Analysis of Patient Adherence to Filling Emergency Department Discharge Prescriptions for Empiric Treatment of Chlamydia.

PURPOSE: Sexually transmitted infections (STIs) represent an enormous public health burden in the United States. Emergency departments (EDs) are a significant source of medical care, particularly for vulnerable patient populations. Guidelines for the treatment of Chlamydia trachomatis have evolved and now recommend doxycycline 100 mg orally twice daily for 7 days as the primary regimen for adults. However, the single-dose azithromycin regimen can be given during the ED visit, while the new regimen has nonadherence hurdles. The purpose of this study will be determining the rate of ED discharge prescription pick ups of doxycycline for Chlamydia trachomatis infection at two discharge pharmacies. METHODS: This is a retrospective chart review of information contained in the electronic medical record (EMR) from August 1st, 2021 - July 31st, 2022. Adult patients who present to the two EDs in the healthcare system and those who received empiric antibiotic treatment for Chlamydia trachomatis infection prior to, or at, ED discharge will be included. Patients who are pregnant, less than 18 years old, those without a Chlamydia trachomatis nucleic acid amplification test during their ED visit, or patients whose antibiotic treatment prescription was sent to a pharmacy other than the two primary discharge pharmacies at the respective medical centers will be excluded. The primary outcome of this study will be determining the rate of emergency department (ED) discharge prescription pick ups of doxycycline for empiric treatment of Chlamydia trachomatis infection at two discharge pharmacies. The secondary outcomes will include the incidence of repeat positive tests between four weeks and 90 days, risk of repeat positive tests in those who do not fill doxycycline, number of positive and negative test results, rate of prescribing adherence to 2021 Centers for Disease Control and Prevention (CDC) Sexually Transmitted Infections Treatment Guidelines regimens for empiric treatment, and insurance status at the time of discharge fill. RESULTS: Seven hundred and thirty patients were pulled from the EMR. One hundred of the patients were excluded from the study as they did not receive empiric antibiotic treatment for Chlamydia trachomatis infection prior to, or at, ED discharge leaving 630 participants. Among this group, 369 patients were excluded as their discharge prescription was not sent to the discharge pharmacies within the medical system, leaving 261 individuals in the study. Per chart review, 215 of the patients picked up their doxycycline prescription (82.4%) and 46 (17.6%) patients failed to pick up their prescription. Additionally, 43 (16.5) of the patients who were prescribed empiric therapy had a positive chlamydia trachomatis test, while 209 (83.5%) of those had a negative test. This study also showed 188 (72%) patients received treatment according to the current CDC recommendations. CONCLUSION: Majority of patients who received prescriptions from the in-hospital discharge pharmacy picked up their prescriptions.

Outcomes of total hip arthroplasty in calcium pyrophosphate deposition disease patients.

OBJECTIVE: We aim to examine the demographics, clinical characteristics, outcomes, and resource utilization following total hip arthroplasty (THA) in patients with and without calcium pyrophosphate deposition (CPPD) disease. METHODS: We queried the National Inpatient Sample database to identify patients who underwent THA between 2006 and 2014. The ICD-9 code 81.51 was used to determine the patients who underwent THA, and of those, we classified 2 groups of patients: (i) those with ICD-9 codes defining CPPD and (ii) those without any CPPD code. Data collection included patient demographics and comorbidities. Outcomes post-THA were mortality, length of stay (LOS), and costs. Associations between CPPD and specific morbidity were evaluated with chi-square tests. T tests were used for continuous variables. RESULTS: Among the 4,111,808 patients who underwent THA, 6198 (0.15 %) had CPPD, with a mean age of 77 years and 64.2 % were females. CPPD patients were more likely to be older (mean age 77 vs 72.7 years; p<0.001) than non-CPPD patients. The Charlson Comorbidity Index score ≥ 2 was more frequently seen in CPPD, however, the mortality post-THA was lower in the CPPD patients (0.7 % vs 1.7 %, OR 0.35, 95 % CI 0.26- 0.47). THA in CPPD patients was associated with a longer mean length of stay (LOS) (6.04 vs 5.15 days, OR 1.15, 95 % CI 1.09-1.22) while mean total charges were not statistically different between the 2 groups (p = 0.344). CPPD patients were more likely to be discharged to rehabilitation or other nursing facilities (42.5 % vs 35.3 %, p<0.001). The number of THA procedures increased in both CPPD and non-CPPD patients over time. CONCLUSIONS: CPPD patients who underwent THA were more likely to be older, with a greater comorbidity burden, longer LOS and discharged to a non-home setting.

