Decontamination efficacy of common liquid disinfectants against non-spore-forming biological agents in soil matrices.

AIMS: The purpose of this study was to evaluate decontamination efficacy, within three soil types, against Yersinia pestis, Burkholderia pseudomallei, and the Venezuelan Equine Encephalitis virus (VEEV). METHODS AND RESULTS: One of three liquid disinfectants (dilute bleach, Virkon-S or Klozur One) was added to three soil types (sand, loam, or clay) and allowed contact for four pre-spike durations: 0, 15, 30 and 60 min. Y. pestis, B. pseudomallei, or VEEV was then spiked into the soil (10 microliters or approx. 1 × 107  CFU or PFU into 1 g soil) and decontamination efficacy assessed at post-spike contact times of 10 or 60 min at ambient environmental conditions. Across all soil types, sandy soil resulted in the least quenching to all three disinfectants tested as shown by sustained decontamination efficacy across all pre-spike and post-spike timepoints. Clay and loam soil types exhibited quenching effects on the hypochlorite and peroxygen based disinfectants (dilute bleach and Virkon S) and in general resulted in decreased efficacy with increased pre-spike contact time. The sodium persulfate (Klozur One) performance was the most consistent across all soil types and pre-spike contact times, resulting in greater efficacy with increased post-spike time. CONCLUSIONS: Liquid disinfectants can provide high levels of decontamination in soil for both viral and non-spore-forming bacterial select agents. Hypochlorite and peroxygen based disinfectants used in soils containing higher organic content (loam or clay) may require extended contact times or re-application of liquid disinfectant, in as little as 15 min of application, to achieve a 6-log reduction. SIGNIFICANCE AND IMPACT OF THE STUDY: These results provide information for the performance of three disinfectants in soil against non-spore-forming select agents. These data may aid response decision makers following a biological contamination incident by informing the selection of disinfectant as well as the re-application time to achieve effective site remediation.

In-situ microwave-assisted catalytic upgrading of heavy oil: Experimental validation and effect of catalyst pore structure on activity.

In-situ combustion alone may not provide sufficient heating for downhole, catalytic upgrading of heavy oil in the Toe-to-Heel Air Injection (THAI) process. In this study, a new microwave heating technique has been proposed as a strategy to provide the requisite heating. Microwave technology is alone able to provide rapid heating which can be targeted at the catalyst packing and/or the incoming oil in its immediate vicinity. It was demonstrated, contrary to previous assertions, that heavy oil can be heated directly with microwaves to 425 °C, which is the temperature needed for successful catalytic upgrading, without the need for an additional microwave susceptor. Upgrading of >3.2° API points, a reduction in viscosity to less than 100 cP, and >12% reduction in sulfur content was achieved using commercially available hydrodesulfurization (HDS) catalyst. The HDS catalyst induced dehydrogenation, with nearly 20% hydrogen detected in the gas product. Hence, in THAI field settings, part of the oil-in-place could be sacrificed for dehydrogenation, with the produced hydrogen directed to aid hydrodesulfurization and improve upgrading. Further, this could provide a route for downhole hydrogen production, which can contribute to the efforts towards the hydrogen economy. A single, unified model of evolving catalyst structure was developed. The model incorporated the unusual gas sorption data, computerized x-ray tomography and electron microprobe characterization, as well as the reaction behavior. The proposed model also highlighted the significant impact of the particular catalyst fabrication process on the catalytic activity.

Decontamination of soil contaminated at the surface with Bacillus anthracis spores using dry thermal treatment.

In the event of a large, aerosol release of Bacillus anthracis spores in a major metropolitan area, soils and other outdoor materials may become contaminated with the biological agent. A study was conducted to assess the in-situ remediation of soil using a dry thermal treatment approach to inactivate a B. anthracis spore surrogate inoculated into soil samples. The study was conducted in two phases, using loam, clay and sand-based soils, as well as biological indicators and spore-inoculated stainless-steel coupons. Initial experiments were performed in an environmental test chamber with temperatures controlled between 80 and 110 °C, with and without added humidity, and with contact times ranging from 4 h to 7 weeks. Tests were then scaled up to assess the thermal inactivation of spores in small soil columns, in which a heating plate set to 141 °C was applied to the soil surface. These column tests were conducted to assess time requirements to inactivate spores as a function of soil depth and soil type. Results from the initial phase of testing showed that increasing the temperature and relative humidity reduced the time requirements to achieve samples in which no surrogate spores were detected. For the test at 80 °C with no added humidity, 49 days were required to achieve soil samples with no spores detected in clay and loam. At 110 °C, 24 h were required to achieve samples in which no spores were detected. In the column tests, no spores were detected at the 2.5 cm depth at four days and at the 5.1 cm depth at 21 days, for two of the three soils. The experiments described in the study demonstrate the feasibility of using dry thermal techniques to decontaminate soils that have been surficially contaminated with B. anthracis spores.

