Carbon Monoxide Levels Produced by Propane/Isobutane Canister Stoves inside a Tent.

INTRODUCTION: Improper use of camp stoves in enclosed spaces has resulted in fatalities from carbon monoxide (CO) poisoning. Prior research has focused on the CO output of stoves burning white gas, unleaded gas, or kerosene. Stoves burning an isobutane/propane fuel have not been investigated and are the focus of this study. METHODS: Three stoves utilizing isobutane/propane fuel were used to heat a pot of water inside a 3-season tent under controlled settings. Multiple runs with each stove were performed, and CO measurements, in parts per million (ppm), were recorded at 1-min intervals for a total of 15 min using a RAE Systems gas monitor. Data are reported as mean with SD. Repeated measures analysis of variance was utilized to examine changes over time. Statistical significance was set at P<0.05. RESULTS: There was a statistically significant main effect of time and CO level, F (14, 168)=7.6, P<0.001. There was a statistically significant difference between-subjects effect of stove group F (2, 12)=8.6, P=0.005, indicating that CO levels were different depending on the stove. Tukey's post-hoc analyses revealed that stove A had the highest CO levels. The average level of stove A was statistically significantly higher than that of stove B and stove C, with a mean CO level difference of 79 ppm (95% CI, 3-156), P=0.043 and 117 ppm (95% CI, 40-194), P=0.004, respectively. CONCLUSIONS: Stoves utilizing isobutane/propane fuel can produce unsafe CO levels and should not be used in enclosed spaces.

Fall, Crush, Kick: Mechanisms and Outcomes in a Cohort of Equine-Related Injuries.

INTRODUCTION: The potential for significant traumatic injury to individuals who interact with horses remains high due to animal size, forces applied, and unpredictability. Despite an estimated 30 million riders in the United States annually, few recent publications have addressed this patient population. OBJECTIVES: This study describes characteristics of patients injured in interactions with horses, focusing on mechanism of injury and use of protective equipment. METHODS: We queried our institution's trauma registry for all patients admitted for equine-related injuries (ERI) between January 1, 2013 and December 31, 2017. We categorized by specific mechanism of injury (fall, crush, kick, fall + crush, and fall + kick) and presence or absence of protective devices. RESULTS: We discovered 143 patients admitted for injuries in equine-related accidents. Patients averaged 49.2 years old, and 62.2% were female. Crush injuries resulted in a high rate of rib fractures. Riders who were kicked had an increased chance of solid organ and facial injuries and falls most commonly led to rib fractures and extremity trauma. Despite lack of documentation on most subjects, protective devices were associated with less severe injuries in those with data (n = 36). CONCLUSIONS: In this relatively large series of patients with ERI, we found mechanism differences within injury groups. Providers should more carefully document specific circumstances of ERIs. All individuals working with or around horses should exercise prudence and consider using protective equipment.

Short Observation Period and Aggressive Discharge of Patients With Head Injury and Serial CT Scans.

Background: Many patients undergo two head computed tomography (CT) scans after mild traumatic brain injury (TBI). Radiographic progression without clinical deterioration does not usually alter management. Evidence-based guidelines offer potential for limited repeat imaging and safe discharge. This study characterizes patients who had two head CTs in the Emergency Department (ED), determines the change between initial and repeat CTs, and describes timing of repeat scans.Methods: This retrospective series includes all patients with head CTs during the same ED visit at an urban trauma center between May 1st, 2016 and April 30th, 2018. Radiographic interpretation was coded as positive, negative, or equivocal.Results: Of 241 subjects, the number of positive, negative, and equivocal initial CT results were 154, 50, and 37, respectively. On repeat CT, 190 (78.8%) interpretations were congruent with the original scan. Out of the 21.2% of repeat scans that diverged from the original read, 14 (5.8%) showed positive to negative conversion, 1 (.4%) showed positive to equivocal conversion, 2 (.88%) showed negative to positive conversion, 20 (8.3%) showed equivocal to negative conversion, and 14 (5.8%) showed equivocal to positive conversion. Average time between scans was 4.4 hours, and median length of stay was 10.2 hours.Conclusions: In this retrospective review, most repeat CT scans had no new findings. A small percentage converted to positive, rarely altering clinical management. This study demonstrates the need for continued prospective research to update clinical guidelines that could reduce admission and serial CT scanning for mild TBI.