Medical events in SARS-Cov-2 infected psychiatric inpatients with and without pre-existing co-morbid medical conditions.

SARS-CoV-2 (COVID-19) infection can be associated with significant medical complications. This risk could be even higher in psychiatric patients due to an increased risk of medical co-morbidity. In addition, psychiatric patients are also vulnerable to acquiring SARS-CoV2 infection due to homelessness, living in crowded areas, and poor adherence to recommended preventive measures. This retrospective study aims to compare two groups of patients, namely COVID-19 positive inpatient psychiatric patients with and without preexisting medical comorbidity on specific clinical and socio-demographic features and more importantly how many patients in the two groups subsequently developed medical complications. All COVID-19 positive psychiatric patients who were admitted to acute psychiatric inpatient units over a one-year period during the peri-pandemic phase were included for this study. Data was collected from the electronic medical records of 174 patients admitted to the inpatient psychiatric facility between January and December 2020. Among the COVID-19 positive patients, twenty individuals out of eighty-nine in the WC (with pre-existing medical comorbidity) group and two individuals out of eighty-five in the WOC (without pre-existing medical comorbidity) group developed COVID-related pneumonia. Ten WC patients and two WOC patients required supplemental oxygen, while only one patient in the WC group developed critical illness and required ventilatory support. The WC group had longer stay in both psychiatric and medical units compared to the WOC group. Consistent with existing literature that patients with comorbid medical condition are higher risk of COVID-19 complications, this study replicates the finding that in psychiatric inpatients pre-existing comorbid medical conditions create a higher risk of experiencing COVID-19 related medical complications. More interestingly, however that increased risk of developing new medical complications was not significantly different from the published rates observed in the general population which is surprising given how vulnerable psychiatric patients are, both medical, psychiatrically and psychosocially. In fact, in some ways and for reasons as yet unclear, the medical complication rate was slightly better in the WC compared to published data in the general population groups.

Factors Associated with Inpatient Narcotic Medication Usage after Robotic-assisted Laparoscopy.

STUDY OBJECTIVE: Describe factors that contribute to an increased narcotic medication use after robotic-assisted laparoscopic (RAL) surgery. DESIGN: A retrospective cohort. SETTING: A teaching hospital. PATIENTS: All patients undergoing RAL surgery by gynecologist oncologists at St. Joseph's Hospital and Medical Center over a 3-year period. INTERVENTIONS: RAL by gynecologist oncologists. MEASUREMENTS AND MAIN RESULTS: Using retrospective chart review, patients who underwent RAL surgery from 2012 to 2015 in the division of gynecologic oncology were identified; 757 patients were eligible for inclusion in the study. Total narcotic use during the postoperative hospital stay was converted to oral morphine milligram equivalents (OME). Bivariate correlations of total OME narcotics to multiple variables were evaluated using Spearman's rho. The average age, body mass index, and length of stay were 53.76 years (17-92), 31.75 kg/m2 (17-56), and 1.56 days (range, 0-19), respectively. Increased OME correlated positively with body mass index (Spearman's rho = .077, p = .036), any intraoperative complication (Spearman's rho = .05, p = .886), any postoperative complication (Spearman's rho = .16, p <.0001), length of stay in days (Spearman's rho = .282, p <.0001), procedure time (Spearman's rho .023, p = .52), and total anesthesia time (Spearman's rho, .032). Total OME narcotics were correlated negatively with age of 65 years or older (Spearman's rho, -.144, p <.0001) and use of patient-controlled analgesia (Spearman's rho, -.185, p <.0001). CONCLUSION: Age younger than 65 years seems to be a predictor for increased requirement of total morphine equivalent medication after RAL surgery, whereas patient-controlled analgesia use had a negative association.

Robotic-assisted gynecologic surgery in an older population: A comparison study.

