Why is naloxone prescription not more common in emergency departments? A survey of physician practices and attitudes.

OBJECTIVE: Emergency physicians (EPs) have a singular opportunity to prescribe naloxone and decrease fatal overdoses in opioid users. We surveyed EPs patterns of naloxone prescription and identified barriers to prescribing naloxone. DESIGN: Surveys were conducted at an emergency medicine conference from 2018 to 2019. We used a Likert scale for all questions and a chi-square or chi-square for trend tests to determine statistical significance. SETTING: Emergency medicine conferences and emergency departments. PARTICIPANTS: Forty-one EPs were surveyed. INTERVENTION: Oral survey. MAIN OUTCOME MEASURES: Prevalence of naloxone prescription and EP attitude toward naloxone. RESULTS: 65.0 percent of residents and 33.3 percent of attending physicians had never prescribed naloxone to patients. 90.2 percent believed ED naloxone prescription is safe, 82.9 percent did not refrain from prescribing due to ethical concerns, and 73.2 percent believed it is not a waste of resources. CONCLUSIONS: Many resident physicians had never prescribed naloxone despite agreeing it was safe, ethical, and a productive use of resources. The time needed to counsel patients on naloxone use was a barrier to prescription, and various interventions are needed to make this practice more common.

Use of viability PCR for detection of live Chlamydia trachomatis in clinical specimens.

Background: The current testing approach to diagnose Chlamydia trachomatis (CT) infection relies on nucleic acid amplification tests (NAATs). These tests are highly sensitive, but do not distinguish between active infection and residual bacterial nucleic acid which may remain after resolution of infection, or via cross-contamination. Better methods to assess the viability of CT detected in clinical samples would be useful in determining the relevance of CT detection in a variety of clinical settings. The goal of this study was to test viability PCR (vPCR) as a method to distinguish viable bacteria from non-viable CT. Methods: The vPCR relies on a propidium monoazide dye (PMAxx), which intercalates into accessible DNA from dead organisms and prevents their detection in a PCR assay for the CT ompA gene. We used digital PCR to quantify absolute genome copy numbers from samples. We validated the vPCR approach using laboratory stocks of CT with known viability. Then, we tested total DNA, viable CT DNA, and culture results from 18 clinical vaginal specimens and 25 rectal clinical specimens, all of which had tested positive by NAAT. Results: In laboratory stocks of CT, vPCR using defined ratios of heat-killed to live bacteria tracked closely with expected results. In vaginal clinical specimens, vPCR and total DNA results were correlated, though total DNA genomes outnumbered viable genomes by 2.2-52.6-fold more copies. As expected, vPCR detected more total genomes than culture results. Both vPCR and total DNA correlated with culture results (Spearman correlation R = 0.8425 for total DNA and 0.8056 for vPCR). Ten rectal NAAT positive specimens were negative by total DNA PCR, vPCR, and were negative or inconclusive by culture. Of the 6 rectal specimens that were culture positive, all were total DNA and vPCR positive. vPCR additionally detected viable bacterial DNA in 8 specimens which were NAAT + and culture negative, though levels were very low (mean 1,357 copies/ml). Conclusions: vPCR is a fast and easy method to assess viability in clinical specimens and is more correlated with culture results than total DNA PCR. Inconsistent ratios between total DNA and vPCR results suggest that the amount of dead bacteria varies considerably in clinical specimens. Results from rectal specimens suggest that many NAAT positive specimens do not in fact represent live replicating bacteria, and likely result in significant overuse of unnecessary antibiotics.

A Point-Based Risk Calculator for Mortality After Hepatectomy.

