20 adolescents, 20 mothers and 20 grandmothers) and 20 Muslim Arab adolescents from a large, mixed city in the same region responded to six dilemmas invoking epistemic thinking. Village adolescents were more subjectivist than their mothers and grandmothers. Sociodemographic characteristics representing greater exposure to diverse people and ideas accounted for generational differences. Both urban and rural adolescents tended towards subjectivist perspectives, and they did not differ. Parents' education levels emerged as the sociodemographic variables most consistently related to epistemic thinking. Epistemic thinking mediated the relationship between generation and gender role/cross-sex relation values.

The effects of sociocultural changes on epistemic thinking across three generations in Romania.

When people experience abrupt social change, from less education to more, from less technology use to more, from a homogeneous to a heterogeneous social environment, can their epistemic thinking adapt? When divergent opinions suddenly come to be valued, does epistemic thinking shift from absolute to more relativistic? We investigate whether and how these sociocultural shifts have produced changes in epistemic thinking in Romania, a country that fell from communism and started democracy in 1989. Our 147 participants were from Timisoara and fell into three groups, each experiencing the shift at a different point in their development: (i) born in 1989 or later, experiencing capitalism and democracy throughout life (N = 51); (ii) 15- to 25-years-old in 1989 when communism fell (N = 52); (iii) 45 or older in 1989 when communism fell (N = 44). As hypothesized, absolutist thinking was less frequent and evaluativist thinking, a relativistic epistemological mode, was more frequent the earlier in life a cohort was exposed to the post-communist environment in Romania. As predicted, younger cohorts experienced greater exposure to education, social media, and international travel. Greater exposure to education and social media were significant factors in the decline of absolutist thinking and the rise of evaluativist thinking across the generations.

Teaching Tracheostomy Tube Changes: Comparison of Operant Learning Versus Traditional Demonstration.

Objective: Tracheostomy tube change is a multistep skill that must be performed rapidly and precisely. Despite the critical importance of this skill, there is wide variation in teaching protocols. Methods: An innovative operant conditioning teaching methodology was employed and compared to traditional educational techniques. Medical student volunteers at a tertiary care academic institution (Albert Einstein College of Medicine) were recruited and randomly distributed into 2 groups: operant vs traditional (control). Following the educational session, each group was provided with practice time and then asked to perform 10 tracheostomy tube changes. Performance was recorded and scored by blinded raters using deidentified video recordings. Results: The operant learning group (OLG) demonstrated greater accuracy in performing a tracheostomy tube change than the traditional demonstration group. Twelve of 13 operant learners performed the skill accurately each time compared to 3 of 13 in the traditional group (P = 0.002). The median lesson time was longer for the OLG (535 seconds) than for the traditional group, (200 seconds P < 0.001). The average time per tracheostomy change was not significantly different between the 2 groups (operant learners mean 7.1 seconds, traditional learners mean 7.5 seconds, P = 0.427). Discussion: Although the operant conditioning methodology necessarily requires a greater time to teach, the results support this methodology over traditional learning modalities as it enhances accuracy in the acquired skill. Operant learning methodology is under consideration for other skills and education sessions in our program. Future steps include the application and adaptation of this education model to students and residents in other settings and fields. Implications for Practice: Operant learning is effective for teaching multistep skills such as tracheostomy tube changes with decreased error rates.

Assessment of Implicit Gender Bias During Evaluation of Procedural Competency Among Emergency Medicine Residents.