Physician Flow at Work: Examining Work Absorption, Clinical Flow, Work Fulfillment, and Flow Thieves.

BACKGROUND: The experience of "flow" at work correlates with positive job outputs and work-related attitudes. Very little current literature describes flow at work in physicians, who experience significant barriers to optimal work outputs, also known as flow thieves (e.g., case interruptions, documenting care). This study aimed to develop a measurement for physician flow (P-Flow) at work and examine the association of P-Flow with physician burnout, job satisfaction, and well-being. METHODS: A pilot instrument was tested with items measuring P-Flow at work. After the pilot administration, a 14-item physician flow (P-Flow-14) scale was administered to physicians. In addition to the P-Flow-14 scale, physician respondents completed items measuring burnout, job satisfaction, and well-being. RESULTS: This study specifies initial psychometric evidence of P-Flow-14 and 7-item P-Flow instruments for researchers interested in studying flow at work in physicians. For each P-Flow instrument, higher levels of the flow experience correlated with superior levels of well-being (p < .01) and job satisfaction (p < .01), and less burnout (p < .001). Results showed initial psychometric evidence of derived subscales (work absorption, clinical flow, flow thieves, work fulfillment) for application in future research. Results showed associations between flow experience by age group and physician specialty. CONCLUSIONS/APPLICATION TO PRACTICE: To enhance well-being and job satisfaction, physicians should aim for concentration and immersion in clinical duties while reducing unnecessary distractions. These findings can be applied by employers and can guide further research on work interruptions and patient safety. Future research can validate the P-Flow scales and subscales to assess interventions aimed to improve the physician work environment.

An analysis of statistical terminology applied in emergency medicine literature methods.

INTRODUCTION: Given the importance of understanding methodical reporting and statistical terminology in ensuring evidence-based decision-making, physicians should possess statistical literacy. The purpose of this study was to distinguish statistical terminology commonly used in emergency medicine methods and describe changes in statistical methods from 2011 to 2021. METHODS: The research team chose four journals in emergency medicine widely read and clinically relevant: Academic Emergency Medicine, American Journal of Emergency Medicine, Annals of Emergency Medicine, and Journal of Emergency Medicine. A total of 400 research articles were included. The team compared overall frequencies in statistical word counts as well as differences by year (2021 vs 2011). RESULTS: Included words from 2011 totaled 31,002 compared to 38,272 in 2021. Unique words for 2011 included 3801 compared to 4291 in 2021. The most common statistical words found in both years were model(s), difference(s), and regression(s). The largest increases in usage included the following words: noninferior(ity), NPV, Fixed, AUC, Mixed, Shapiro, and Wilk. Compared to 2011, results showed a 10% decrease in "p" for 2021. While the terms "Confidence" (2%) and "Intervals" (6%) decreased from 2011 to 2021, there was a 25% increase in "CI(s)". CONCLUSION: By understanding common statistical terms and trends over time, educational efforts can be targeted to consumers of EM literature. Additionally, this work provides evidence suggesting an overall improvement in processes in statistical methodology, enhancing the quality of research outputs and ultimately allowing better clinical decision-making.

Improving Medical Student Attitudes Toward Suicide Prevention Through a Patient Safety Planning Clerkship Initiative.

OBJECTIVE: This project aimed to understand medical students' attitudes toward suicide prevention and their experiences in an innovative clerkship training program that engaged students in patient safety planning. METHODS: Medical students were invited to complete the Attitudes to Suicide Prevention (ASP) scale to explore student perceptions of suicide prevention and risk assessment. Seventy-five psychiatry clerkship students also completed a new safety planning training program with at-risk patients on psychiatry inpatient units. Each student observed a patient safety plan being completed, discussed this process with the resident or attending, completed a safety plan with another patient, and then debriefed with the observing physician. Participants completed the ASP before and after the rotation. RESULTS: The cross-sectional data (n=490) showed that student perceptions of suicide prevention were generally positive (M=27.8, SD=6.1) with variation among classes, but many students did not fully recognize the potential effectiveness of suicide risk reduction strategies. After the clerkship intervention, students were significantly more likely to report that working with suicidal patients was rewarding (p=0.035) and less likely to report discomfort assessing patients for suicide risk (p=0.001). CONCLUSIONS: Medical educators can reinforce the process and efficacy of suicide interventions by modeling the described initiative. Psychiatry clerkship training that intentionally engages students in safety planning with patients is generalizable, and these skills could be extended to the student burnout crisis. Longitudinal studies will help determine how individual perceptions change through medical school and whether students apply safety planning skills in psychiatry and other specialties to care for suicidal patients.