INTRODUCTION: Robotic-assisted surgery in select patients has been shown to result in less peri-operative morbidity. Few studies have explored the association of robotic-assisted gynecology oncology surgery complication rates and increasing age. Our objective was to evaluate the peri- and postoperative complication rates in patients age 65 years or above in minimally-invasive robotic gynecologic surgery. MATERIAL AND METHODS: We performed a retrospective review of data from 765 consecutive minimally-invasive robotic-assisted surgeries performed by high-volume gynecologic oncologists. The patients were divided into "younger" patients aged <65 years and "older" patients aged ≥65 years. The primary outcomes were intraoperative and postoperative complications. RESULTS: Of the 765 patients analyzed, 185 (24%) were ≥ 65. The intraoperative complication rate in patients <65 was 1.9% (11/580) versus 1.62% (3/185) in females ≥65 (p = 0.808). The postoperative complication rate in patients <65 was 15.5% (90/580) versus 22.7% (42/185) in females ≥65 (p = 0.328). We observed more post-operative complications with patients who had intraoperative complications compared to patients who developed post-operative complications without intraoperative complcations in our sample, but it was not statisticaly significant (OR = 2.78, p = 0.097). The average estimated blood loss was 137.5 ml (0-1000) for patients younger than 65 years and 134.81 ml (0-2200) in patients 65 years or older (p = 0.097). DISCUSSION: Robotic gynecologic oncology surgery is common. When performed by expert surgeons, complications are not associated with increasing age.

Identification of Endometrial Cancer-Specific microRNA Biomarkers in Endometrial Fluid.

Abnormal uterine bleeding is a common benign gynecological complaint and is also the most common symptom of endometrial cancer (EC). Although many microRNAs have been reported in endometrial carcinoma, most of them were identified from tumor tissues obtained at surgery or from cell lines cultured in laboratories. The objective of this study was to develop a method to detect EC-specific microRNA biomarkers from liquid biopsy samples to improve the early diagnosis of EC in women. Endometrial fluid samples were collected during patient-scheduled in-office visits or in the operating room prior to surgery using the same technique performed for saline infusion sonohysterography (SIS). The total RNA was extracted from the endometrial fluid specimens, followed by quantification, reverse transcription, and real-time PCR arrays. The study was conducted in two phases: exploratory phase I and validation phase II. In total, endometrial fluid samples from 82 patients were collected and processed, with 60 matched non-cancer versus endometrial carcinoma patients used in phase I and 22 in phase II. The 14 microRNA biomarkers, out of 84 miRNA candidates, with the greatest variation in expression from phase I, were selected to enter phase II validation and statistical analysis. Among them, three microRNAs had a consistent and substantial fold-change in upregulation (miR-429, miR-183-5p, and miR-146a-5p). Furthermore, four miRNAs (miR-378c, miR-4705, miR-1321, and miR-362-3p) were uniquely detected. This research elucidated the feasibility of the collection, quantification, and detection of miRNA from endometrial fluid with a minimally invasive procedure performed during a patient in-office visit. The screening of a larger set of clinical samples was necessary to validate these early detection biomarkers for endometrial cancer.

Association of quality of prenatal care with contraceptive planning in a United States population: a retrospective cohort study.

BACKGROUND: Understanding how prenatal care influences planned postpartum contraception can help guide shared decision-making. This study looks to examine the association of the quality of prenatal care with planned postpartum contraception. METHODS: This is a retrospective cohort study conducted in a single tertiary, academic urban institution in the southwest United States. The institutional review board (IRB) for human research at Valleywise Health Medical Center approved this study. Using a validated measure of prenatal care, the Kessner index, prenatal care was classified as adequate, intermediate, or inadequate. The World Health Organization (WHO) protocol for contraceptive effectiveness was used to classify contraceptives as very effective, effective, and less effective. The planned contraceptive choice was determined at the time of hospital discharge after delivery by discharge summary. Chi-squared testing and logistic regression were used to measure associations between the adequacy of prenatal care and contraceptive planning. RESULTS: This study included 450 deliveries, 404 (90%) patients with adequate prenatal care, and 46 (10%) patients without adequate (intermediate or inadequate) prenatal care. There was not a statistically significant difference in planning for very effective or effective methods of contraception at hospital discharge between adequate (74%) and non-adequate (61%) prenatal care groups (p = 0.06). There was no association between the adequacy of prenatal care and the effectiveness of contraceptive planning after controlling for age and parity (aOR = 1.7, 95% CI 0.89-3.22). CONCLUSIONS: Many women chose very effective and effective methods of postpartum contraception; however, there was no statistically significant association between the quality of prenatal care and planned contraception at hospital discharge.