Evaluating the Environmental Persistence and Inactivation of MS2 Bacteriophage and the Presumed Ebola Virus Surrogate Phi6 Using Low Concentration Hydrogen Peroxide Vapor.

Ebola virus (EBOV) disease outbreaks, as well as the ability of EBOV to persist in the environment under certain conditions, highlight the need to develop effective decontamination techniques against the virus. We evaluated the efficacy of hydrogen peroxide vapor (HPV) to inactivate MS2 and Phi6 bacteriophages, the latter a recommended surrogate for EBOV. The phages were inoculated onto six material types with and without the presence of whole human blood. The inoculated materials were then exposed to either a high or low concentration of HPV for various elapsed times. The phages were also recovered from positive controls at these same elapsed times, to assess environmental persistence and decontamination efficacy. Low concentration hydrogen peroxide vapor (LCHP; 25 ppm) was effective against both phages on all materials without the presence of blood at 2 h. LCHP was ineffective against the phages in the presence of blood, on all materials, even with a 3-day contact time. Higher concentrations of HPV (>400 ppm) with contact times of 24-32 h achieved approximately 2-6 log reduction of the phages in the presence of blood.

Review of Decontamination Techniques for the Inactivation of Bacillus anthracis and Other Spore-Forming Bacteria Associated with Building or Outdoor Materials.

Since the intentional release of Bacillus anthracis spores through the U.S. Postal Service in the fall of 2001, research and development related to decontamination for this biological agent have increased substantially. This review synthesizes the advances made relative to B. anthracis spore decontamination science and technology since approximately 2002, referencing the open scientific literature and publicly available, well-documented scientific reports. In the process of conducting this review, scientific knowledge gaps have also been identified. This review focuses primarily on techniques that are commercially available and that could potentially be used in the large-scale decontamination of buildings and other structures, as well as outdoor environments. Since 2002, the body of scientific data related to decontamination and microbial sterilization has grown substantially, especially in terms of quantifying decontamination efficacy as a function of several factors. Specifically, progress has been made in understanding how decontaminant chemistry, the materials the microorganisms are associated with, environmental factors, and microbiological methods quantitatively impact spore inactivation. While advancement has been made in the past 15 years to further the state of the science in the inactivation of bacterial spores in a decontamination scenario, further research is warranted to close the scientific gaps that remain.

Inactivation of Bacillus anthracis spores to decontaminate subway railcar and related materials via the fogging of peracetic acid and hydrogen peroxide sporicidal liquids.

The inactivation of Bacillus anthracis spores on subway and used subway railcar materials was evaluated using fogged peracetic acid/hydrogen peroxide (PAA) and hydrogen peroxide (H2O2). A total of 21 separate decontamination tests were conducted using bacterial spores of both B. anthracis Ames (B.a.) and Bacillus atrophaeus (B.g.) inoculated onto several types of materials. Tests were conducted using commercial off-the-shelf fogging equipment filled with either PAA or H2O2 to fumigate a ∼15 cubic meter chamber under uncontrolled ambient relative humidity and controlled temperature (10 or 20 °C) from 8 to 168 h. For the present study, no conditions were found that resulted in complete inactivation of either B.a. Ames or B.g. on all test materials. Approximately 41% and 38% of the decontamination efficacies for B.a. and B.g., respectively, exhibited ≥6 log10 reduction (LR); efficacy depended greatly on the material. When testing at 10 °C, the mean LR was consistently lower for both B.a. and B.g. as compared to 20 °C. Based on the statistical comparison of the LR results, B.g. exhibited equivalent or greater resistance than B.a. for approximately 92% of the time across all 21 tests. The efficacy data suggest that B.g. may be a suitable surrogate for B.a. Ames when assessing the decontamination efficacy of fogged PAA or H2O2. Moreover, the results of this testing indicate that in the event of B.a. spore release into a subway system, the fogging of PAA or H2O2 represents a decontamination option for consideration.