Physical activity and exercise interventions for individuals with opioid use disorder: a scoping review.

Exercise may be a valuable adjunct therapy for individuals with opioid use disorder (OUD) due to its known benefits in brain health, sleep, overall quality of life, and reduced anxiety and depression. Additionally, physical activity may mitigate the experience of pain, leading to better control of chronic pain. The purpose of this scoping review was to evaluate the evidence to support physical activity (which includes exercise) interventions for individuals with OUD. Systematic searches were conducted by a librarian in September 2021 in PubMed, PsycINFO, EMBASE, Web of Science, Cochrane CENTRAL, and clinicaltrials.gov. Two reviewers independently screened titles and abstracts to reduce risk of bias. A total of 13 studies met inclusion criteria. Ten publications presented data specifically studying a physical activity intervention for OUD. Three studies provided retrospective data on the exercise experience and attitudes. Results indicated different exercise modalities led to positive outcomes related to immune function, reduction of pain, cravings, anxiety and depression, as well as improvements in mood and quality of life. Additionally, participants noted exercise as an acceptable and feasible adjunct treatment. Exercise may be a valuable adjunct therapy for individuals with OUD; however, the majority of the published literature consisted of small samples presenting an opportunity for future investigators to corroborate findings with larger sample sizes, utilizing different exercise modalities in different populations of patients with OUD.

Prospective study of haloperidol plus lorazepam versus droperidol plus midazolam for the treatment of acute agitation in the emergency department.

STUDY OBJECTIVES: The objective of this study was to compare the combination of intramuscular (IM) droperidol/midazolam to haloperidol/lorazepam regarding time to sedation in patients with acute undifferentiated agitation in the emergency department (ED). METHODS: This was a prospective, unblinded observational study in the ED of a university teaching hospital. Subjects with acute undifferentiated agitation refractory to verbal de-escalation were assigned to receive a combination of either haloperidol 5 mg/lorazepam 2 mg or droperidol 5 mg/midazolam 5 mg IM. The primary outcome was the proportion of patients adequately sedated at 10 min defined as ED Sedation Assessment Tool (SAT) score of 0 or less. Secondary outcomes included change in ED SAT score at 5, 15, 30, and 60 min, the need for oxygen supplementation, and the need for airway intervention. RESULTS: A total of 86 patients were enrolled in the study, with 43 patients receiving droperidol/midazolam and 43 patients receiving haloperidol/lorazepam. Ten minutes after receiving medication, 51.2% of patients in the droperidol/midazolam group were adequately sedated compared to 7% of patients in the haloperidol/lorazepam group (OR: 14; 95% CI: 3.7, 52.1). Median time to adequate sedation was 10 min for the droperidol/midazolam group and 30 min for the haloperidol/lorazepam group. Eleven patients (25.6%) in the droperidol/midazolam group received oxygen supplementation compared to four patients (9.3%) in the haloperidol/lorazepam group. No study patients experienced extrapyramidal symptoms or required endotracheal intubation. CONCLUSION: Intramuscular droperidol/midazolam was superior to intramuscular haloperidol/lorazepam in achieving adequate sedation at 10 min. Patients in the droperidol/midazolam arm may be more likely to receive oxygen supplementation than those in the haloperidol/lorazepam arm.

Equal incidence of COVID-19 among homeless and non-homeless ED patients when controlling for confounders.

