Characteristics of Suspected COVID-19 Discharged Emergency Department Patients Who Returned During the First Wave.

INTRODUCTION: Limited information exists on patients with suspected coronavirus disease 2019 (COVID-19) who return to the emergency department (ED) during the first wave. In this study we aimed to identify predictors of ED return within 72 hours for patients with suspected COVID-19. METHODS: Incorporating data from 14 EDs within an integrated healthcare network in the New York metropolitan region from March 2-April 27, 2020, we analyzed this data on predictors for a return ED visit-including demographics, comorbidities, vital signs, and laboratory results. RESULTS: In total, 18,599 patients were included in the study. The median age was 46 years old [interquartile range 34-58]), 50.74% were female, and 49.26% were male. Overall, 532 (2.86%) returned to the ED within 72 hours, and 95.49% were admitted at the return visit. Of those tested for COVID-19, 59.24% (4704/7941) tested positive. Patients with chief complaints of "fever" or "flu" or a history of diabetes or renal disease were more likely to return at 72 hours. Risk of return increased with persistently abnormal temperature (odds ratio [OR] 2.43, 95% CI 1.8-3.2), respiratory rate (2.17, 95% CI 1.6-3.0), and chest radiograph (OR 2.54, 95% CI 2.0-3.2). Abnormally high neutrophil counts, low platelet counts, high bicarbonate values, and high aspartate aminotransferase levels were associated with a higher rate of return. Risk of return decreased when discharged on antibiotics (OR 0.12, 95% CI 0.0-0.3) or corticosteroids (OR 0.12, 95% CI 0.0-0.9). CONCLUSION: The low overall return rate of patients during the first COVID-19 wave indicates that physicians' clinical decision-making successfully identified those acceptable for discharge.

Novel Discharge Center for Transition of Care in Vulnerable Emergency Department Treat and Release Patients.

Introduction The majority of emergency department (ED) patients are discharged following evaluation and treatment. Most patients are recommended to follow up with a primary care provider (PCP) or specialist. However, there is considerable variation between providers and EDs in discharge process practices that might facilitate such follow-up (e.g., simply discharging patients with follow-up physician names/contact information vs. making appointments for patients). Patients who do not follow up with their PCPs or specialists are more likely to be readmitted within 30 days than those who do. Furthermore, vulnerable patients have difficulty arranging transitional care appointments due to poor health literacy, inadequate insurance, appointment availability, and self-efficacy. Our innovative ED discharge process utilizes an Emergency Department Discharge Center (EDDC) staffed by ED Care Coordinators and assists patients with scheduling post-discharge appointments to improve rates of follow-up with outpatient providers. This study describes the structure and activities of the EDDC, characterizes the EDDC patient population, and demonstrates the volume and specialties of appointments scheduled by EDDC Care Coordinators. The impact of the EDDC on operational metrics (72-hour returns, 30-day admissions, and length-of-stay [LOS]) and the impact of the EDDC on patient satisfaction are evaluated. Methods The Long Island Jewish Medical Center (LIJMC) EDDC is an intervention developed in July 2020 within a 583-bed urban hospital serving a racially, ethnically, and socio-economically diverse population, with many patients having limited access to healthcare. Data from the Emergency Medicine Service Line (EMSL), an ED Care Coordinator database, and manual chart review were collected from July 2020 to July 2021 to examine the impact of the EDDC on 72-hour returns, 30-day admissions, and Press Ganey's® "likelihood to recommend ED" score (a widely used patient satisfaction survey question). The EDDC pilot cohort was compared to non-EDDC discharged patients during the same period. Results In unadjusted analysis, EDDC patients were moderately less likely to return to the ED within 72 hours (5.3% vs. 6.5%; p = 0.0044) or be admitted within 30 days (3.4% vs. 4.2%). The program was particularly beneficial for uninsured and elderly patients. For both EDDC and non-EDDC patients, most revisits and 30-day admissions were for the same chief complaint as the index visit. The length-of-stay increased by ~10 minutes with no impact on satisfaction with ED visits. Musculoskeletal conditions (~20%) and specialties (~15%) were the most commonly represented. Approximately 10% of referrals were to obtain a PCP. Nearly 90% were to new providers or specialties. Most scheduled appointments occurred within a week.  Conclusion This novel EDDC program, developed to facilitate outpatient follow-up for discharged ED patients, produced a modest but statistically significant difference in 72-hour returns and 30-day admissions for patients with EDDC-scheduled appointments vs. those referred to outpatient providers using the standard discharge process. ED LOS increased by ~10 minutes for EDDC vs. non-EDDC patients, with no difference in satisfaction. Future analyses will investigate impacts on 72-hour returns, 30-day admissions, LOS, and satisfaction after adjusting for characteristics such as age, insurance, having a PCP, and whether the scheduled appointment was attended.

