S100B vs. "GFAP and UCH-L1" assays in the management of mTBI patients.

OBJECTIVES: To compare for the first time the performance of "GFAP and UCH-L1" vs. S100B in a cohort of patients managed for mild traumatic brain injury (mTBI) according to actualized French guidelines. METHODS: A prospective study was recently carried at the Emergency Department of Clermont-Ferrand University Hospital in France. Patients with mTBI presenting a medium risk of complications were enrolled. Blood S100B and "GFAP and UCHL-1" were sampled and measured according to French guidelines. S100B was measured in patients with samples within 3 h of trauma (Cobas®, Roche Diagnostics), while GFAP and UCHL-1 were measured in all patients (samples <3 h and 3-12 h) using another automated assay (i-STAT® Alinity, Abbott). RESULTS: For sampling <3 h, serum S100B correctly identifies intracranial lesions with a specificity of 25.7 % (95 % CI; 19.5-32.6 %), a sensitivity of 100 % (95 % CI; 66.4-100 %), and a negative predictive value of 100 % (95 % CI; 92.5-100 %). For sampling <12 h, plasma "GFAP and UCH-L1" levels correctly identify intracranial lesions with a specificity of 31.7 % (95 % CI; 25.7-38.2 %), a sensitivity of 100 % (95 % CI; 73.5-100 %), and a negative predictive value of 100 % (95 % CI; 95-100 %). Comparison of specificities (25.7 vs. 31.7 %) did not reveal a statistically significant difference (p=0.16). CONCLUSIONS: We highlight the usefulness of measuring plasma "GFAP and UCH-L1" levels to target mTBI patients (sampling within 12 h post-injury) and optimize the reduction of CT scans.

Serious illness communication skills training for emergency physicians and advanced practice providers: a multi-method assessment of the reach and effectiveness of the intervention.

BACKGROUND: EM Talk is a communication skills training program designed to improve emergency providers' serious illness conversational skills. Using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, this study aims to assess the reach of EM Talk and its effectiveness. METHODS: EM Talk consisted of one 4-h training session during which professional actors used role-plays and active learning to train providers to deliver serious/bad news, express empathy, explore patients' goals, and formulate care plans. After the training, emergency providers filled out an optional post-intervention survey, which included course reflections. Using a multi-method analytical approach, we analyzed the reach of the intervention quantitatively and the effectiveness of the intervention qualitatively using conceptual content analysis of open-ended responses. RESULTS: A total of 879 out of 1,029 (85%) EM providers across 33 emergency departments completed the EM Talk training, with the training rate ranging from 63 to 100%. From the 326 reflections, we identified meaning units across the thematic domains of improved knowledge, attitude, and practice. The main subthemes across the three domains were the acquisition of Serious Illness (SI) communication skills, improved attitude toward engaging qualifying patients in SI conversations, and commitment to using these learned skills in clinical practice. CONCLUSION: Our study showed the extensive reach and the effectiveness of the EM Talk training in improving SI conversation. EM Talk, therefore, can potentially improve emergency providers' knowledge, attitude, and practice of SI communication skills. TRIAL REGISTRATION: Clinicaltrials.gov: NCT03424109; Registered on January 30, 2018.

Assessment of discordance between radiologists and emergency physicians of RADIOgraphs among discharged patients in an emergency department: the RADIO-ED study.

BACKGROUND: The possibility to perform standard X-rays is mandatory for all French Emergency Department (ED). Initial interpretation is under the prescriber emergency physician-who continually works under extreme conditions, but a radiologist needs to describe a report as soon as possible. We decided to assess the rate of discordance between emergency physicians and radiologists among discharged patients. METHODS: We performed a monocentric study on an adult ED among discharged patients who had at least one X-ray during their consult. We used an automatic electronic system that classified interpretation as concordant or discordant. We review all discordant interpretation, which were classified as false negative, false positive, or more exam needed. RESULTS: For 1 year, 8988 patients had 12,666 X-rays. We found a total of 742 (5.9%) discordant X-rays, but only 277 (2.2%) discordance had a consequence (new consult or exam not initially scheduled). We found some factors associated with discordance such as male sex, or ankle, foot, knee, finger, wrist, ribs, and elbow locations. CONCLUSIONS: On discharged patients, using a systematic second interpretation of X-ray by a radiologist, we found a total of 2.2% discordance that had an impact on the initial care.