INTRODUCTION: The World Health Organization (WHO) declared severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) a pandemic in March 2020. Theoretically, homeless patients could have disproportionately worse outcomes from COVID-19, but little research has corroborated this claim. This study aimed to examine the demographics and incidence of COVID-19 in homeless vs non-homeless emergency department (ED) patients. METHODS: This is a retrospective study of all patients seen in the University of Louisville Hospital Emergency Department (ULH ED) from March 2019 to December 2020, excluding January and February 2020. Data was collected from the Kentucky Homeless Management Information System (HMIS) and ULH electronic health records. RESULTS: A total of 51,532 unique patients had 87,869 visits during the study period. There was a 18.1% decrease in homeless patient visits over the time period, which was similar to the decrease in non-homeless patient visits (19.2%). In the total population, 9471 individuals had known COVID-19 testing results, with a total of 610 positive (6.4% positivity rate). Of the 712 homeless ED patients, 39 tested positive (5.5% positivity rate). After adjusting for age, gender identity, race, and insurance, there was no statistically significant difference in test positivity between homeless and non-homeless patients, OR 1.23 (0.88, 1.73). Homeless patients were less likely to be admitted to either the intensive care unit (ICU) or hospital (OR = 0.55, 95% CI: OR 0.51, 0.60) as they were more likely to be discharged (OR = 1.65, 95% CI: 1.52, 1.79). CONCLUSION: Previous literature has indicated that higher disease burden, lack of access to social distancing, and poor hygiene would increase the risk of homeless individuals contracting COVID-19 and experiencing serious morbidity. However, this study found that homelessness was not an independent risk factor for COVID-19 infection.

Perceptions of individuals in treatment for substance use disorder during COVID-19: insight on mental health, sobriety, access to treatment, and telehealth.

During the pandemic, the US has seen increases in substance use and the number of deaths by overdose. This study aimed to identify specific impacts of the COVID-19 pandemic on those with SUD. Specifically, we catalogued the perceptions and impact of the pandemic on mental health, sobriety, access to medication for opioid use disorder (MOUD), and utility of telehealth in the treatment of SUD. Findings showed important perceptions patients had lower agreement on the difficulty of staying sober compared to COVID-19's effects on mental health and high agreement on openness to telehealth as treatment. Researchers and clinicians must continue efforts to understand and ameliorate the disproportionate burden in morbidity and mortality in individuals with SUD.

The COVID-19 pandemic and opioid use disorder: Expanding treatment with buprenorphine, and combining safety precautions with telehealth.

BACKGROUND: This study investigated the efficacy and safety of providing medication for opioid use disorder (MOUD) and individualized telehealth in Kentucky, a state severely impacted simultaneously by the opioid epidemic and the COVID-19 pandemic. METHODS: The investigation analyzed pre- and post-COVID-19 characteristics in 191 opioid use disorder (OUD) buprenorphine outpatients who completed an 18-question survey in late 2020 related to COVID testing, OUD relapses, obstacles to maintaining abstinence, and treatment resources. RESULTS: The study revealed no statistically significant changes in drug use before and after the onset of the COVID-19 pandemic despite monthly volume increases. Results further demonstrated statistically significant barriers to treatment, including loss of housing and transportation, food insecurity, and onset of depression. No patients required hospitalization or succumbed to OUD or COVID-19. Potentially effective resource utilization findings included clinic transportation and 24/7 crisis intervention. Respondents rated telehealth as helpful when used in an individualized hybrid model matching patient's need to available resources based on COVID-19 safety guidelines. CONCLUSION: This report yields key clinical insights into providing outpatient MOUD care during the COVID-19 pandemic, validating in-person care as both safe and effective. Patients' experiences proved helpful in identifying and quantifying obstacles to abstinence in conjunction with facilitating continued patient access to essential clinical resources. Notably, telehealth can supplement rather than replace in-person treatment.

Planning virtual residency interviews as a result of COVID-19: insight from residency applicants and physicians conducting interviews.

