A novel emergency medicine cultural competency curriculum addressing health care disparities.

Background: Effective cultural competency (CC) training for future health professionals is an important first step towards improving healthcare disparities (HCD). The Accreditation Council for Graduate Medical Education (ACGME) now requires that institutions train residents and faculty members in CC relevant to the patient population they serve. Methods: Using Kern's Model, we created and implemented a novel CC curriculum tailored to specific program needs in an emergency medicine residency program. Results: At the end of the curriculum, respondents reported having a better understanding of the importance of CC for their practice (p = 0.004) and of how a patient's personal and historical context affects treatment (p = 0.002). They also reported an increase in the frequency of practicing strategies to reduce bias in themselves (p < 0.001) and others (p < 0.001), as well as comfort interacting with and treating patients from different backgrounds (p < 0.001). Lastly, they reported improved preparedness to collaborate with communities to address HCD (p = 0.004) and to identify community leaders to do so (p < 0.001). Conclusions: The challenges of CC training demonstrate the need for a standard yet adaptable framework. We have designed, implemented, and evaluated a novel curriculum tailored to the specific needs of our EM residency program. The curriculum improved participants' attitudes, preparedness, and self-reported behaviors regarding CC and HCD. This framework represents an example of a successful model to meet ACGME requirements.

Emergency Medicine Influencers' Twitter Use During the COVID-19 Pandemic: A Mixed-methods Analysis.

INTRODUCTION: The objective of this study was to analyze the messages of influential emergency medicine (EM) Twitter users in the United States (US) during the early stages of the coronavirus disease 2019 (COVID-19) global pandemic by characterizing the themes, emotional tones, temporal viewpoints, and depth of engagement with the tweets. METHODS: We performed a retrospective mixed-methods analysis of publicly available Twitter data derived from the publicly available "Coronavirus Tweet IDs" dataset, March 3, 2020-May 1, 2020. Original tweets and modified retweets in the dataset by 50 influential EM Twitter users in the US were analyzed using linguistic software to report the emotional tone and temporal viewpoint. We qualitatively analyzed a 25% random subsample and report themes. RESULTS: There were 1315 tweets available in the dataset from 36/50 influential EM Twitter users in the US. The majority of tweets were either positive (455/1315, 34.6%) or neutral (407/1315, 31%) in tone and focused on the present (1009/1315, 76.7%). Qualitative analysis identified six distinct themes, with users most often sharing news or clinical information. CONCLUSIONS: During the early weeks of the COVID-19 pandemic, influential EM Twitter users in the US delivered mainly positive or neutral messages, most often pertaining to news stories or information directly relating to patient care. The majority of these messages led to engagement by other users. This study underscores how EM influencers can leverage social media in public health outbreaks to bring attention to topics of importance.

Safety profile of intraoperative methadone for analgesia after major spine surgery: An observational study of 1,478 patients.

OBJECTIVE: To investigate the incidence of perioperative adverse events in patients receiving intravenous methadone for major spine surgery. DESIGN: Retrospective review of perioperative records from March 2011 and February 2016. SETTING: University of Virginia Healthsystem. PATIENTS: Adult patients undergoing elective spinal fusion of two or more levels. MAIN OUTCOME MEASURES: Incidence of respiratory depression, time to extubation, hypotension, hypoxemia, reintubation, cardiac complications, and death. RESULTS: Reviewed 1,478 patient records. Mean intraoperative methadone dose was 0.14 ± 0.07 mg/kg. A total of 1,142 patients (77.4 percent) were extubated in the operating room, 543 (36.8 percent) experienced respiratory depression, 1,180 (79.8 percent) hypoxemia, and 22 (1.5 percent) required reintubation. Cardiac complications included arrhythmias (289 patients, 29.9 percent), QTc prolongation (568 patients, 58.8 percent), and myocardial infarction (16 patients, 1.1 percent). Two in hospital deaths occurred (0.14 percent). CONCLUSIONS: Mild-moderate respiratory depression is observed following a one-time dose of intraoperative methadone, and monitoring in an appropriate postoperative setting is recommended.

Incidence and Risk Factors for Chronic Postoperative Opioid Use After Major Spine Surgery: A Cross-Sectional Study With Longitudinal Outcome.

BACKGROUND: Chronic opioid use is a significant public health concern. Surgery is a risk factor for developing chronic opioid use. Patients undergoing major spine surgery frequently are prescribed opioids preoperatively and may be at risk for chronic opioid use postoperatively. The aim of this study was to investigate the incidence of and perioperative risk factors associated with chronic opioid use after major spine surgery. METHODS: The records of patients who underwent elective major spine surgery at the University of Virginia between March 2011 and February 2016 were retrospectively reviewed. The primary outcome was chronic opioid use through 12 months postoperatively. Demographic data, medical comorbidities, preoperative pain scores, and medication use including daily morphine-equivalent (ME) dose, intraoperative use of lidocaine and ketamine, estimated blood loss, postoperative pain scores and medication use, and postoperative opioid use were collected. Logistic regression models were used to examine factors associated with chronic opioid use. RESULTS: Of 1477 patient records reviewed, 412 patients (27.9%) were opioid naive and 1065 patients (72.3%) used opioids before surgery. Opioid data were available for 1325 patients, while 152 patients were lost to 12-month follow-up and were excluded. Of 958 preoperative opioid users, 498 (52.0%) remained chronic users through 12 months. There was a decrease in opioid dosage (mg ME) from preoperative to 12 months postoperatively with a mean difference of -14.7 mg ME (standard deviation, 1.57; 95% confidence interval [CI], -17.8 to -11.7). Among 367 previously opioid-naive patients, 67 (18.3%) became chronic opioid users. Factors associated with chronic opioid use were examined using logistic regression models. Preoperative opioid users were nearly 4 times more likely to be chronic opioid users through 12 months than were opioid-naive patients (odds ratio, 3.95; 95% CI, 2.51-6.33; P < .001). Mean postoperative pain score (0-10) was associated with increased odds of chronic opioid use (odds ratio for a 1 unit increase in pain score 1.25, 95% CI, 1.13-1.38; P < .001). Use of intravenous ketamine or lidocaine was not associated with chronic opioid use through 12 months. CONCLUSIONS: Greater than 70% of patients presenting for major spine surgery used opioids preoperatively. Preoperative opioid use and higher postoperative pain scores were associated with chronic opioid use through 12 months. Use of ketamine and lidocaine did not decrease the risk for chronic opioid use. Surveillance of patients for these factors may identify those at highest risk for chronic opioid use and target them for intervention and reduction strategies.

3,4- and 3,5-Disubstituted 2-Pyridones Using an Intermolecular Cycloaddition / Cycloreversion Strategy: Toward the Synthesis of Aristopyridinone A.

The intermolecular cycloaddition of pyrazinone precursors with alkyne substrates was evaluated. The resulting regioisomeric [2.2.2]-diketopiperazine alkene cycloadducts were diverted into 2-pyridone products through cycloreversion of the [2.2.2]-bicyclic intermediates. New insights into the regioselectivity of pyrazinone azadiene Diels-Alder reactions as well as cycloreversion reactivity were revealed in this study. Synthetic sequences using this [4+2]/r[4+2] strategy were determined that can produce predominantly the 3,5-disubstituted 2-pyridone alkaloid structures; pyridones featuring the 3,4-substitution pattern are observed as the minor regioisomeric products.