User Experience of Access to Sexual Assault Nurse Examiner and Emergency Contraception in Emergency Departments in the United States: A National Survey.

Background: Despite the prevalence of sexual assault presentations to emergency departments (ED) in the United States, current access to sexual assault nurse examiners (SANE) and emergency contraception (EC) in EDs is unknown. Methods: In this study we employed a "secret shopper," cross-sectional telephonic survey. A team attempted phone contact with a representative sample of EDs and asked respondents about the availability of SANEs and EC in their ED. Reported availability was correlated with variables including region, urban/rural status, hospital size, faith affiliation, academic affiliation, and existence of legislative requirements to offer EC. Results: Over a two-month period in 2019, 1,046 calls to hospitals were attempted and 960 were completed (91.7% response rate). Of the 4,360 eligible hospitals listed in a federal database, 960 (22.0%) were contacted. Access to SANEs and EC were reported to be available in 48.9% (95% confidence interval [CI] 45.5-52.0) and 42.5% (95% CI 39.4-45.7) of hospitals, respectively. Access to EC was positively correlated with SANE availability. The EDs reporting SANE and EC availability were more likely to be large, rural, and affiliated with an academic institution. Those reporting access to EC were more likely to be in the Northeast and in states with legislative requirements to offer EC. Conclusion: Our results suggest that perceived access to sexual assault services and emergency contraception in EDs in the United States remains poor with regional and legislative disparities. Results suggest disparities in perceived access to EC and SANE in the ED, which have implications for improving ED practices regarding care of sexual assault victims.

Quantifying Health Outcome Disparity in Invasive Methicillin-Resistant Staphylococcus aureus Infection using Fairness Algorithms on Real-World Data.

This study quantifies health outcome disparities in invasive Methicillin-Resistant Staphylococcus aureus (MRSA) infections by leveraging a novel artificial intelligence (AI) fairness algorithm, the Fairness-Aware Causal paThs (FACTS) decomposition, and applying it to real-world electronic health record (EHR) data. We spatiotemporally linked 9 years of EHRs from a large healthcare provider in Florida, USA, with contextual social determinants of health (SDoH). We first created a causal structure graph connecting SDoH with individual clinical measurements before/upon diagnosis of invasive MRSA infection, treatments, side effects, and outcomes; then, we applied FACTS to quantify outcome potential disparities of different causal pathways including SDoH, clinical and demographic variables. We found moderate disparity with respect to demographics and SDoH, and all the top ranked pathways that led to outcome disparities in age, gender, race, and income, included comorbidity. Prior kidney impairment, vancomycin use, and timing were associated with racial disparity, while income, rurality, and available healthcare facilities contributed to gender disparity. From an intervention standpoint, our results highlight the necessity of devising policies that consider both clinical factors and SDoH. In conclusion, this work demonstrates a practical utility of fairness AI methods in public health settings.

Optimizing Dynamic Antibiotic Treatment Strategies against Invasive Methicillin-Resistant Staphylococcus Aureus Infections using Causal Survival Forests and G-Formula on Statewide Electronic Health Record Data.

Developing models for individualized, time-varying treatment optimization from observational data with large variable spaces, e.g., electronic health records (EHR), is problematic because of inherent, complex bias that can change over time. Traditional methods such as the g-formula are robust, but must identify critical subsets of variables due to combinatorial issues. Machine learning approaches such as causal survival forests have fewer constraints and can provide fine-tuned, individualized counterfactual predictions. In this study, we aimed to optimize time-varying antibiotic treatment -identifying treatment heterogeneity and conditional treatment effects- against invasive methicillin-resistant Staphylococcus Aureus (MRSA) infections, using statewide EHR data collected in Florida, USA. While many previous studies focused on measuring the effects of the first empiric treatment (i.e., usually vancomycin), our study focuses on dynamic sequential treatment changes, comparing possible vancomycin switches with other antibiotics at clinically relevant time points, e.g., after obtaining a bacterial culture and susceptibility testing. Our study population included adult individuals admitted to the hospital with invasive MRSA. We collected demographic, clinical, medication, and laboratory information from the EHR for these patients. Then, we followed three sequential antibiotic choices (i.e., their empiric treatment, subsequent directed treatment, and final sustaining treatment), evaluating 30-day mortality as the outcome. We applied both causal survival forests and g-formula using different clinical intervention policies. We found that switching from vancomycin to another antibiotic improved survival probability, yet there was a benefit from initiating vancomycin compared to not using it at any time point. These findings show consistency with the empiric choice of vancomycin before confirmation of MRSA and shed light on how to manage switches on course. In conclusion, this application of causal machine learning on EHR demonstrates utility in modeling dynamic, heterogeneous treatment effects that cannot be evaluated precisely using randomized clinical trials.