Use of Endocrine Consultation for Hemoglobin A1C ≥9.0% as a Standardized Practice in an Emergency Department Observation Unit.

OBJECTIVE: Severely uncontrolled diabetes mellitus (DM) is associated with poor long-term outcomes and may remain unrecognized. A high frequency of uncontrolled DM has been identified in the acute-care setting, including the emergency department observation unit (EDOU). We assess the use of standardized endocrine consultation in the EDOU for hemoglobin A1C (HbA1C) levels ≥9%. METHODS: Standard practice in our EDOU includes universal HbA1C screening and endocrine consultation for HbA1C levels ≥9.0%. As part of a quality improvement program, EDOU patients with HbA1C levels ≥9.0% had an endocrinology consult. One-month follow-up phone calls assessed the effects of consultation after discharge. RESULTS: HbA1C tests were administered to 3688 (95.7%) of 3853 EDOU patients, of which 7.0% (n = 258) were found to have an HbA1C level ≥9% (mean ± SD, 11.7 ± 1.8%; range, 9%-16.6%). Endocrine consults were completed for 73.6% (190/258) patients with severely uncontrolled DM. Among the 190 patients, 92.1% (n = 175) had discharge DM medication adjustments. For known patients with DM (n = 142), injectable diabetes medication prescriptions increased from 47.2% (67/142) on EDOU arrival to 78.2% (111/142) upon discharge. Newly diagnosed DM injectable prescriptions increased from 0% (0/48) on arrival to 72.9% (35/48) upon discharge. A total of 72.6% (n = 138) were contacted at a 1-month follow-up and 94.9% (n = 131) reported taking DM medications, compared with 68.2% (n = 94) before consult. CONCLUSION: HbA1C screening coupled with endocrine consultation for HbA1C levels ≥9.0% was assessed as a performance improvement study and is shown to have valuable results. Further investigation is required to determine the long-term clinical impact and cost analysis for this novel approach.

The use of light spectrum blocking films to reduce populations of Drosophila suzukii Matsumura in fruit crops.

Spotted wing drosophila, Drosophila suzukii, is a serious invasive pest impacting the production of multiple fruit crops, including soft and stone fruits such as strawberries, raspberries and cherries. Effective control is challenging and reliant on integrated pest management which includes the use of an ever decreasing number of approved insecticides. New means to reduce the impact of this pest that can be integrated into control strategies are urgently required. In many production regions, including the UK, soft fruit are typically grown inside tunnels clad with polyethylene based materials. These can be modified to filter specific wavebands of light. We investigated whether targeted spectral modifications to cladding materials that disrupt insect vision could reduce the incidence of D. suzukii. We present a novel approach that starts from a neuroscientific investigation of insect sensory systems and ends with infield testing of new cladding materials inspired by the biological data. We show D. suzukii are predominantly sensitive to wavelengths below 405 nm (ultraviolet) and above 565 nm (orange & red) and that targeted blocking of lower wavebands (up to 430 nm) using light restricting materials reduces pest populations up to 73% in field trials.

A Case Report of Coronavirus Disease 2019 Presenting with Tremors and Gait Disturbance.