Emergency Nurses' Perceived Barriers and Solutions to Engaging Patients With Life-Limiting Illnesses in Serious Illness Conversations: A United States Multicenter Mixed-Method Analysis.

INTRODUCTION: This study aimed to assess emergency nurses' perceived barriers toward engaging patients in serious illness conversations. METHODS: Using a mixed-method (quant + QUAL) convergent design, we pooled data on the emergency nurses who underwent the End-of-Life Nursing Education Consortium training across 33 emergency departments. Data were extracted from the End-of-Life Nursing Education Consortium post-training questionnaire, comprising a 5-item survey and 1 open-ended question. Our quantitative analysis employed a cross-sectional design to assess the proportion of emergency nurses who report that they will encounter barriers in engaging seriously ill patients in serious illness conversations in the emergency department. Our qualitative analysis used conceptual content analysis to generate themes and meaning units of the perceived barriers and possible solutions toward having serious illness conversations in the emergency department. RESULTS: A total of 2176 emergency nurses responded to the survey. Results from the quantitative analysis showed that 1473 (67.7%) emergency nurses reported that they will encounter barriers while engaging in serious illness conversations. Three thematic barriers-human factors, time constraints, and challenges in the emergency department work environment-emerged from the content analysis. Some of the subthemes included the perceived difficulty of serious illness conversations, delay in daily throughput, and lack of privacy in the emergency department. The potential solutions extracted included the need for continued training, the provision of dedicated emergency nurses to handle serious illness conversations, and the creation of dedicated spaces for serious illness conversations. DISCUSSION: Emergency nurses may encounter barriers while engaging in serious illness conversations. Institutional-level policies may be required in creating a palliative care-friendly emergency department work environment.

Creatine supplementation and VO2max: a systematic review and meta-analysis.

Although creatine supplementation is well-known to increase exercise performance in acute high-intensity exercises, its role in aerobic performance based on VO2max is more controversial. Thus, we performed a systematic review and meta-analysis on the effects of creatine supplementation on VO2max. PubMed, Cochrane, Embase, and ScienceDirect were searched for randomized controlled trials (RCTs) reporting VO2max in creatine supplementation and placebo groups before and after supplementation. We computed a random-effects meta-analysis on VO2max at baseline, within groups following supplementation, on changes on VO2max between groups, and after supplementation between groups. Sensitivity analyses and meta-regression were conducted. We included 19 RCTs for a total of 424 individuals (mean age 30 years old, 82% men). VO2max did not differ at baseline between groups (creatine and placebo). Participants in both groups were engaged in exercise interventions in most studies (80%). Using changes in VO2max, VO2max increased in both groups but increased less after creatine supplementation than placebo (effect size [ES] = -0.32, 95%CI = -0.51 to -0.12, p = 0.002). Comparisons after creatine supplementation confirmed a lower VO2max in the creatine group compared to the placebo group (ES= -0.20, 95%CI = -0.39 to -0.001, p = 0.049). Meta-analysis after exclusion from meta-funnel resulted in similar outcomes in a subgroup of young and healthy participants. Meta-regressions on characteristics of supplementation, physical training, or sociodemographic were not statistically significant. Creatine supplementation has a negative effect on VO2max, regardless of the characteristics of training, supplementation, or population characteristics.Supplemental data for this article is available online at https://doi.org/10.1080/10408398.2021.2008864 .

[Coronary anaphylaxis or Kounis syndrome]. / Anaphylaxie coronaire ou syndrome de Kounis.

Although not well known, Kounis syndrome represents 3.4 % of anaphylactic reactions and has a high level of mortality (7 %). Its main clinical presentation looks like an acute coronary syndrome. We report the case of a 61-year old patient who was admitted in the emergency department because of a malaise with loss of consciousness due to a Kounis syndrome that occurred after the ingestion of amoxycilline.

Le syndrome de Kounis représente une entité mal connue, bien que présent dans 3,4 % des réactions anaphylactiques avec une mortalité élevée de 7 %. Ses manifestations sont des symptômes mimant un syndrome coronarien aigu. Nous présentons ici le cas d'un patient de 61 ans admis au service des urgences pour un malaise avec perte de connaissance attribué à un syndrome de Kounis survenu dans les suites de la prise d'amoxycilline.