Cardiac arrest: An interdisciplinary scoping review of clinical literature from 2020.

Objectives: The Interdisciplinary Cardiac Arrest Research Review (ICARE) group was formed in 2018 to conduct an annual search of peer-reviewed literature relevant to cardiac arrest. Now in its third year, the goals of the review are to highlight annual updates in the interdisciplinary world of clinical cardiac arrest research with a focus on clinically relevant and impactful clinical and population-level studies from 2020. Methods: A search of PubMed using keywords related to clinical research in cardiac arrest was conducted. Titles and abstracts were screened for relevance and sorted into 7 categories: Epidemiology & Public Health Initiatives; Prehospital Resuscitation, Technology & Care; In-Hospital Resuscitation & Post-Arrest Care; Prognostication & Outcomes; Pediatrics; Interdisciplinary Guidelines & Reviews; and a new section dedicated to the coronavirus disease 2019 (COVID-19) pandemic. Screened manuscripts underwent standardized scoring of methodological quality and impact on the respective fields by reviewer teams lead by a subject matter expert editor. Articles scoring higher than 99 percentiles by category were selected for full critique. Systematic differences between editors' and reviewers' scores were assessed using Wilcoxon signed-rank test. Results: A total of 3594 articles were identified on initial search; of these, 1026 were scored after screening for relevance and deduplication, and 51 underwent full critique. The leading category was Prehospital Resuscitation, Technology & Care representing 35% (18/51) of fully reviewed articles. Four COVID-19 related articles were included for formal review that was attributed to a relative lack of high-quality data concerning cardiac arrest and COVID-19 specifically by the end of the 2020 calendar year. No significant differences between editor and reviewer scoring were found among review articles (P = 0.697). Among original research articles, section editors scored a median 1 point (interquartile range, 0-3; P < 0.01) less than reviewers. Conclusions: Several clinically relevant studies have added to the evidence base for the management of cardiac arrest patients including methods for prognostication of neurologic outcome following arrest, airway management strategy, timing of coronary intervention, and methods to improve expeditious performance of key components of resuscitation such as chest compressions in adults and children.

Pregabalin for Recurrent Seizures in Critical Illness: A Promising Adjunctive Therapy, Especially for cyclic Seizures.