Evaluation of the Efficacy of Methyl Bromide in the Decontamination of Building and Interior Materials Contaminated with Bacillus anthracis Spores.

The primary goal of this study was to determine the conditions required for the effective inactivation of Bacillus anthracis spores on materials by using methyl bromide (MeBr) gas. Another objective was to obtain comparative decontamination efficacy data with three avirulent microorganisms to assess their potential for use as surrogates for B. anthracis Ames. Decontamination tests were conducted with spores of B. anthracis Ames and Geobacillus stearothermophilus, B. anthracis NNR1Δ1, and B. anthracis Sterne inoculated onto six different materials. Experimental variables included temperature, relative humidity (RH), MeBr concentration, and contact time. MeBr was found to be an effective decontaminant under a number of conditions. This study highlights the important role that RH has when fumigation is performed with MeBr. There were no tests in which a ≥6-log10 reduction (LR) of B. anthracis Ames was achieved on all materials when fumigation was done at 45% RH. At 75% RH, an increase in the temperature, the MeBr concentration, or contact time generally improved the efficacy of fumigation with MeBr. This study provides new information for the effective use of MeBr at temperatures and RH levels lower than those that have been recommended previously. The study also provides data to assist with the selection of an avirulent surrogate for B. anthracis Ames spores when additional tests with MeBr are conducted.

Capture of methyl bromide emissions with activated carbon following the fumigation of a small building contaminated with a Bacillus anthracis spore simulant.

A wide-area Bacillus anthracis spore contamination incident will present immense challenges related to decontamination capacity. For this reason, fumigation with methyl bromide (MeBr) has been proposed as a potential remediation option. Although a few bench-scale laboratory studies have been conducted to evaluate activated carbon for the capture of MeBr, these studies were conducted at conditions replicating commodity fumigation using relatively low MeBr concentrations, temperatures, and/or relative humidity (RH) levels. The more rigorous MeBr fumigation requirements to fully inactivate B. anthracis spores are much more of a challenge for an activated carbon system (ACS) to capture MeBr, and warrant their own investigation. Further, while the aforementioned studies have shown activated carbon to be a possible option for the capture of MeBr in gas streams, these tests were conducted at laboratory bench scale, and thus lack operational perspective and data. Thus, we present for the first time the results of a full-scale study to evaluate an ACS employed for the capture of MeBr at conditions that would be used for decontaminating a building structure contaminated with B. anthracis spores. Airflow rate, temperature, RH, and MeBr levels were measured within the ACS during its operation. Despite the relatively high humidity, temperature, and MeBr levels, the MeBr capture efficiency of the ACS was demonstrated to be more than 99%. The concentration of MeBr exhausted from the structure was reduced from 41,000 to 136 ppmv in 3.5 hr, corresponding to an overall atmospheric emission rate of less than 2 kg. The practical adsorption rate of the ACS was determined to be 4.83 kg MeBr/100 kg carbon. The information and data presented here will facilitate future use of this technology when fumigating with MeBr.

Emergency department rapid medical assessment: overall effect and mechanistic considerations.

BACKGROUND: Although the use of a physician and nurse team at triage has been shown to improve emergency department (ED) throughput, the mechanism(s) by which these improvements occur is less clear. OBJECTIVES: 1) To describe the effect of a Rapid Medical Assessment (RMA) team on ED length of stay (LOS) and rate of left without being seen (LWBS); 2) To estimate the effect of RMA on different groups of patients. METHODS: For Objective 1, we compared LOS and LWBS on dates when we utilized RMA to comparable dates when we did not. For Objective 2, we utilized patient logs to divide patients into groups and estimated the effects of the RMA on each. RESULTS: Objective 1. LOS fell from 297.8 min pre-RMA to 261.7 min during RMA, an improvement of 36.1 (95% confidence interval 21.8-50.4) min; LWBS did not change significantly. Objective 2. Patients seen and dispositioned by the RMA had an estimated decrease in LOS of 117.8 min (estimated decrease in LOS of 45%), but patients seen by the RMA whose care was transitioned to the main ED had an estimated increase in LOS of 25.0 min (estimated increase in LOS of 8%). CONCLUSIONS: On a system level, the addition of an RMA shift at a single facility was associated with an improvement in LOS, but not LWBS. On a mechanistic level, it seems that improvements occurred as a result of the rapid disposition component of the RMA rather than placing advanced orders at triage.

Emerging insights into the role of microRNAs in the pathogenesis of cholangiocarcinoma.