Perspective: The viscoelastic properties of biofilm infections and mechanical interactions with phagocytic immune cells.

Biofilms are viscoelastic materials that are a prominent public health problem and a cause of most chronic bacterial infections, in large part due to their resistance to clearance by the immune system. Viscoelastic materials combine both solid-like and fluid-like mechanics, and the viscoelastic properties of biofilms are an emergent property of the intercellular cohesion characterizing the biofilm state (planktonic bacteria do not have an equivalent property). However, how the mechanical properties of biofilms are related to the recalcitrant disease that they cause, specifically to their resistance to phagocytic clearance by the immune system, remains almost entirely unstudied. We believe this is an important gap that is ripe for a large range of investigations. Here we present an overview of what is known about biofilm infections and their interactions with the immune system, biofilm mechanics and their potential relationship with phagocytosis, and we give an illustrative example of one important biofilm-pathogen (Pseudomonas aeruginosa) which is the most-studied in this context. We hope to inspire investment and growth in this relatively-untapped field of research, which has the potential to reveal mechanical properties of biofilms as targets for therapeutics meant to enhance the efficacy of the immune system.

The relative risk of ischemic cerebrovascular accident in patients with Von Willebrand disease.

Cerebrovascular accident (CVA) is one of the leading causes of death in the United States. Von Willebrand factor plays an important role in platelet activation and adhesion. It remains unclear whether Von Willebrand disease (vWD) is associated with a decreased risk of developing CVA. The study aimed to compare the relative risk (RR) of CVA in patients with and without vWD. We queried the National Inpatient Sample from 2009 to 2014 for discharge data and records for vWD and CVA using International Classification of Diseases, Ninth-Revision codes. The unadjusted and adjusted RR of CVA in patients with and without vWD were estimated using log-binomial model. Descriptive measures including means, medians, standard deviations, and range were presented based on normality test of continuous data. The prevalence of CVA was lower in patients with vWD than in those without vWD (1.31% vs 2.04%), with a RR of 0.64 (95% confidence interval (CI): 0.60-0.68). After adjusting for common CVA risk factors, the RR remained lower in vWD patients: 0.81 (95% CI: 0.76-0.86). vWD is associated with a lower RR of developing CVA. This suggests that deficiency of Von Willebrand factor is potentially protective against the development of CVA. To the best of our knowledge, this is the first study in humans to compare the RR of CVA in patients with and without vWD. Future studies are needed to explore causal relationships and therapeutic benefits.

Physician Self-Reported Practice Patterns: Midazolam for Minor Procedures in Pediatric Patients.

Midazolam is frequently used as a single agent to provide minimal sedation (also called anxiolysis) when performing procedures in minor children. Published guidelines on the optimal use of intranasal (INM) and oral midazolam (POM) are lacking. The purpose of this study is to explore the self-reported physician practice related to midazolam use in facilitating minor procedures in children. We developed a survey that was approved by the Academy of Pediatrics Section on Emergency Medicine (APP-SOEM) and was then electronically distributed via its listserve. Questions were posed about the therapeutic and maximum dosing of INM and POM, consideration of Nothing-By-Mouth (NPO) status, use of cardiopulmonary monitors, as well as discharge criteria. There was a 47% (218/465) response rate. For therapeutic INM doses, 65% of responders used a dose range of 0.3 to 0.6 mg/kg, and 75% selected a maximum dose of 10 mg irrespective of the child's weight. About 20% of the responders selected a dosage range of 0.7 to 1 mg/kg for therapeutic POM dose, with 43% opting for a maximum dose of 20 mg irrespective of the child's weight. We observed a dichotomous variation in reported physician use of cardiopulmonary monitors; 42% never employ monitors, and the remainder used monitors some of the time. There was consensus on the NPO status and discharge criteria; 80% of physicians did not consider NPO status prior to midazolam use. The level of alertness was the most commonly selected discharge criterion. This nationwide survey of physicians indicates practice variation with midazolam dosing and cardiopulmonary monitor usage when performing minor procedures in children. Implementing practice guidelines, specifically for minimal sedation with mainstay agents such as midazolam, may standardize physician practice and improve overall patient care.