Evaluation of serum neurofilament light in the early management of mTBI patients.

OBJECTIVES: Serum S100B allows a one-third reduction of computed tomography (CT) scans performed for mild traumatic brain injury (mTBI) patients. In this study, we evaluated the diagnostic performance of serum NF-L in the detection of intracranial lesions induced by mTBI. METHODS: One hundred seventy-nine adult mTBI patients presenting to the emergency department of Clermont-Ferrand University Hospital with a Glasgow Coma Scale (GCS) score of 14-15 were included. S100B assays were performed for clinical routine while NF-L samples were stored at -80 °C until analysis. CT scans were performed for patients with S100B levels above the decision threshold of 0.10 µg/L. Later, NF-L and S100B levels were compared to CT scan findings to evaluate the biomarkers' performances. RESULTS: The area under the ROC curve (AUC) evaluating the diagnostic ability in the prediction of intracranial lesions was 0.72 (95% CI; 0.58-0.87) for S100B and 0.58 (95% CI; 0.45-0.71) for NF-L, the specificities (at a threshold allowing a 100% sensitivity) were 35.7% for S100B, and 28% for NF-L (p=0.096). AUCs of NF-L and S100B for the identification of patients with neurological disorders were statistically different (p<0.001). The AUCs were 0.87 (95% CI; 0.82-0.93) for NF-L and 0.57 (95% CI; 0.48-0.66) for S100B. There was a poor correlation between NF-L and S100B, and NF-L levels were correlated to patients' age (Spearman coefficient of 0.79). CONCLUSIONS: NF-L showed poor performances in the early management of mTBI patients. NF-L levels are strongly correlated to neurodegeneration, whether physiological, age-related, or pathological.

Assessment of sick building syndrome using visual analog scales.

BACKGROUND: Despite there is no recommendations for assessing symptoms of sick building syndrome, the use of visual analog scales (VAS) seems attractive and appropriate. We aimed to demonstrate the benefits of using VAS for evaluating subjective symptoms of sick building syndrome. METHOD: We compared an exposed group to a control group with a one-year follow-up. To assess chronology of symptoms, employees were asked to complete four VAS at different times: after vacations (time 1), beginning of the week-beginning of the day (time 2), beginning of the week-end of the day (time 3), and end of the week-end of the day (time 4). Measurements were repeated before and after ventilation work for the exposed group and at the same time in the control group without intervention. Confounding factors were assessed. RESULTS: We included 36 employees (21 in the exposed group and 15 in the control group). Both groups were comparable. Prior to ventilation work, the exposed group had more subjective symptoms than the control group with a chronology of symptoms. After ventilation work, symptoms did not differ between groups, and most symptoms decreased within the exposed group. PRACTICAL IMPLICATION: The use of VAS provided reliable data for assessing sick building syndrome and showed a dose-response relationship between occupational exposure and symptoms.

Psychometric Properties of the Functional Assessment of Cancer Therapy-General for Evaluating Quality of Life in Patients With Life-Limiting Illness in the Emergency Department.

Background: The Functional Assessment of Cancer Therapy-General (FACT-G) is a widely used quality-of-life measure. However, no studies have examined the FACT-G among patients with life-limiting illnesses who present to emergency departments (EDs). Objective: The goal of this study was to examine the psychometric properties of the FACT-G among patients with life-limiting illnesses who present to EDs in the United States. Methods: This cross-sectional study pooled data from 12 EDs between April 2018 and January 2020 (n = 453). Patients enrolled in the study were adults with one or more of the four life-limiting illnesses: advanced cancer, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, or End-Stage Renal Disease. We conducted item, exploratory, and confirmatory analyses (exploratory factor analysis [EFA] and confirmatory factor analysis [CFA]) to determine the psychometric properties of the FACT-G. Results: The FACT-G had good internal consistency (Cronbach's alpha α = 0.88). The simplest EFA model was a six-factor structure. The CFA supported the six-factor structure, evidenced by the adequate fit indices (comparative fit index = 0.93, Tucker-Lewis index = 0.92, root-mean-square error of approximation = 0.05; 90% confidence interval: 0.04 - 0.06). The six-factor structure comprised the physical, emotional, work and daily activities-related functional well-being, and the family and friends-related social well-being domains. Conclusions: The FACT-G is a reliable measure of health-related quality of life among patients with life-limiting illnesses who present to the ED. Clinical Trial Registration: NCT03325985.