BACKGROUND: Pregabalin (PGB) is an effective adjunctive treatment for focal epilepsy and acts by binding to the alpha2-delta subunit of voltage-gated calcium channels to reduce excitatory neurotransmitter release. Limited data exist on its use in the neurocritical care setting, including cyclic seizures-a pattern of recurrent seizures occurring at nearly regular intervals. Although the mechanism underpinning cyclic seizures remains elusive, spreading excitation linked to spreading depolarizations may play a role in seizure recurrence and periodicity. PGB has been shown to increase spreading depolarization threshold; hence, we hypothesized that the magnitude of antiseizure effect from PGB is more pronounced in patients with cyclic versus noncyclic seizures in a critically ill cohort with recurrent seizures. METHODS: We conducted a retrospective case series of adults admitted to two academic neurointensive care units between January 2017 and March 2019 who received PGB for treatment of seizures. Data collected included demographics, etiology of brain injury, antiseizure medications, and outcome. Continuous electroencephalogram recordings 48 hours before and after PGB administration were reviewed by electroencephalographers blinded to the administration of antiseizure medications to obtain granular data on electrographic seizure burden. Cyclic seizures were determined quantitatively (i.e., < 50% variation of interseizure intervals for at least 50% of consecutive seizures). Coprimary outcomes were decrease in hourly seizure burden in minutes and decrease in seizure frequency in the 48 hours after PGB initiation. We used nonparametric tests for comparison of seizure frequency and burden and segmented linear regression to assess PGB effect. RESULTS: We included 16 patients; the median age was 69 years, 11 (68.7%) were women, three (18.8%) had undergone a neurosurgical procedure, and five (31%) had underlying epilepsy. All seizures had focal onset; ten patients (62.5%) had cyclic seizures. The median hourly seizure burden over the 48 hours prior to PGB initiation was 1.87 min/hour (interquartile range 1.49-8.53), and the median seizure frequency was 1.96 seizures/hour (interquartile range 1.06-3.41). In the 48 hours following PGB (median daily dose 300 mg, range 75-300 mg), the median number of seizures per hour was reduced by 0.80 seizures/hour (95% confidence interval 0.19-1.40), whereas the median hourly seizure burden decreased by 1.71 min/hour (95% confidence interval 0.38-3.04). When we compared patients with cyclic versus noncyclic seizures, there was a relative decrease in hourly seizure frequency (- 86.7% versus - 2%, p = 0.04) and hourly seizure burden (- 89% versus - 7.8%, p = 0.03) at 48 hours. CONCLUSIONS: PGB was associated with a relative reduction in seizure burden in neurocritically ill patients with recurrent seizures, especially those with cyclic seizures, and may be considered in the therapeutic arsenal for refractory seizures. Whether this effect is mediated via modulation of spreading depolarization requires further study.

Unrecognized cardiac arrests: A one-year review of audio from emergency medical dispatch calls.

OBJECTIVES: Immediate recognition of out-of-hospital cardiac arrest (OHCA) by Emergency Medical Dispatch (EMD) operators is crucial to facilitate timely initiation of telephone cardiopulmonary resuscitation (T-CPR) and to enable the appropriate level of Emergency Medical Services (EMS) response. The goal of this study was to identify patterns that can increase EMD-level recognition of cardiac arrests prior to EMS arrival. METHODS: The Combined Communications Center in Alachua County, Florida provided audio recordings of all emergency calls from January 1, 2018 to November 16, 2018 dispatched as a chief complaint other than OHCA, but later identified as cardiac arrest. A multi-disciplinary medical team transcribed and analyzed the calls to determine common themes and trends. RESULTS: Out of an initial 81 calls meeting inclusion criteria, 69 were immediately recognized as OHCA by EMDs, leaving 12 calls of unrecognized OHCA. In 11 of 12 calls respiratory issues were described to EMD. In 10 of 12 calls the subject was described as unconscious, and in the other 2 calls, the subject lost consciousness during the call. CONCLUSIONS: Lack of recognition of OHCA by EMD occurred in most calls due to difficulty communicating the subject's respiratory status. Further emphasis should be placed on identifying non-viable respirations in unconscious patients in EMD training and algorithms to increase recognition of OHCA and initiation of T-CPR. A multi-year review of a comparable dataset from geographically and socioeconomically diverse regions in the United States can validate and expand these preliminary trends.

Ultra-early serum concentrations of neuronal and astroglial biomarkers predict poor neurological outcome after out-of-hospital cardiac arrest-a pilot neuroprognostic study.