INTRODUCTION: Neurologic symptoms present as significant complications of coronavirus disease 2019 (COVID-19) infection. This report describes a novel manifestation of tremors triggered by severe acute respiratory syndrome coronavirus 2 infection. CASE PRESENTATION: We describe a case of a 46-year-old man with COVID-19 infection complicated by a bilateral intention tremor and wide-based gait. Although neurological manifestations have been reported related to COVID-19, tremulousness has not yet been described. CONCLUSION: Considering the evolving diversity of neurologic manifestations in this infection, emergency physicians should be vigilant of possible COVID-19 infection in patients presenting with unexplained neurologic symptoms.

Pesticides and the perils of synecdoche in the history of science and environmental history.

When the Environmental Protection Agency banned DDT late in 1972, environmentalists hailed the decision. Indeed, the DDT ban became a symbol of the power of environmental activism in America. Since the ban, several species that were decimated by the effects of DDT have significantly recovered, including bald eagles, peregrines, ospreys, and brown pelicans. Yet a careful reading of Rachel Carson's Silent Spring reveals DDT to be but one of hundreds of chemicals in thousands of formulations. Carson called for a reduction in the use of all chemical insecticides. Carson's recommendations notwithstanding, policymakers focused on DDT and other chlorinated hydrocarbons, culminating in the DDT ban, passage of the Federal Environmental Pesticide Control Act of 1972, and subsequent bans on aldrin and dieldrin. Similarly, the history of pesticides has focused inordinately on DDT, providing a myopic image of the ongoing challenges of pesticides in agricultural practice and ongoing environmental protection efforts in the modern world. "Pesticides and the perils of synecdoche" argues that focusing on DDT oversimplified the environmental risks of chemical insecticides and narrowed the parameters of the debate, and in the process both policy and subsequent histories neglected the highly toxic organophosphate insecticides, which dominated agriculture in the United States and the world after the DDT ban, with unintended consequences for farmworkers and wildlife.

Silent Spring after 50 years.

As Silent Spring passed the half-century mark, historians have continued to reflect on its significance. For this issue of Endeavour, we drew together six articles that explore a few of the many legacies of this remarkable book. Given the impressive scope and breadth of the papers in this issue, it is clear that Silent Spring, and the shock waves surrounding its publication, continue to provide rich fodder for historical analysis.

'Like a Keen North Wind': how Charles Elton influenced Silent Spring.

Drawing upon archival and published sources, 'Like a Keen North Wind,' suggests that Charles Elton's book-The Ecology of Invasions by Animals and Plants-served to galvanize Rachel Carson's ideas while she was writing Silent Spring. Carson had already amassed numerous cases of the poisoning of the environment and wildlife as well as humans. Elton's book helped Carson to draw connections between the various kinds of exposures. Yet, it was Carson's genius to animate Silent Spring with vivid examples that captivated her readers and convinced them to question indiscriminate use of pesticides. Moreover, Carson adroitly bridged the growing divide between scientists and the public.

A randomized trial of 2 prescription strategies for opioid treatment of chronic nonmalignant pain.

UNLABELLED: The use of opioid medications for treating chronic noncancer pain is growing; however, there is a lack of good evidence regarding their long-term effectiveness, association with substance abuse, and proper prescribing guidelines. The current study directly compares for the first time in a randomized trial the effectiveness of a conservative, hold the line (Stable Dose) prescribing strategy for opioid medications with a more liberal dose escalation (Escalating Dose) approach. This 2-arm, parallel, randomized pragmatic clinical trial followed 135 patients referred to a specialty pain clinic at a Veterans Affairs Hospital for 12 months (94% male and 74% with musculoskeletal pain). Primary outcomes included monthly or quarterly evaluations of pain severity, pain relief from medications, pain-related functional disability, and opioid misuse behaviors. All subjects received identical pain treatment except for the application of treatment group specific strategies for opioid prescriptions. No group differences were found for primary outcomes of usual pain or functional disability although the Escalating Dose group did show a small but significantly larger increase in self-rated pain relief from medications. About 27% of patients were discharged over the course of the study due to opioid misuse/noncompliance, but there were no group differences in rate of opioid misuse. PERSPECTIVE: The results of this study demonstrate that even in carefully selected patients there is a significant risk of problematic opioid misuse. Although in general there were no statistically significant differences in the primary outcomes between groups, the escalating dose strategy did lead to small improvements in self-reported acute relief from medications without an increase in opioid misuse, compared to the stable dose strategy.