The Effect of a Single Dose of Prophylactic Vancomycin Prior to Peripherally Inserted Central Catheter Removal on Sepsis.

OBJECTIVE: To evaluate the effect of a single dose of prophylactic vancomycin prior to the removal of a peripherally inserted central catheter (PICC) in decreasing sepsis evaluations, positive cultures, and antibiotic usage in neonates. METHODS: A retrospective review was conducted from December 1, 2015, through November 30, 2019, to evaluate outcomes of sepsis evaluations, positive cultures, and antibiotic usage in neonates not receiving prophylactic vancomycin prior to the discontinuation of a PICC as compared with those receiving prophylaxis vancomycin in a neonatal intensive care unit (NICU). RESULTS: Of the 138 neonates enrolled in the study, 82 did not receive vancomycin prophylaxis (Cohort 1), and 56 did (Cohort 2). Both cohorts were similar in sex distribution, gestational age, and PICC days. The frequency of sepsis evaluations, positive cultures, and the need for antibiotics was not found to be significant (p = 0.404, 0.703, 0.808) (Table 2).CONCLUSIONS The results did not show a statistically significant improvement in the incidence of sepsis in neonates who received prophylactic vancomycin prior to PICC discontinuation. However, there were lower percentages of sepsis evaluations, positive cultures, and antibiotics administered in the Cohort 2 patients. Although the advantage of implementing this antibiotic policy is uncertain based on this study, further research across multiple centers including a larger number of subjects may provide more conclusive results.

Virtual Town Hall Meetings to Convey Emergency Medicine Residency Program Information to Students.

BACKGROUND: Applying to emergency medicine (EM) residency programs as a medical student is challenging and complicated in a normal year, but the 2020/2021 application cycle was further complicated by the COVID-19 pandemic. Due to the decrease of in-person opportunities for students to connect with residency programs, virtual "town-hall" meetings were developed. In this study our primary objective was to determine whether attendance at a virtual residency program information session improved the perceived knowledge of curriculum information and program exposure to medical students applying to an EM residency. METHODS: Four study sites hosted a total of 12 virtual events consisting of residents, faculty, or both. Standardized pre-event/post-event surveys were conducted to capture medical student perceptions before/after each of the virtual sessions. Apart from measuring the improvement in students' perceived knowledge of a program by gauging their responses to each question, we used a 10-question composite score to compare pre- vs post-event improvement among the participants. RESULTS: The pre-event survey was completed by 195 attendees, and the post-event survey was completed by 123 attendees. The median and mean composite score to this 10-question survey improved from 32.19 to 45, and 31.45 to 44.2, respectively, in the pre- to post-event survey. CONCLUSION: This study showed improvement of medical students' perceived knowledge of residency programs (reflected as increased agreement from pre- to post-event survey). The data demonstrates through question responses that students not only obtained information about the programs but also were able to gain exposure to the culture and "feel" of a program. In a non-traditional application season in which students are unable to pursue their interest in a program through audition rotations, virtual town hall events, along with other asynchronous events, may be a reasonable approach to increasing medical student understanding and awareness of a program and its culture.

The Cardioprotective Potential of von Willebrand Disease in Ischemic Heart Disease.

von Willebrand factor (vWF) aids coagulation at sites of vessel injury. Elevated vWF levels have been associated with an increased risk of ischemic heart disease (IHD); however, it is unclear whether vWF deficiency, seen in patients with von Willebrand disease (vWD), protects people against IHD. We determined and compared the prevalence and risk of IHD in patients with versus without vWD by using data from the National Inpatient Sample (2009-2014), excluding patients younger than 18 and older than 75 years. The primary outcome was the odds ratio (OR) of IHD in patients with versus without vWD. Secondary outcomes were major medical comorbidities and demographic characteristics in patients with vWD. Of 224,475,443 weighted hospital-discharge samples, we identified 82,809 patients with a vWD diagnosis. The odds of IHD were lower in patients with vWD than in those without (OR=0.54; 95% CI, 0.52-0.56). After multivariable logistic regression analysis and adjustment for age, sex, and typical IHD risk factors (hypertension, smoking, diabetes, hyperlipidemia, chronic kidney disease, obesity, and family history of IHD), the likelihood of IHD remained lower in patients with vWD than in patients without (OR=0.65; 95% CI, 0.63-0.67). Our study shows that vWF deficiency, as seen in patients with vWD, is associated with a decreased prevalence of IHD. Further investigation may confirm these findings.