OBJECTIVES: To assess ultra-early neuroprognostic significance of GFAP, NF-L, UCH-L1, tau, and S100B concentrations, change trajectory, and combination profile after Out-of-Hospital Cardiac Arrest (OHCA). METHODS: Prospective enrollment of 22 OHCA and 10 control patients at an academic tertiary care center between May 1, 2017 and January 28, 2020. Blood was collected within one hour of return of spontaneous circulation (ROSC) (H0), at hours 6 (H6), 12, 18, 24, and daily or until discharge or death. Biomarker concentrations, multifactor score, and trajectory change were assessed and compared to final neurologic status (good vs poor Cerebral Performance Category; CPC 1-2 vs CPC 3-5, respectively). RESULTS: 10 patients had good and 12 had poor neurologic outcomes. Poor outcome patients had higher biomarker concentrations and combined biomarker scores at early time points. The earliest significant difference between good and poor outcome patients' serum biomarkers were at H12 for GFAP (good median: 425 pg/mL [IQR:370-630] vs poor: 5954[1712-65,055] pg/mL; p < 0.001), H12 for NF-L (64[41-69] vs 898[348-1990] pg/mL; p < 0.001), H0 for Tau (31[8-51] vs 124[53-238] pg/mL; p = 0.025), H0 for UCH-L1 (898[375-1600] vs 2475[1898-4098] pg/mL; p = 0.008), and H6 for S100B (123[70-290] vs 895[360-1199] pg/mL; p = 0.002). Four biomarker composite scores differed by H12 (78.03[52.03-111.25] vs 749 [198.46-4870.63] pg/mL; p = 0.003). Machine-learning approach also identified that four-marker score trajectory group memberships are in concordance with patient outcome. CONCLUSIONS: Ultra-early serial serum concentrations of neuronal and astroglial biomarkers may be of neuroprognostic significance following OHCA.

Diagnostic Performance of High-Sensitivity Cardiac Troponin T Strategies and Clinical Variables in a Multisite US Cohort.

BACKGROUND: European data support the use of low high-sensitivity troponin (hs-cTn) measurements or a 0/1-hour (0/1-h) algorithm for myocardial infarction to exclude major adverse cardiac events (MACEs) among patients in the emergency department with possible acute coronary syndrome. However, modest US data exist to validate these strategies. This study evaluated the diagnostic performance of an initial hs-cTnT measure below the limit of quantification (LOQ: 6 ng/L), a 0/1-h algorithm, and their combination with history, ECG, age, risk factors, and initial troponin (HEART) scores for excluding MACE in a multisite US cohort. METHODS: A prospective cohort study was conducted at 8 US sites, enrolling adult patients in the emergency department with symptoms suggestive of acute coronary syndrome and without ST-elevation on ECG. Baseline and 1-hour blood samples were collected, and hs-cTnT (Roche; Basel, Switzerland) was measured. Treating providers blinded to hs-cTnT results prospectively calculated HEART scores. MACE (cardiac death, myocardial infarction, and coronary revascularization) at 30 days was adjudicated. The proportion of patients with initial hs-cTnT measures below the LOQ and risk according to a 0/1-h algorithm was determined. The negative predictive value (NPV) was calculated for both strategies when used alone or with a HEART score. RESULTS: Among 1462 participants with initial hs-cTnT measures, 46.4% (678 of 1462) were women and 37.1% (542 of 1462) were Black with an age of 57.6±12.9 (mean±SD) years. MACEs at 30 days occurred in 14.4% (210 of 1462) of participants. Initial hs-cTnT measures below the LOQ occurred in 32.8% (479 of 1462), yielding an NPV of 98.3% (95% CI, 96.7-99.3) for 30-day MACEs. A low-risk HEART score with an initial hs-cTnT below the LOQ occurred in 20.1% (294 of 1462), yielding an NPV of 99.0% (95% CI, 97.0-99.8) for 30-day MACEs. A 0/1-h algorithm was complete in 1430 patients, ruling out 57.8% (826 of 1430) with an NPV of 97.2% (95% CI, 95.9-98.2) for 30-day MACEs. Adding a low HEART score to the 0/1-h algorithm ruled out 30.8% (441 of 1430) with an NPV of 98.4% (95% CI, 96.8-99.4) for 30-day MACEs. CONCLUSIONS: In a prospective multisite US cohort, an initial hs-cTnT below the LOQ combined with a low-risk HEART score has a 99% NPV for 30-day MACEs. The 0/1-h hs-cTnT algorithm did not achieve an NPV >99% for 30-day MACEs when used alone or with a HEART score. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02984436.

Cardiac arrest: An interdisciplinary review of the literature from 2018.