The addiction behaviors checklist: validation of a new clinician-based measure of inappropriate opioid use in chronic pain.

This study introduces the Addiction Behaviors Checklist (ABC), which is a brief (20-item) instrument designed to track behaviors characteristic of addiction related to prescription opioid medications in chronic pain populations. Items are focused on observable behaviors noted both during and between clinic visits. One hundred thirty-six consecutive veterans in a multidisciplinary Veterans Affairs Chronic Pain Clinic who were receiving long-term opioid medication treatment were included in this study. This study represents one of the first to follow a sample of chronic pain patients on opioid therapy over time, using a structured assessment tool to evaluate and track behaviors suggestive of addiction. Interrater reliability and concurrent validity data are presented, as well as a cut-off score for use in determining inappropriate medication use. The psychometric findings support the ABC as a viable assessment tool that can increase a provider's confidence in determinations of appropriate vs. inappropriate opioid use.

Pain medication beliefs and medication misuse in chronic pain.

UNLABELLED: This study assessed the influence of medication beliefs, symptom severity, disability, mood, and psychiatric history on opiate medication misuse behaviors in 288 chronic pain patients. Data were gathered by questionnaires and systematic reviews of electronic medical records. The results demonstrate that patients with a history of substance abuse, compared to those without, showed greater medication misuse despite similar dosages and self-rated opiate effectiveness. Misusers believed more strongly in the potential for opiate addiction and that they required higher doses than others, but also had greater belief in opiate effectiveness and the importance of free access. Although both anxiety and substance abuse history are related to medication misuse, a multivariate analysis indicated that these factors can be seen as mediated by medication beliefs. These data suggest important roles for historical, affective, and cognitive variables in understanding medication misuse. Patients with a history of substance abuse report stronger beliefs in opiate effectiveness while simultaneously showing awareness of their addiction potential. Providers may help patients by addressing these issues prior to prescribing opiates. PERSPECTIVE: History of substance abuse is associated with increased opiate medication misuse independent of differences in reported opiate effectiveness. Self-attributions regarding opiate treatment related to need for higher doses, dose control, and addiction potential, may be important mediators of this relationship and interact with anxiety to produce heightened risk of opiate misuse.

Saving sea turtles: the evolution of the IUCN Marine Turtle Group.

When Peter Scott became chairman of the Survival Service Commission of the International Union for the Conservation of Nature and Natural Resources (IUCN) in 1963, he invited Archie Carr to chair the Marine Turtle Group (MTG). A leading authority on the ecology and conservation of sea turtles, Carr believed that the MTG could be the first international forum for sea turtle research and conservation. The assembly of data for the IUCN Red Data Book revealed which species of turtles were threatened with extinction and the array of risks that they faced. Although Carr and Scott differed on what courses of action should be taken in light of this, the MTG did emerge as an important international congress that remains an inspiration to current marine protection efforts.

Treatment of stress fractures in athletes with intravenous pamidronate.

OBJECTIVE: To determine if the use of a second-generation biphosphonate, pamidronate, is an effective treatment option for stress fractures in intercollegiate athletes. Pamidronate is successfully used to increase bone mass in patients with Charcot arthropathy and osteoporosis. DESIGN: Case series. SETTING: Academic sports medicine clinic with primary responsibility for intercollegiate athletics. PARTICIPANTS: Five intercollegiate female athletes. INTERVENTIONS: Intravenous pamidronate administered weekly for a total of 5 treatments. MAIN OUTCOME MEASUREMENT: Athletes' ability to continue training without restrictions. RESULTS: Four of 5 treated athletes were able to continue training and competition within 1 week of treatment. CONCLUSIONS: Pamidronate may be a useful adjunct to the treatment of stress fractures.