BACKGROUND: In response to the COVID-19 pandemic, the 2020-2021 residency interview process will undergo significant changes. Residency programme stakeholders would benefit from knowledge on what students and physicians expect from this process. OBJECTIVE: The purpose of the study was to describe and contrast the perspectives of student applicants and interviewing physicians related to the residency programme virtual interview process. METHODS: A survey consisting of 24 Likert statements was administered across listservs in summer 2020 to physicians (attendings and residents who interview medical students). Medical students also received an anonymous survey and were recruited via email to participate. RESULTS: A total of 155 individuals (104 fourth-year medical students and 51 physicians) completed a survey. Results showed students would prefer in-person interviews over virtual. Residency applicants had high agreement on the limited ability to fully assess the programme and city due to virtual interviews. Individuals with lower step 1 scores had higher agreement on preferring in-person interviews. Individuals in the lowest and highest scoring groups appear more worried about the representation of themselves as a result of virtual interviews. Furthermore, applicants feel that more weight will be placed on steps 1 and 2 scores and class ranks, and they may not be able to fully demonstrate their personality compared with interviewers. CONCLUSION: The result of COVID-19 has created challenges and subsequent reshuffling of medical education requiring careful preparation and planning. This study provides insight for residency programmes to better understand the applicants' expectations for the 2020-2021 residency interview and matching process.

Self-compassion in individuals with substance use disorder: the association with personal growth and well-being.

Individuals with Substance Use Disorder (SUD) who do not have empathy toward oneself, or self-compassion, may limit their opportunities for personal growth and overall well-being. Due to scarce empirical studies examining interactions between self-compassion, personal growth and well-being in persons with SUD, the goal of this research was to examine associations among these concepts. A survey was administered to patients in treatment for SUD using validated scales (Sussex-Oxford Compassion for the Self Scale (SSOCS-S), Personal Growth Initiative (PGI) Scale-II, and World Health Organization (WHO)-5 Well-Being Index) and 153 responses were collected. Over two-thirds (69.9%) of the sample were seeking treatment for addiction to prescription opioids; other substances used included heroin (37.3%), methamphetamine (30.7%), benzodiazepines (17%), fentanyl (15.7%), cocaine (9.8%), alcohol (9.8%), and other substances (3.9%). Gender identity, age, and length of treatment did not correlate with personal growth or well-being. Total self-compassion was significantly associated with personal growth initiative (r = .568, p < 0.001) and each of PGI subscales. Additionally, total self-compassion was significantly associated with well-being (r = .567, p < 0.001). When interacting with persons with SUD, we should instill the practice of self-compassion which may help accomplish personal growth and enhance well-being. These individuals need support and humanity from not only providers and loved ones, but also themselves.

Racial disparities in linkage to care among patients with substance use disorders.

OBJECTIVE: Peer support specialists (PSSs) can effectively link patients with substance use disorders (SUD) to treatment. These specialists can engage patients in treatment after emergency department (ED) visits or inpatient hospitalization, crucial points in time when these patients have contact with the health care system. We describe success of PSSs in recruiting SUD patients into treatment, with attention to racial disparities in linkage to care. METHODS: This is a retrospective, observational cohort study performed at an urban, academic medical center. Patients with SUD who indicated interest in pursuing addiction treatment were linked with PSSs by staff at discharge from the ED or inpatient hospitalization. PSSs then transported willing patients to a partnering addiction treatment facility. The treatment facility provided data on successful linkage to care, defined as enrolling in an inpatient or outpatient treatment program. Our primary outcome was successful enrollment in treatment after engagement. The secondary outcome was patients' agreement to transport to the treatment facility after engagement by a PSS. We performed subgroup analysis of patients by self-described race. RESULTS: A total of 785 patients met inclusion criteria for the study: 168 Black patients and 617 White patients. White patients were more likely than Black patients to be enrolled in treatment by PSSs (adjusted odds ratio [aOR; 95% confidence interval {CI}] = 1.61 [1.11 to 2.34]), after adjusting for the effects of age, sex, insurance, and marital status, p = 0.012. We found no statistically significant differences between races in agreeing to be transported for the total sample or inpatient subjects. For ED patients, White individuals were more likely to be transported to treatment compared to Black or African American patients (adjusted odds ratio [aOR; 95% confidence interval {CI}] = 1.50 [1.00 to 2.23]). CONCLUSION: Our results provide evidence of racial disparities in successful linkage to care by PSSs among patients with SUD. Fewer Black patients were successfully linked to care when approached in the ED, where the majority of these patients were engaged, and after controlling age, sex, insurance, and marital status. Future research should study factors that drive these disparities, and how to successfully link all patients to care.