OBJECTIVES: The Interdisciplinary Cardiac Arrest Research Review (ICARE) group was formed in 2018 to conduct a systematic annual search of peer-reviewed literature relevant to cardiac arrest (CA). The goals of the review are to illustrate best practices and help reduce knowledge silos by disseminating clinically relevant advances in the field of CA across disciplines. METHODS: An electronic search of PubMed using keywords related to CA was conducted. Title and abstracts retrieved by these searches were screened for relevancy, separated by article type (original research or review), and sorted into 7 categories. Screened manuscripts underwent standardized scoring of overall methodological quality and importance. Articles scoring higher than 99 percentiles by category-type were selected for full critique. Systematic differences between editors and reviewer scores were assessed using Wilcoxon signed-rank test. RESULTS: A total of 9119 articles were identified on initial search; of these, 1214 were scored after screening for relevance and deduplication, and 80 underwent full critique. Prognostication & Outcomes category comprised 25% and Epidemiology & Public Health 17.5% of fully reviewed articles. There were no differences between editor and reviewer scoring. CONCLUSIONS: The total number of articles demonstrates the need for an accessible source summarizing high-quality research findings to serve as a high-yield reference for clinicians and scientists seeking to absorb the ever-growing body of CA-related literature. This may promote further development of the unique and interdisciplinary field of CA medicine.

Cardiac arrest: An interdisciplinary scoping review of the literature from 2019.

OBJECTIVES: The Interdisciplinary Cardiac Arrest Research Review (ICARE) group was formed in 2018 to conduct a systematic annual search of peer-reviewed literature relevant to cardiac arrest. Now in its second year, the goals of the review are to illustrate best practices in research and help reduce compartmentalization of knowledge by disseminating clinically relevant advances in the field of cardiac arrest across disciplines. METHODS: An electronic search of PubMed using keywords related to cardiac arrest was conducted. Title and abstracts retrieved by these searches were screened for relevance, classified by article type (original research or review), and sorted into 7 categories. Screened manuscripts underwent standardized scoring of overall methodological quality and impact on the categorized fields of study by reviewer teams lead by a subject-matter expert editor. Articles scoring higher than 99 percentiles by category-type were selected for full critique. Systematic differences between editors' and reviewers' scores were assessed using Wilcoxon signed-rank test. RESULTS: A total of 3348 articles were identified on initial search; of these, 1364 were scored after screening for relevance and deduplication, and forty-five underwent full critique. Epidemiology & Public Health represented 24% of fully reviewed articles with Prehospital Resuscitation, Technology & Care, and In-Hospital Resuscitation & Post-Arrest Care Categories both representing 20% of fully reviewed articles. There were no significant differences between editor and reviewer scoring. CONCLUSIONS: The sheer number of articles screened is a testament to the need for an accessible source calling attention to high-quality and impactful research and serving as a high-yield reference for clinicians and scientists seeking to follow the ever-growing body of cardiac arrest-related literature. This will promote further development of the unique and interdisciplinary field of cardiac arrest medicine.

Patient, Neighborhood, and Spatial Determinants of Out-of-Hospital Cardiac Arrest Outcomes Throughout the Chain of Survival: A Community-Oriented Multilevel Analysis.

Objective: Global and national trends of out-of-hospital cardiac arrest (OHCA) have been examined; however, geographic variation and socioeconomic disparities of OHCA outcomes in the community setting are less understood. We developed and tested a replicable, community-oriented assessment strategy aimed to identify spatial variations in OHCA outcomes using socioeconomic, prehospital, and in-hospital factors. Methods: Emergency medical service (EMS) records of adult, non-traumatic OHCA within Alachua County, FL (2012-2017) were retrospectively reviewed and matched to corresponding medical records at the University of Florida (UF). Incidence of cardiac arrest was geocoded to census tracts and connected to U.S. census socioeconomic attribute data. Primary outcomes include survival to emergency department (ED), hospital admission, discharge, and discharge to home. Multilevel mixed-effects logistic regression models were developed to assess sub-county geographic variance, probabilities of survival, and prehospital risk factors. Getis-Ord Gi statistic and Moran's I-test was applied to assess spatial clustering in outcome survival rates. Results: Of the 1562 OHCA cases extracted from EMS records, 1,335 (85.5%) were included with 372 transported to study site. Predicted probability of survival to ED was 57.0% (95CI: 51.3-62.3%). Of transported cases to study site ED, predicted probabilities of survival was to 41.7% (95CI: 36.1-47.6%) for hospital admission, 16.1% (95CI: 10.7-23.5%) for hospital discharge, and 7.1% (95CI: 3.7-13.3%) for home discharge. Census tracts accounted for significant variability in survival to ED (p < 0.001), discharge (p = 0.031), and home discharge outcomes (p = 0.036). There was no significant geographic variation in survival to admission outcome. Neighborhood-level factors significantly improved model fit for survival to ED, discharge, and discharge home outcomes. Multiple modifiable patient- and neighborhood-level variables of interest were identified, including rural-urban differences. Conclusion: We identified important geographic disparities that exist in OHCA outcomes at the community level. By using a replicable schematic, this variation can be explained through community-oriented modifiable socioeconomic and prehospital factors.