Outcomes and resource utilization in calcium pyrophosphate deposition disease patients who underwent total knee arthroplasty: a cross-sectional analysis.

This cross-sectional study aims to evaluate the predictors, outcomes, and resource utilization of total knee arthroplasty (TKA) in calcium pyrophosphate deposition disease (CPPD) patients. We used the US National Inpatient Sample database to identify CPPD and non-CPPD who underwent TKA from 2006 to 2014. Data collection included patient demographics and comorbidities. Outcomes following TKA included in-hospital mortality, complications, length of hospitalization, hospital charges, and disposition. Among the 5,564,005 patients who have undergone TKA, 11,529 (0.20%) had CPPD, with a median age of 72 years, and 53.7% were females. Compared with non-CPPD, patients with CPPD were more likely to be older (mean 72 vs 66 years; p < 0.001), male, white, and have Medicare insurance. CPPD patients were more likely to have ≥ 2 comorbidities calculated by the Charlson Comorbidity Index and discharge to an inpatient/rehabilitation facility. Regarding inpatient complications, myocardial infarction and knee reoperation were significantly more common in CPPD patients. TKA in CPPD patients was associated with significantly higher odds of increased length of stay (> 3 days) than those without CPPD (OR 1.43, 95% CI 1.37-1.49). There was no significant difference in the in-hospital mortality even after adjusting for possible confounders. CPPD patients who underwent TKA were more likely to have a longer hospital stay and discharge to a non-home setting than non-CPPD. Also, CPPD patients had a higher comorbidity burden and risk for myocardial infarction and reoperation.Key Points• This is the largest study to analyze data of CPPD patients who underwent TKA and compare them with non-CPPD patients, using a large nationwide database.• Compared to non-CPPD patients, TKA in CPPD patients is associated with a greater length of stay and disposition to a nursing/rehabilitation facility.• In-hospital complications such as myocardial infarction and reoperation were more frequently observed in CPPD patients than non-CPPD.• The results of this study should alert healthcare providers to develop strategies in order to improve outcomes of CPPD patients undergoing TKA.

Factors Associated with Survival of Hepatocellular Carcinoma (HCC) Patients at a Safety Net Hospital in Arizona without On-Site Liver Transplant Program.

BACKGROUND: With the rising incidence of hepatocellular carcinoma (HCC), ongoing efforts should be focused on providing equitable and state-of-the-art care to patients. PURPOSE: The aim of this study was to determine the survival of patients with HCC seen at a high-proportion Safety Net Hospital (h-SNH), where loco-regional therapy and hepatology services are available and liver transplantation (LT) is referred to outside facilities. PATIENTS AND METHODS: A retrospective cohort study was conducted on all patients with HCC seen at Valley Wise Health Center (VWHC) over a ten-year period. Clinical variables, treatment modalities, survival duration, hospice, and LT referrals of 161 patients were collected from the medical records. Survival analysis was used to determine the relationship of clinically relevant variables and survival among patients with HCC. A Log rank test was used to compare univariate variables. A Cox regression analysis was used to compare and control for multiple variables. RESULTS: Of the 161 patients included in the study, 33% were uninsured. The median age was 59 (21 to >89) years with 47% Hispanic, 31% Caucasian, 15% African American and 7% other races included for the analysis. The median survival for the cohort was 20.1 months. In the multivariate model, insurance status, final MELD, tumor within the Milan criteria and having received treatment for HCC were associated with survival. Surveillance for HCC was associated with HCC in the univariate analysis, but not in the multivariable model. Thirty percent of patients were referred for LT and 1.25% of the entire cohort received it. CONCLUSION: Despite the availability of treatment modalities available for HCC at VWHC and the option of liver transplantation for appropriate candidates at outside centers, OS was less than reported from programs with on-site liver transplant programs. Reasons for lower survival in centers without liver transplant programs should be further studied.

Adult emergency department naloxone education and prescription program: Video and pamphlet education comparison.