BACKGROUND: Preoperative risk stratification for hepatectomy patients can aid clinical decision making. The objective of this retrospective cohort study was to determine postoperative mortality risk factors and develop a score-based risk calculator using a limited number of preoperative predictors to estimate mortality risk in patients undergoing hepatectomy. METHODS: Data were collected from patients that underwent hepatectomy from the National Surgical Quality Improvement Program dataset from 2014 to 2020. Baseline characteristics were compared between survival and 30-day mortality cohorts using the χ 2 test. Next, the data were split into a training set to build the model and a test set to validate the model. A multivariable logistic regression model modeling 30-day postoperative mortality was trained on the training set using all available features. Next, a risk calculator using preoperative features was developed for 30-day mortality. The results of this model were converted into a score-based risk calculator. A point-based risk calculator was developed that predicted 30-day postoperative mortality in patients who underwent hepatectomy surgery. RESULTS: The final dataset included 38,561 patients who underwent hepatectomy. The data were then split into a training set from 2014 to 2018 (n = 26,397) and test set from 2019 to 2020 (n = 12,164). Nine independent variables associated with postoperative mortality were identified and included age, diabetes, sex, sodium, albumin, bilirubin, serum glutamic-oxaloacetic transaminase (SGOT), international normalized ratio, and American Society of Anesthesiologists classification score. Each of these features were then assigned points for a risk calculator based on their odds ratio. A univariate logistic regression model using total points as independent variables were trained on the training set and then validated on the test set. The area under the receiver operating characteristics curve on the test set was 0.719 (95% confidence interval, 0.681-0.757). CONCLUSIONS: Development of risk calculators may potentially allow surgical and anesthesia providers to provide a more transparent plan to support patients planned for hepatectomy.

Implementation of an Electronic Health Record-Based Messaging System in the Emergency Department: Effects on Physician Workflow and Resident Burnout.

INTRODUCTION: The traditional methods of communication between nurses and physicians through paging or phone calls have been known to cause patient care interruptions, increase stress and workload, and cause burnout. Our study assessed the impact of using an electronic health record-based messaging system (Epic Secure Chat) for nonemergent communication between nurses and physicians in the emergency department (ED). METHOD: This study was performed at a large urban academic ED. Surveys were distributed through e-mail using Google forms. Preimplementation and postimplementation surveys were performed from May 2019 (presurvey) to August 2019 (postsurvey). RESULT: The number of nonurgent phone calls from registered nurse staff decreased after intervention (P < 0.001). The frequency of nonurgent calls disrupting workflow decreased after the intervention (P = 0.029). The number of calls that were appropriately alerted to increased but was not significant (P = 0.120), whereas the degree of burnout from nonurgent calls remained relatively the same (P = 0.841). CONCLUSIONS: The findings provide insight into the implementation of an EMR messaging system in an ED setting. These findings suggest the messaging system can decrease unnecessary nonurgent calls from registered nurses and medical doctors, allowing for more efficient workflow in the ED. These findings suggest further research especially regarding burnout implemented on a larger scale and yield redesign suggestions in the ED.

A Modified CREATE Intervention Improves Student Cognitive and Affective Outcomes in an Upper-Division Genetics Course.

Many national reports have called for undergraduate biology education to incorporate research and analytical thinking into the curriculum. In response, interventions have been developed and tested. CREATE (Consider, Read, Elucidate the hypotheses, Analyze and interpret the data, and Think of the next Experiment) is an instructional strategy designed to engage students in learning core concepts and competencies through careful reading of primary literature in a scaffolded fashion. CREATE has been successfully implemented by many instructors across diverse institutional contexts and has been shown to help students develop in the affective, cognitive, and epistemological domains, consistent with broader meta-analyses demonstrating the effectiveness of active learning. Nonetheless, some studies on CREATE have reported discrepant results, raising important questions on effectiveness in relation to the fidelity and integrity of implementation. Here, we describe an upper-division genetics course that incorporates a modified version of CREATE. Similar to the original CREATE instructional strategy, our intervention's design was based on existing learning principles. Using existing concept inventories and validated survey instruments, we found that our modified CREATE intervention promotes higher affective and cognitive gains in students in contrast to three comparison groups. We also found that students tended to underpredict their learning and performance in the modified CREATE intervention, while students in some comparison groups had the opposite trend. Together, our results contribute to the expanding literature on how and why different implementations of the same active-learning strategy contribute to student outcomes.