Importance: Gender disparities exist throughout medicine. Recent studies have highlighted an attainment gap between male and female residents in performance evaluations on Accreditation Council for Graduate Medical Education (ACGME) milestones. Because of difficulties in blinding evaluators to gender, it remains unclear whether these observed disparities are because of implicit bias or other causes. Objective: To estimate the magnitude of implicit gender bias in assessments of procedural competency in emergency medicine residents and whether the gender of the evaluator is associated with identified implicit gender bias. Design, Setting, and Participants: A cross-sectional study was performed from 2018 to 2020 in which emergency medicine residency faculty assessed procedural competency by evaluating videos of residents performing 3 procedures in a simulated environment. They were blinded to the intent of the study. Proceduralists were filmed performing each procedure from 2 different viewpoints simultaneously by 2 different cameras. One was a gender-blinded (ie, hands-only) view, and the other a wide-angled gender-evident (ie, whole-body) view. The faculty evaluators viewed videos in a random order and assessed procedural competency on a global rating scale with extensive validity evidence for the evaluation of video-recorded procedural performance. Main Outcomes and Measures: The primary outcome was to determine if there was a difference in the evaluation of procedural competency based on gender. The secondary outcome was to determine if there was a difference in the evaluations based on the gender of the evaluator. Results: Fifty-one faculty evaluators enrolled from 19 states, with 22 male participants (43.1%), 29 female participants (56.9%), and a mean (SD) age of 37 (6.4) years. Each evaluator assessed all 60 procedures: 30 gender-blinded (hands-only view) videos and 30 identical gender-evident (wide angle) videos. There were no statistically significant differences in the study evaluators' scores of the proceduralists based on their gender, and the gender of the evaluator was not associated with the difference in mean scores. Conclusions and Relevance: In this study, we did not identify a difference in the evaluation of procedural competency based upon the gender of the resident proceduralist or the gender of the faculty evaluator.

High-Risk Medicolegal Conditions in Pediatric Emergency Medicine.

The top 5 reasons for pediatric malpractice are cardiac or cardiorespiratory arrest, appendicitis, disorder of male genital organs, encephalopathy, and meningitis. Malpractice is most likely to result from an "error in diagnosis." Claims involving a "major permanent injury" were more likely to pay out money, but of all claims, only 30% result in a monetary pay out. Consideration of "high-risk misses" may help to direct a history, examination, testing, and discharge instructions.

Interpretive theory of mind and empathic prosocial moral reasoning.

Theory of mind (ToM) is seen as fundamental in development of social understanding. The study proposes that interpretive theory of mind (iToM), which follows ToM attainment, underlies important shifts towards mature social understanding. With ToM found to predict the needs orientation in prosocial moral reasoning (PMR), we hypothesized that iToM, unlike ToM, would account for PMR orientations requiring empathic reasoning. Those with iToM recognize the role of subjective processes, such as interpretation, in knowing. They can invoke others' subjective processes, not just their physical perspectives, in explaining others' decisions. A study with 225 7- to 11-year-old children (Mage  = 9.04, SD = 0.91) found that iToM, but not ToM, predicted empathic and internalized values PMR orientations when controlling for age, emotion understanding and inhibitory control. These findings show that iToM attainment plays a unique role in developing social understanding such as reflected in empathic reasoning-based PMR orientations.

Aerosol and Droplet Risk of Common Otolaryngology Clinic Procedures.

OBJECTIVES: Define aerosol and droplet risks associated with routine otolaryngology clinic procedures during the COVID-19 era. METHODS: Clinical procedures were simulated in cadaveric heads whose oral and nasal cavities were coated with fluorescent tracer (vitamin B2) and breathing was manually simulated through retrograde intubation. A cascade impactor placed adjacent to the nares collected generated particles with aerodynamic diameters ≤14.1 µm. The 3D printed models and syringes were used to simulate middle and external ear suctioning as well as open suctioning, respectively. Provider's personal protective equipment (PPE) and procedural field contamination were also recorded for all trials using vitamin B2 fluorescent tracer. RESULTS: The positive controls of nebulized vitamin B2 produced aerosol particles ≤3.30 µm and endonasal drilling of a 3D model generated particles ≤14.1 µm. As compared with positive controls, aerosols and small droplets with aerodynamic diameter ≤14.1 µm were not detected during rigid nasal endoscopy, flexible fiberoptic laryngoscopy, and rigid nasal suction of cadavers with simulated breathing. There was minimal to no field contamination in all 3 scenarios. Middle and external ear suctioning and open container suctioning did not result in any detectable droplet contamination. The clinic suction unit contained all fluorescent material without surrounding environmental contamination. CONCLUSION: While patients' coughing and sneezing may create a baseline risk for providers, this study demonstrates that nasal endoscopy, flexible laryngoscopy, and suctioning inherently do not pose an additional risk in terms of aerosol and small droplet generation. An overarching generalization cannot be made about endoscopy or suctioning being an aerosol generating procedure. LEVEL OF EVIDENCE: 3.