OBJECTIVES: This study looked at the fill rate of naloxone prescriptions, after the implementation of an opioid overdose and naloxone education intervention for adult patients in the emergency department (ED). The study compared fill rates between recipients who received this education by video versus written format. METHODS: This was a prospective, randomized controlled study of patients seen in the adult ED for opioid-related complaints between August 1, 2017, and December 1, 2018. The study randomized patients to education through video or written pamphlet, and all patients received a prescription for a free naloxone kit redeemable at the discharge pharmacy. The study calculated and compared naloxone prescription fill rates for the respective education methods. RESULTS: Of the 770 patients reviewed for recruitment, the study excluded 703. Of the 67 patients enrolled, 59 were contacted at follow-up and eighteen (30.5%) had filled a naloxone prescription. Thirty-three percent (13/39) of patients who received video education and 25% (5/20) who received written pamphlet education filled naloxone prescriptions. The p-value of the chi-square for this data was 0.53. CONCLUSIONS: There is a large population affected by opioid overdose both nationally and locally in Arizona. Opioid overdose and naloxone distribution education for ED patients through both video and pamphlet is feasible but requires more research to determine which education method is superior. Legislative changes, improved identification of patients at high risk for opioid overdose, opiate education for medical providers, and naloxone availability from multiple venues are needed to create a holistic approach to improve naloxone access to those who need it most.

Severe acute respiratory syndrome coronavirus 2: a canary in the coal mine for public safety net hospitals.

BACKGROUND: The coronavirus disease 2019 pandemic has exposed disproportionate health inequities among underserved populations, including refugees. Public safety net healthcare systems play a critical role in facilitating access to care for refugees and informing coordinated public health prevention and mitigation efforts during a pandemic. OBJECTIVE: This study aimed to evaluate the prevalence ratios of severe acute respiratory syndrome coronavirus 2 infection between refugee women and nonrefugee parturient patients admitted to the hospital for delivery. Here, we suspected that the burden of infection was disproportionately distributed across refugee communities that may act as sentinels for community outbreaks. STUDY DESIGN: A cross-sectional study was conducted examining parturient women admitted to the maternity unit between May 6, 2020, and July 22, 2020, when universal testing for severe acute respiratory syndrome coronavirus 2 was first employed. Risk factors for severe acute respiratory syndrome 2 positivity were ascertained, disaggregated by refugee status, and other clinical and sociodemographic variables examined. Prevalence ratios were calculated and comparisons made to county-level community prevalence over the same period. RESULTS: The positive test percentage at the county-level during this study period was 21.6%. Of 350 women admitted to the hospital for delivery, 33 (9.4%) tested positive for severe acute respiratory syndrome 2. When refugee status was determined, 45 women (12.8%) were identified as refugees. Of the 45 refugee women, 8 (17.8%) tested positive for severe acute respiratory syndrome 2 compared with 25 nonrefugee patients (8.19%) who tested positive for severe acute respiratory syndrome 2 (prevalence ratio, 2.16; 95% confidence interval, 1.04-4.51). In addition, 7 of the refugee women who tested positive for severe acute respiratory syndrome coronavirus 2 were from Central Africa. CONCLUSION: The severe acute respiratory syndrome coronavirus 2 outbreak has disproportionately affected refugee populations. This study highlighted the utility of universal screening in mounting a rapid response to an evolving pandemic and how we can better serve refugee communities. Focused response may help achieve more equitable care related to severe acute respiratory syndrome 2 among vulnerable communities. The identification of such populations may help mitigate the spread of the disease and facilitate a timely, culturally, and linguistically enhanced public health response.

Association of clinical characteristics, disease activity and health-related quality of life in SLE patients with major depressive disorder.