The influence of burnout on cardiovascular disease: a systematic review and meta-analysis.

Background: Burnout is a public health problem with various health consequences, among which cardiovascular disease is the most investigated but still under debate. Our objective was to conduct a systematic review and meta-analysis on the influence of burnout on cardiovascular disease. Methods: Studies reporting risk (odds ratio, relative risk, and hazard ratio) of cardiovascular disease following burnout were searched in PubMed, PsycINFO, Cochrane, Embase, and ScienceDirect. We performed a random-effect meta-analysis stratified by type of cardiovascular disease and searched for putative influencing variables. We performed sensitivity analyses using the most adjusted models and crude risks. Results: We included 25 studies in the systematic review and 9 studies in the meta-analysis (4 cross-sectional, 4 cohort, and 1 case-control study) for a total of 26,916 participants. Burnout increased the risk of cardiovascular disease by 21% (OR = 1.21, 95% CI 1.03 to 1.39) using the most adjusted risks and by 27% (OR = 1.27, 95% CI 1.10 to 1.43) using crude risks. Using stratification by type of cardiovascular disease and the most adjusted risks, having experienced burnout significantly increased the risk of prehypertension by 85% (OR = 1.85, 95% CI 1.00 to 2.70) and cardiovascular disease-related hospitalization by 10% (OR = 1.10, 95% CI 1.02 to 1.18), whereas the risk increase for coronary heart disease (OR = 1.79, 95% CI 0.79 to 2.79) and myocardial infarction (OR = 1.78, 95% CI 0.85 to 2.71) was not significant. Results were also similar using crude odds ratio. The risk of cardiovascular disease after a burnout was not influenced by gender. Insufficient data precluded other meta-regressions. Conclusions: Burnout seems to increase the risk of cardiovascular disease, despite the few retrieved studies and a causality weakened by cross-sectional studies. However, numerous studies focused on the pathophysiology of cardiovascular risk linked to burnout, which may help to build a preventive strategy in the workplace.

Impact of 24 h shifts on urinary catecholamine in emergency physicians: a cross-over randomized trial.

24-h shift (24 hS) exposed emergency physicians to a higher stress level than 14-h night shift (14 hS), with an impact spreading on several days. Catecholamines are supposed to be chronic stress biomarker. However, no study has used catecholamines to assess short-term residual stress or measured them over multiple shifts. A shift-randomized trial was conducted to study urinary catecholamines levels of 17 emergency physicians during a control day (clerical work on return from leave) and two working day (14 hS and 24 hS). The Wilcoxon matched-pairs test was utilized to compare the mean catecholamine levels. Additionally, a multivariable generalized estimating equations model was employed to further analyze the independent relationships between key factors such as shifts (compared to control day), perceived stress, and age with catecholamine levels. Dopamine levels were lower during 24 hS than 14 hS and the control day. Norepinephrine levels increased two-fold during both night shifts. Epinephrine levels were higher during the day period of both shifts than on the control day. Despite having a rest day, the dopamine levels did not return to their normal values by the end of the third day after the 24 hS. The generalized estimating equations model confirmed relationships of catecholamines with workload and fatigue. To conclude, urinary catecholamine biomarkers are a convenient and non-invasive strong measure of stress during night shifts, both acutely and over time. Dopamine levels are the strongest biomarker with a prolonged alteration of its circadian rhythm. Due to the relation between increased catecholamine levels and both adverse psychological effects and cardiovascular disease, we suggest that emergency physicians restrict their exposure to 24 hS to mitigate these risks.

Prevalence of FGF23 elevation in patients with hypophosphatemia.