The microRNAs (miRNAs) are small noncoding RNAs that are potent regulators of gene expression and can regulate several diverse biological functions. This minireview provides an overview of recent studies that have examined the role and involvement of miRNAs in cholangiocarcinomas. These studies provide evidence for deregulated expression of miRNA and are providing new insights into the potential contribution of these in the pathogenesis of cholangiocarcinoma.

Exposure to the cyanotoxin microcystin arising from interspecific differences in feeding habits among fish and shellfish in the James River Estuary, Virginia.

The cyanotoxin, microcystin (MC), is known to accumulate in the tissues of diverse aquatic biota although factors influencing exposure, such as feeding habits and seasonal patterns in toxin production, are poorly known. We analyzed seasonal variation in the MC content of primary and secondary consumers, and used dietary analysis (gut contents and stable isotopes) to improve understanding of cyanotoxin transport in food webs. Periods of elevated toxin concentration were associated with peaks in the abundance of genes specific to Microcystis and MC toxin production (mcyD). Peak toxin levels in consumer tissues coincided with peak MC concentrations in seston. However, toxins in tissues persisted in overwintering populations suggesting that potential health impacts may not be limited to bloom periods. Interspecific differences in tissue MC concentrations were related to feeding habits and organic matter sources as pelagic fishes ingested a greater proportion of algae in their diet, which resulted in greater MC content in liver and muscle tissues. Sediments contained a greater proportion of allochthonous (terrestrial) organic matter and lower concentrations of MC, resulting in lower toxin concentrations among benthic detritivores. Among shellfish, the benthic suspension feeder Rangia cuneata (wedge clam) showed seasonal avoidance of toxin ingestion due to low feeding rates during periods of elevated MC. Among predators, adult Blue Catfish had low MC concentrations, whereas Blue Crabs exhibited high levels of MC in both muscle and viscera.

Nitrogen Retention in a Restored Tidal Stream (Kimages Creek, VA) Assessed by Mass Balance and Tracer Approaches.

Tidal streams are attractive candidates for restoration because of their capacity to retain nutrients from upland and estuarine sources. We quantified N retention in Kimages Creek, VA, following a dam breach that restored its historical (pre-1920) connection to the James River Estuary. Estimates of N retention derived from mass balance analysis were compared to tracer-based retention estimates obtained by injecting NHCl during an incoming tide and measuring recovery on the outgoing tide. The injection experiments showed that dissolved inorganic N (DIN) retention in the restored tidal and nontidal segments was similar to nearby streams and previously published values. These data suggest that the stream has attained expected levels of functioning less than 2 yr after restoration despite 80 yr of impoundment. The mass balance analysis provided additional information for restoration assessment as this approach allowed us to track multiple N fractions. These results showed that DIN retention was offset by export of total organic N resulting in net loss of total N from the restored creek. Seasonal variation in DIN retention was significantly and positively related to tidal exchange volume and ecosystem metabolism (gross primary production and respiration). Our findings show that existing methods for measuring nutrient retention in nontidal streams can be adapted to the bidirectional flow patterns of tidal streams to assess restoration effectiveness.

Chest pain and diarrhea: a case of Campylobacter jejuni-associated myocarditis.

BACKGROUND: Diarrhea and chest pain are common symptoms in patients presenting to the emergency department (ED). However, rarely is a relationship between these two symptoms established in a single patient. OBJECTIVE: Describe a case of Campylobacter-associated myocarditis. CASE REPORT: A 43-year-old man with a history of hypertension presented to the ED with angina-like chest pain and a 3-day history of diarrhea. Electrocardiogram revealed ST-segment elevation in the lateral leads. Coronary angiogram revealed no obstructive coronary artery disease. Troponin T rose to 1.75 ng/mL. Cardiac magnetic resonance imaging showed subepicardial and mid-myocardial enhancement, particularly in the anterolateral wall and interventricular septum, consistent with a diagnosis of myocarditis. Stool studies were positive for Campylobacter jejuni. CONCLUSIONS: Campylobacter-associated myocarditis is rare, but performing the appropriate initial diagnostic testing, including stool cultures, is critical to making the diagnosis. Identifying the etiology of myocarditis as bacterial will ensure that appropriate treatment with antibiotics occurs in addition to any cardiology medications needed for supportive care.

Effect of inoculation method on the determination of decontamination efficacy against Bacillus spores.