OBJECTIVE: To determine the contributing factors associated with major depressive disorder (MDD) in SLE patients and examine the association between disease-specific health-related quality of life [lupus quality of life (LupusQoL)] domains and MDD. METHODS: Depression was assessed by the patient health questionnaire (PHQ)-9, and scores ≥10 indicate MDD. Demographic data, LupusQoL domains, clinical and other features of the SLE patients were described and compared between MDD (PHQ-9 ≥10) and non-MDD (PHQ-9 <10) groups using χ2 tests for categorical variables and Wilcoxon rank sum tests for non-normal continuous variables. The risk of MDD was evaluated for the patient and physician-reported features individually using log-binomial models to estimate relative risks and 95% confidence limits. RESULTS: Eighty-eight patients with SLE met eligibility criteria, with a mean (range) age of 48.6 (19-80), mostly female (80%) and with a mean disease duration of 13.2 years. Compared with the non-MDD group, patients with MDD (n = 32, 36%) were more likely to have the following SLE manifestations: mucocutaneous, vascular, ocular, pulmonary and musculoskeletal involvement. Self-rated health described as poor/fair was markedly associated with MDD (P < 0.001, relative risk = 0.48). Based on relative risks, higher pain visual analogue score, and patient and physician global assessment scores were also linked to MDD. The LupusQoL domain scores were notably lower in the MDD patients, with a statistically significant reduction in all LupusQoL domains. CONCLUSION: Predictors of MDD in SLE patients include higher scores in pain and global assessment, poor or fair self-reported health, and specific organ involvement. These findings may help clinicians to recognize and manage MDD promptly.

Characteristics and Outcomes Among Patients With Autoimmune Rheumatic Diseases Requiring a Higher Level of Care.

OBJECTIVE: Patients with autoimmune rheumatic diseases (ARDs) have a higher risk of developing organ failure, and they may require admission to the intensive care unit (ICU). The aim of our study is to determine the reasons for admission to the ICU, identify potential risk factors associated with mortality, and assess the outcomes of patients with ARD diseases admitted to the ICU. METHODS: We conducted a medical records review study of patients with ARD admitted to the ICU from 2012 to 2018. Patient data included demographic and clinical characteristics, ICU admission diagnoses, length of stay, complications, and immunosuppressive regimen. Short-term and long-term outcomes were assessed. RESULTS: A total of 80 ARD patients were identified with the mean age of 48.8, 67% were female, and 56% were Hispanic. The most common disease associated with ICU admission was systemic lupus erythematosus (42%), followed by rheumatoid arthritis (26%), and 12% of patients had systemic vasculitis. Sepsis was the leading cause of ICU admission, accounting for 31%, followed by respiratory failure due to pneumonia (10%) and congestive heart failure (10%). Twenty percent of patients died in the ICU, 5% died 30 days after ICU admission, and 7.5% died within 1 year after the ICU stay, resulting in overall mortality of 33% by the end of 1 year. Nonsurvivors were more likely to need mechanical ventilation (p = 0.001), vasopressor support (p < 0.001), had renal (p = 0.041) or cardiovascular (p < 0.001) involvement on admission, APACHE II score higher than 19 (p = 0.001), and 4 days or longer stay in the ICU (p = 0.001). CONCLUSIONS: Our findings indicated that systemic lupus erythematosus is the most common ARD associated with ICU admission, and sepsis was the most frequent cause. Predictors associated with higher mortality were the requirement for mechanical ventilation, vasopressor support, increase length of ICU stay, and renal and cardiovascular involvement on admission.

Pediatric Cervical Spine Clearance and Immobilization Practice Among Prehospital Emergency Medical Providers: A Statewide Survey.

OBJECTIVES: Pediatric cervical spine injuries are rare but potentially life threatening. Although published guidelines for assessment of such injuries exist, there is less uniformity in its implementation in out-of-hospital settings. Our purpose was to assess the knowledge and practice patterns for pediatric cervical spine immobilization among prehospital emergency medical services (EMS) providers in Arizona. METHODS: A cross-sectional web-based survey was conducted (October-December 2018), using an electronic mailing list of certified EMS providers (ground and air) in Arizona. A 20-question structured web-based survey was developed and deployed. RESULTS: One hundred eight EMS stations were contacted with the survey. Sixty-eight providers responded; majority were emergency medical paramedics (73.1%). Most of the stations surveyed did not have a pediatric trauma center (66.2%). When treating children younger than 3 years, half of the respondents stated they did not know of a specific cervical spine clearance criterion; 59.3% felt that cervical spine immobilization was required "sometimes," and 40.0% were unaware of the state's EMS pediatric cervical spine clearance algorithm; 93.9% of EMS providers felt that an age-based algorithm for cervical spine clearance in children would be useful. CONCLUSIONS: In this statewide survey involving prehospital EMS providers, we found that pediatric cervical spine clearance and immobilization practices, even within a specific geographic location, remain inconsistent.