BACKGROUND AND AIMS: To investigate the contribution of FGF23 in explaining the cases of hypophosphatemia observed in clinical practice, we aimed to determine for the first time the prevalence of FGF23 elevation in patients with hypophosphatemia and to describe the different mechanisms of FGF23-related hypophosphatemic disorders. MATERIALS AND METHODS: We performed a prospective, observational, multicenter, cohort study of 260 patients with hypophosphatemia. Blood measurements (PTH, 1,25-dihydroxyvitamin D, bone alkaline phosphatase, 25-hydroxyvitamin D, and FGF23) were performed on a Liaison XL® (DiaSorin) analyzer. RESULTS: Primary elevation of FGF23 (>95.4 pg/mL) was reported in 10.4% (95CI: 7.0-14.7) of patients (n = 27) with hypophosphatemia, suggesting that at least 1 in 10 cases of hypophosphatemia was erroneously attributed to an etiology other than FGF23 elevation. Patients with elevated blood FGF23 were grouped according to the etiology of the FGF23 elevation. Thus, 10 patients had a renal pathology, chronic kidney disease or post-renal transplantation condition. The remaining patients (n = 17) had the following etiologies: malignancies (n = 9), benign pancreatic tumor (n = 1), post-cardiac surgery (n = 4), cirrhosis (n = 2), and chronic obstructive pulmonary disease (n = 1). CONCLUSION: In order to improve patient management, it seems essential to better integrate plasma FGF23 measurement into the routine evaluation of hypophosphatemia.

Effect of the 1-h bundle on mortality in patients with suspected sepsis in the emergency department: a stepped wedge cluster randomized clinical trial.

PURPOSE: The efficacy of the 1-h bundle for emergency department (ED) patients with suspected sepsis, which includes lactate measurement, blood culture, broad-spectrum antibiotics administration, administration of 30 mL/kg crystalloid fluid for hypotension or lactate ≥ 4 mmol/L, remains controversial. METHODS: We carried out a pragmatic stepped-wedge cluster-randomized trial in 23 EDs in France and Spain. Adult patients with Sepsis-3 criteria or a quick sequential organ failure assessment (SOFA) score ≥ 2 or a lactate > 2 mmol/L were eligible. The intervention was the implementation of the 1-h sepsis bundle. The primary outcome was in-hospital mortality truncated at 28 days. Secondary outcomes included volume of fluid resuscitation at 24 h, acute heart failure at 24 h, SOFA score at 72 h, intensive care unit (ICU) length of stay, number of days on mechanical ventilation or renal replacement therapy, vasopressor free days, unnecessary antibiotic administration, and mortality at 28 days. 1148 patients were planned to be analysed; the study period ended after 873 patients were included. RESULTS: 872 patients (mean age 66, 42% female) were analyzed: 387 (44.4%) in the intervention group and 485 (55.6%) in the control group. Median SOFA score was 3 [1-5]. Median time to antibiotic administration was 40 min in the intervention group vs 113 min in the control group (difference - 73 [95% confidence interval (CI) - 93 to - 53]). There was a significantly higher rate, volume, and shorter time to fluid resuscitation within 3 h in the intervention group. There were 47 (12.1%) in-hospital deaths in the intervention group compared to 61 (12.6%) in the control group (difference in percentage - 0.4 [95% CI - 5.1 to 4.2], adjusted relative risk (aRR) 0.81 [95% CI 0.48 to 1.39]). There were no differences between groups for other secondary endpoints. CONCLUSIONS: Among patients with suspected sepsis in the ED, the implementation of the 1-h sepsis bundle was not associated with significant difference in in-hospital mortality. However, this study may be underpowered to report a statistically significant difference between groups.

Advancing patient-centered research practices in a pragmatic patient-level randomized clinical trial: A thematic analysis of stakeholder engagement in Emergency Medicine Palliative Care Access (EMPallA).