Infection Responsive Smart Delivery of Antibiotics Using Recombinant Spider Silk Nanospheres.

Frequent and inappropriate usage of antibiotics has changed the natural evolution of bacteria by reducing susceptibility and increasing resistance towards antibacterial agents. New resistance mechanisms evolved in the response to host defenses and pharmaceutical interventions are threatening our ability to treat common infections, resulting in increased mortality. In the face of this rising epidemic, antibiotic drug discovery, which has long been overlooked by big pharma, is reaching a critical low. Thus, the development of an infection-responsive drug delivery system, which may mitigate multidrug resistance and preserve the lifetime of our current antibiotic arsenal, has garnered the attention of both popular science and funding agencies. The present work describes the development of a thrombin-sensitive linker embedded into a recombinant spider silk copolymer to create a nanosphere drug delivery vehicle. Recent studies have suggested that there is an increase in thrombin-like activity during Staphylococcus aureus infection; thus, drug release from this new "smart" nanosphere can be triggered in the presence of infection. A thrombin sensitive peptide (TSP) was synthesized, and the thrombin cleavage sensitivity was determined by HPLC. The results showed no cleavage of the peptide when exposed to human serum whereas the peptide was cleaved when incubated with S. aureus exudate. Subsequently, the peptide was coupled with a silk copolymer via EDC-NHS chemistry and formulated into nanospheres encapsulating antibiotic vancomycin. These nanospheres were evaluated for in vitro infection-responsive drug release and antimicrobial activity. Finally, the drug responsive nanospheres were assessed for efficacy in an in vivo septic arthritis model. Our study provides evidence that the protein conjugate was enzyme responsive and can be used to formulate targeted drug release to combat infections against multidrug-resistant bacterial strains.

Smart glasses and video conferencing provide valuable medical student clinical exposure during COVID-19.

BACKGROUND: Responses to the COVID-19 pandemic impose significant limitations on clinical education in emergency medicine. METHODS: An emergency physician with smart glasses technology (SGT) was deployed into our emergency department (ED) to identify, enable, and curate a remote ED clinical learning experience for preclinical medical students in lieu of onsite shadowing. Students were assigned to one of four (2-h) sessions in May or June 2020. RESULTS: All 22 students participated remotely and responded to postrotation surveys. Feedback showed enthusiastic acceptance by instructors and students. Difficulty with technology was minimal. All students "strongly agreed" that they would participate in future sessions. CONCLUSIONS: This SGT instructional method represents a feasible and effective strategy to expose preclinical medical students to clinical medicine in the ED.

A Global Pandemic and Substance Use Disorder: Healthcare Professionals' Viewpoints on the Merging of Two Crises.

INTRODUCTION: COVID-19 has resulted in extraordinary adversities. Mandates such as distancing and variations to treatment services were implemented to slow transmission of the virus, but created new challenges for persons with Substance Use Disorder (SUD). To better understand this phenomenon, we surveyed healthcare professionals on how they believe COVID-19 has impacted persons with SUD and what needs to occur to effectively treat this vulnerable population. Methods: Attending physicians, residents, nurses, medical and nursing students, and other healthcare professionals were asked to respond to three open-ended questions related to the impact of COVID-19 on persons with SUD. Two independent coders reviewed the comments utilizing constant comparative analysis to develop themes. Results: Common themes of concern were found from the respective participants (n = 205) including: lack of access to treatment, feelings of isolation, negative impacts on mental health, and the possibility of relapse. Healthcare strategies to effectively treat and help persons with SUD included increasing access to treatment including telehealth, development of peer support groups, availability of mental health resources, development of enhanced communication channels between providers and patients, and systematic changes. Conclusion: During the COVID-19 pandemic, overdose deaths have dramatically increased. As the short-term and long-term effects of the pandemic become more apparent, swift and comprehensive responses and policies must be enacted. This study provides insight from healthcare providers on the effects of the pandemic for persons with SUD. Many preexisting issues remain unresolved (e.g. stigma and healthcare disparities), and now the pandemic has presented new obstacles as noted by the providers. The findings from this study provide implications for important discussion regarding the development of strategies for substance use treatment and harm reduction.