Health Impact of Hurricanes Irma and Maria on St Thomas and St John, US Virgin Islands, 2017-2018.

Objectives. To assess the health impact of Hurricane Irma and Hurricane Maria on St Thomas, US Virgin Islands.Methods. We collected data from interviews conducted 6 and 9 months after the hurricanes, a review of 597 randomly selected emergency department (ED) encounters, and administrative records from 10 716 ED visits 3 months before, between, and 3 months after the hurricanes.Results. Informants described damaged hospital infrastructure, including flooding, structural damage, and lost staff. The greatest public health impact was on the elderly and persons with chronic diseases. In the setting of loss of the electronic medical record system, ED chart reviews were limited by problems with missing data. ED administrative data demonstrated that posthurricane patients, compared with prehurricane patients, were older and had less severe complaints. There was a significant increase in patients being seen for diabetes-related and respiratory complaints, especially asthma. Suboptimal recordkeeping for medical evacuees limited the ability to assess outcomes for patients with severe illnesses.Conclusions. Hurricanes Irma and Maria caused major disruptions to health care on St Thomas. Emphasis should be given to building a resilient health care system that will optimally respond to future hurricanes.

Public perception towards bystander cardiopulmonary resuscitation.

OBJECTIVE: Bystander cardiopulmonary resuscitation (CPR) after out-of-hospital cardiac arrest (OHCA) improves survival and neurological outcomes. Nonetheless, many OHCA patients do not receive bystander CPR during a witnessed arrest. Our aim was to identify potential barriers to bystander CPR. METHODS: Participants at CPR training events conducted in the USA between February and May 2018 answered a 14-question survey prior to training. Respondents were asked about their overall comfort level performing CPR, and about potential concerns specific to performing CPR on a middle-aged female, a geriatric male, and male and female adolescent patients. Open-ended responses were analysed qualitatively by categorising responses into themes. RESULTS: Of the 677 participants, 582 (86.0%) completed the survey, with 509 (88.1%) between 18 and 29 years of age, 341 (58.6%) without prior CPR training and 556 (96.0%) without prior CPR experience. Across all four scenarios of patients in cardiac arrest, less than 65% of respondents reported that they would be 'Extremely Likely' (20.6%-29.1%) or 'Moderately Likely' (26.9%-34.8%) to initiate CPR. The leading concerns were 'causing injury to patient' for geriatric (n=193, 63.1%), female (n=51, 20.5%) and adolescent (n=148, 50.9%) patients. Lack of appropriate skills was the second leading concern when the victim was a geriatric (n=41, 13.4%) or adolescent (n=68, 23.4%) patient, whereas for female patients, 35 (14.1%) were concerned about exposing the patient or the patient's breasts interfering with performance of CPR and 15 (6.0%) were concerned about being accused of sexual assault. Significant differences were observed in race, ethnicity and age regarding the likelihood of starting to perform CPR on female and adolescent patients. CONCLUSIONS: Participants at CPR training events have multiple concerns and fears related to performing bystander CPR. Causing additional harm and lack of skills were among the leading reservations reported. These findings should be considered for improved CPR training and public education.