BACKGROUND: Involving patient and community stakeholders in clinical trials adds value by ensuring research prioritizes patient goals both in conduct of the study and application of the research. The use of stakeholder committees and their impact on the conduct of a multicenter clinical trial have been underreported clinically and academically. The aim of this study is to describe how Study Advisory Committee (SAC) recommendations were implemented throughout the Emergency Medicine Palliative Care Access (EMPallA) trial. EMPallA is a multi-center, pragmatic two-arm randomized controlled trial (RCT) comparing the effectiveness of nurse-led telephonic case management and specialty, outpatient palliative care of older adults with advanced illness. METHODS: A SAC consisting of 18 individuals, including patients with palliative care experience, members of healthcare organizations, and payers was convened for the EMPallA trial. The SAC engaged in community-based participatory research and assisted in all aspects from study design to dissemination. The SAC met with the research team quarterly and annually from project inception to dissemination. Using meeting notes and recordings we completed a qualitative thematic analysis using an iterative process to develop themes and subthemes to summarize SAC recommendations throughout the project's duration. RESULTS: The SAC convened 16 times between 2017 and 2020. Over the course of the project, the SAC provided 41 unique recommendations. Twenty-six of the 41 (63%) recommendations were adapted into formal Institutional Review Board (IRB) study modifications. Recommendations were coded into four major themes: Scientific, Pragmatic, Resource and Dissemination. A majority of the recommendations were related to either the Scientific (46%) or Pragmatic (29%) themes. Recommendations were not mutually exclusive across three study phases: Preparatory, execution and translational. A vast majority (94%) of the recommendations made were related to the execution phase. Major IRB study modifications were made based on their recommendations including data collection of novel dependent variables and expanding recruitment to Spanish-speaking patients. CONCLUSIONS: Our study provides an example of successful integration of a SAC in the conduct of a pragmatic, multi-center RCT. Future trials should engage with SACs in all study phases to ensure trials are relevant, inclusive, patient-focused, and attentive to gaps between health care and patient and family needs. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT03325985, 10/30/2017.

Clinical research should involve patient and community stakeholder perspectives to make sure the study addresses questions important to the studied population. One way to do this is by creating a group of stakeholders who can advise on the conduct of a study. We assembled a Study Advisory Committee (SAC) for the Emergency Medicine Palliative Care Access (EMPallA) trial. The purpose of this clinical trial is to compare the effectiveness of nurse-led telephonic case management and specialty, outpatient palliative care of older adults with advanced illness. This paper describes how the SACs involvement translated into direct impacts on the EMPallA trial. The trial research team held regular meetings with the SAC throughout the trial process. Their involvement led to many significant changes in the trial, such as  expanding recruitment inclusion criteria (Spanish-speaking patients), and including survey instruments to measure lonelines and caregiver burden. The SAC also devised strategies to overcome patient and caregiver recruitment and retention challenges, including the creation of patient-friendly materials and training for research coordinators. This study provides a successful example of how actively engaging patient and community stakeholders, through committee engagement, can promote patient priorities in all phases of a trial while facilitating patient recruitment and retention.

Knowledge and Attitudes Toward Hospice and Palliative Care: Instrument Validation Among Emergency Providers.

Background: Emergency providers can engage in goals of care discussions and hospice and palliative care referrals. Little is known about their knowledge and attitudes, which may influence these care practices. Objective: This study aims to re-validate the knowledge and attitude towards hospice and palliative care (KAHP) scale and assess the scale's latent constructs among emergency providers. Methods: The scale consists of ten items measured on a five-point Likert scale. Five of the ten items were reverse scored. Content validation was performed by ten experts in Hospice and Palliative Medicine and Emergency Medicine. Baseline surveys of emergency physicians, advance practice providers, and nurses conducted in the context of a pragmatic, randomized control trial were used for the item analysis and the exploratory and confirmatory factor analyses. Results: The KAHP scale is a ten-item scale scored from 10 to 50. Based on the synthesis of content validation results and the item analysis, all ten items were retained. The item and scale Content Validity Index were each .91. The reliability of the scale was .64 and the exploratory factor analysis identified three underlying constructs defined as self-rated knowledge, support for hospice and palliative care practice, and views on provider-patient communication. The presence of good model fit indices supported the structural integrity of the constructs. Conclusion: We present a validated instrument that is suitable for assessing knowledge and attitude variations toward interventions designed to improve hospice and palliative care practice among emergency providers.

Poverty, Health Care Access Barriers, and Functional Limitations among Individuals with Chronic Obstructive Pulmonary Disease: An 11-Year Cross-sectional Analysis, 2008-2018.