Decontamination studies investigating the effectiveness of products and processes for the inactivation of Bacillus species spores have traditionally utilized metering viable spores in a liquid suspension onto test materials (coupons). The current study addresses the representativeness of studies using this type of inoculation method compared to when coupons are dosed with a metered amount of aerosolized spores. The understanding of this comparability is important in order to assess the representativeness of such laboratory-based testing when deciding upon decontamination options for use against Bacillus anthracis spores. Temporal inactivation of B. anthracis surrogate (B. subtilis) spores on representative materials using fumigation with chlorine dioxide, spraying of a pH-adjusted bleach solution, or immersion in the solution was investigated as a function of inoculation method (liquid suspension or aerosol dosing). Results indicated that effectiveness, measured as log reduction, was statistically significantly lower when liquid inoculation was used for some material and decontaminant combinations. Differences were mostly noted for the materials observed to be more difficult to decontaminate (i.e., wood and carpet). Significant differences in measured effectiveness were also noted to be a function of the pH-adjusted bleach application method used in the testing (spray or immersion). Based upon this work and the cited literature, it is clear that inoculation method, decontaminant application method, and handling of non-detects (i.e., or detection limits) can have an impact on the sporicidal efficacy measurements.

Review of techniques for the in-situ sterilization of soil contaminated with Bacillus anthracis spores or other pathogens.

This review summarizes the literature on efficacy of techniques to sterilize soil. Soil may need to be sterilized if contaminated with pathogens such as Bacillus anthracis. Sterilizing soil in-situ minimizes spread of the bio-contaminant. Soil is difficult to sterilize, with efficacy generally diminishing with depth. Methyl bromide, formaldehyde, and glutaraldehyde are the only soil treatment options that have been demonstrated at full-scale to effectively inactivate Bacillus spores. Soil sterilization modalities with high efficacy at bench-scale include wet and dry heat, metam sodium, chlorine dioxide gas, and activated sodium persulfate. Simple oxidants such as chlorine bleach are ineffective in sterilizing soil.

Neutralization of ricin toxin on building interior surfaces using liquid decontaminants.

Ricin is a highly toxic protein, capable of inhibiting protein synthesis within cells, and is produced from the beans of the Ricinus communis (castor bean) plant. Numerous recent incidents involving ricin have occurred, many in the form of mailed letters resulting in both building and mail sorting facility contamination. The goal of this study was to assess the decontamination efficacy of several commercial off-the-shelf (COTS) cleaners and decontaminants (solutions of sodium hypochlorite [bleach], quaternary ammonium, sodium percarbonate, peracetic acid, and hydrogen peroxide) against a crude preparation of ricin toxin. The ricin was inoculated onto four common building materials (pine wood, drywall joint tape, countertop laminate, and industrial carpet), and the decontaminants were applied to the test coupons using a handheld sprayer. Decontamination efficacy was quantified using an in-vitro cytotoxicity assay to measure the quantity of bioactive ricin toxin extracted from test coupons as compared to the corresponding positive controls (not sprayed with decontaminant). Results showed that decontamination efficacy varied by decontaminant and substrate material, and that efficacy generally improved as the number of spray applications or contact time increased. The solutions of 0.45% peracetic acid and the 20,000-parts per million (ppm) sodium hypochlorite provided the overall best decontamination efficacy. The 0.45% peracetic acid solution achieved 97.8 to 99.8% reduction with a 30-min contact time.

Fate and transport of viable Bacillus anthracis simulant spores in ambient air during a large outdoor decontamination field exercise.

The Wide Area Demonstration (WAD) was a field exercise conducted under the U.S. EPA's Analysis of Coastal Operational Resiliency program, in conjunction with the U.S. Department of Homeland Security and the U.S. Coast Guard. The purpose of the WAD was to operationalize at field scale aspects of remediation activities that would occur following an outdoor release of Bacillus anthracis spores, including sampling and analysis, decontamination, data management, and waste management. The WAD was conducted in May 2022 at Fort Walker (formerly known as Fort A.P. Hill) and utilized Bacillus atrophaeus as a benign simulant for B. anthracis. B. atrophaeus spores were inoculated onto the study area at the beginning of the study, and air samples were collected daily during each of the different phases of the WAD using Dry Filter Units (DFUs). Ten DFU air samplers were placed at the perimeter of the study area to collect bioaerosols onto two parallel 47-mm diameter polyester felt filters, which were then subsequently analyzed in a microbiological laboratory for the quantification of B. atrophaeus. The study demonstrated the use of DFUs as a rugged and robust bioaerosol collection device. The results indicated that the highest B. atrophaeus spore air concentrations (up to ~ 5 colony forming units/m3) occurred at the beginning of the demonstration (e.g. during inoculation and characterization sampling phases) and generally downwind from the test site, suggesting transport of the spores was occurring from the study area. Very few B. atrophaeus spores were detected in the air after several weeks and following decontamination of exterior surfaces, thus providing an indication of the site decontamination procedures' effectiveness. No B. atrophaeus spores were detected in any of the blank or background samples.Implications: Following an incident involving a release of Bacillus anthracis spores or other biological threat agent into the outdoor environment, understanding the factors that may affect the bioagent's fate and transport can help predict viable contaminant spread via the ambient air. This paper provides scientific data for the first time on ambient air concentrations of bacterial spores over time and location during different phases of a field test in which Bacillus atrophaeus (surrogate for B. anthracis) spores were released outdoors as part of a full-scale study on sampling and decontamination in an urban environment. This study advances the knowledge related to the fate and transport of bacterial spores (such as those causing anthrax disease) as an aerosol in the outdoor environment over the course of three weeks in a mock urban environment and has exposure and health risk implications. The highest spore air concentrations occurred at the beginning of the study (e.g. during inoculation of surfaces and characterization sampling), and in the downwind direction, but diminished over time; few B. atrophaeus spores were detected in the air after several weeks and following decontamination. Therefore, in an actual incident, potential reaerosolization of the microorganism and subsequent transport in the air during surface sampling and remediation efforts should be considered for determining exclusion zone locations and estimating potential risk to neighboring communities. The data also provide evidence suggesting that the large-scale decontamination of outdoor surfaces may reduce air concentrations of the bioagent, which is important since exposure of B. anthracis via inhalation is a primary concern.

A geriatric game to strengthen older adult healthcare delivery and outcomes.

BACKGROUND: Serious games enhance learner engagement and knowledge, yet few medical education games target older adults' healthcare. Addressing this gap, we developed Geri-POP (Geriatrics Population Health), focusing on the Age-Friendly Health System (AFHS) framework and Geriatric 4Ms. METHODS: Geri-POP, a healthcare game is aimed at educating health profession learners about the AFHS framework. Geri-POP employs plan-do-study-act cycles of rapid improvement to apply AFHS principles and explore evidence-based geriatric practices within the game environment while garnering points for insight, trust and outcomes. Faculty and medical students were surveyed for feedback on an alpha version of Geri-POP. RESULTS: Players manage patient panels across three age groups (65-74, 75-84, and 85 years and older) while engaging in plan-do-study-act (PDSA) cycles, applying Geriatric 4Ms (What Matters, Medications, Mentation, and Mobility), and refining strategies based on resource utilization, health outcomes, and real-time feedback. Alpha testing of the game received mixed perceptions on graphics, with faculty endorsing the game for training and integration into the curriculum, while students prioritize academic commitments. Suggestions include enhancing graphics and refining dialogue for a more professional tone. CONCLUSIONS: Geri-POP demonstrates the potential of gamifying older adult population health and quality improvement around AFHS. Feedback on a prototype game revealed different attitudes between faculty and students, thus emphasizing the importance of game development as an iterative process that accounts for educator and learner-centric needs. A future consideration is whether the game informs user's clinical practices and changes healthcare outcomes for older adults.

A survey of emergency physicians regarding due process, financial pressures, and the ability to advocate for patients.

BACKGROUND: A 1998 survey of emergency physicians indicated that many were threatened with adverse actions when advocating regarding the quality of care or raising concerns about financial issues. STUDY OBJECTIVES: To assess the current state of these issues. METHODS: An anonymous electronic survey of emergency physicians was conducted using the American Medical Association's database. RESULTS: Of the 1035 emergency physicians who received the survey, 389 (37.6%) answered the questions. Over half had been in practice for 16 or more years and 86% were board certified. Of those who knew the answer to the question, 62% (197 of 317) reported that their employer could terminate them without full due process and 76% (216 of 284) reported that the hospital administration could order their removal from the clinical schedule. Nearly 20% reported a possible or real threat to their employment if they raised quality-of-care concerns. Financial pressures related to admission, discharge, and transfer of patients were also noted by a number of respondents. Physicians who worked for contract management companies reported a higher incidence of impaired practice rights. CONCLUSION: Practicing emergency physicians continue to report substantial concerns regarding their ability to speak up about the quality of care and pressure regarding financial matters related to patient care.