OBJECTIVES: To assess the relationship between poverty, delayed care, unaffordable care, and functional limitations among individuals with chronic obstructive pulmonary disease (COPD). METHODS: Using the National Health Interview Survey data, we selected respondents with COPD, aged 40 years and older. The predictor variables were poverty and measures of delayed and unaffordable care. The outcome variable was functional limitations. We performed a survey-weighted multivariate logistic regression analysis, adjusting for sociodemographic characteristics. RESULTS: Respondents classified as poor had three times the odds of functional limitations compared with those classified as not poor. Respondents who reported having measures of delayed care or unaffordable care had two to nine times and two to four times the adjusted odds of functional limitations compared with those who did not report such measures of delayed and unaffordable care, respectively. CONCLUSIONS: Poverty and delayed and unaffordable care are associated with functional limitations among individuals with COPD.

Influence of COVID-19 on Stress at Work During the First Wave of the Pandemic Among Emergency Health Care Workers.

OBJECTIVES: For more than 2 years, coronavirus disease (COVID-19) has forced worldwide health care systems to adapt their daily practice. These adaptations add to the already stressful demands of providing timely medical care in an overcrowded health care system. Specifically, the COVID-19 pandemic added stress to an already overwhelmed emergency and critical care health care workers (HCWs) on the front lines during the first wave of the pandemic.This study assessed comparative subjective and objective stress among frontline HCWs using a visual analog scale and biometric data, specifically heart rate variability (HRV). METHODS: This is a prospective, observational study using surveys and heart rate monitoring among HCWs who work in 3 frontline health care units (emergency department, mobile intensive care unit, and intensive care unit) in the University Hospital of Clermont-Ferrand, France. Two sessions were performed: 1 during the first wave of the pandemic (April 10 to May 10, 2020) and 1 after the first wave of the pandemic (June 10 to July 15, 2020).The primary outcome is the difference in stress levels between the 2 time points. Secondary objectives were the impact of overcrowding, sociodemographics, and other variables on stress levels. We also assessed the correlation between subjective and objective stress levels. RESULTS: Among 199 HCWs, 98 participated in biometric monitoring, 84 had biometric and survey data, and 12 with only biometric data. Subjective stress was higher during the second time point compared to the first (4.39 ± 2.11 vs 3.16 ± 2.34, P = 0.23). There were higher objective stress levels with a decrease in HRV between the first and the second time points. Furthermore, we found higher patient volumes as a source of stress during the second time point. We did not find any significant correlation between subjective and objective stress levels. CONCLUSION: HCWs had higher stress levels between the 2 waves of the pandemic. Overcrowding in the emergency department is associated with higher stress levels. We did not find any correlation between subjective and objective stress among intensive care and emergency HCWs during the first wave of the pandemic.

Cannabis Use in Physicians: A Systematic Review and Meta-Analysis.

Background: Cannabis use by physicians can be detrimental for them and their patients. We conducted a systematic review and meta-analysis on the prevalence of cannabis use by medical doctors (MDs)/students. Method: PubMed, Cochrane, Embase, PsycInfo and ScienceDirect were searched for studies reporting cannabis use in MDs/students. For each frequency of use (lifetime/past year/past month/daily), we stratified a random effect meta-analysis depending on specialties, education level, continents, and periods of time, which were further compared using meta-regressions. Results: We included 54 studies with a total of 42,936 MDs/students: 20,267 MDs, 20,063 medical students, and 1976 residents. Overall, 37% had used cannabis at least once over their lifetime, 14% over the past year, 8% over the past month and 1.1 per thousand (‱) had a daily use. Medical students had a greater cannabis use than MDs over their lifetime (38% vs. 35%, p < 0.001), the past year (24% vs. 5%, p < 0.001), and the past month (10% vs. 2%, p < 0.05), without significance for daily use (0.5% vs. 0.05%, NS). Insufficient data precluded comparisons among medical specialties. MDs/students from Asian countries seemed to have the lowest cannabis use: 16% over their lifetime, 10% in the past year, 1% in the past month, and 0.4% daily. Regarding periods of time, cannabis use seems to follow a U-shape, with a high use before 1990, followed by a decrease between 1990 and 2005, and a rebound after 2005. Younger and male MDs/students had the highest cannabis use. Conclusions: If more than a third of MDs tried cannabis at least once in their lifetime, this means its daily use is low but not uncommon (1.1‱). Medical students are the biggest cannabis users. Despite being common worldwide, cannabis use is predominant in the West, with a rebound since 2005 making salient those public health interventions during the early stage of medical studies.