Prediction of anemia in real-time using a smartphone camera processing conjunctival images.

Anemia is defined as a low hemoglobin (Hb) concentration and is highly prevalent worldwide. We report on the performance of a smartphone application (app) that records images in RAW format of the palpebral conjunctivae and estimates Hb concentration by relying upon computation of the tissue surface high hue ratio. Images of bilateral conjunctivae were obtained prospectively from a convenience sample of 435 Emergency Department patients using a dedicated smartphone. A previous computer-based and validated derivation data set associating estimated conjunctival Hb (HBc) and the actual laboratory-determined Hb (HBl) was used in deriving Hb estimations using a self-contained mobile app. Accuracy of HBc was 75.4% (95% CI 71.3, 79.4%) for all categories of anemia, and Bland-Altman plot analysis showed a bias of 0.10 and limits of agreement (LOA) of (-4.73, 4.93 g/dL). Analysis of HBc estimation accuracy around different anemia thresholds showed that AUC was maximized at transfusion thresholds of 7 and 9 g/dL which showed AUC values of 0.92 and 0.90 respectively. We found that the app is sufficiently accurate for detecting severe anemia and shows promise as a population-sourced screening platform or as a non-invasive point-of-care anemia classifier.

The Accuracy of Predictive Analytics in Forecasting Emergency Department Volume Before and After Onset of COVID-19.

Introduction: Big data and improved analytic techniques, such as triple exponential smoothing (TES), allow for prediction of emergency department (ED) volume. We sought to determine 1) which method of TES was most accurate in predicting pre-coronavirus 2019 (COVID-19), during COVID-19, and post-COVID-19 ED volume; 2) how the pandemic would affect TES prediction accuracy; and 3) whether TES would regain its pre-COVID-19 accuracy in the early post-pandemic period. Methods: We studied monthly volumes of four EDs with a combined annual census of approximately 250,000 visits in the two years prior to, during the 25-month COVID-19 pandemic, and the 14 months following. We compared the accuracy of four models of TES forecasting by measuring the mean absolute percentage error (MAPE), mean square errors (MSE) and mean absolute deviation (MAD), comparing actual to predicted monthly volume. Results: In the 23 months prior to COVID-19, the overall average MAPE across four forecasting methods was 3.88% ± 1.88% (range 2.41-6.42% across the four ED sites), rising to 15.21% ± 6.67% during the 25-month COVID-19 period (range 9.97-25.18% across the four sites), and falling to 6.45% ± 3.92% in the 14 months after (range 3.86-12.34% across the four sites). The 12-month Holt-Winter method had the greatest accuracy prior to COVID-19 (3.18% ± 1.65%) and during the pandemic (11.31% ± 4.81%), while the 24-month Holt-Winter offered the best performance following the pandemic (5.91% ± 3.82%). The pediatric ED had an average MAPE more than twice that of the average MAPE of the three adult EDs (6.42% ± 1.54% prior to COVID-19, 25.18% ± 9.42% during the pandemic, and 12.34% ± 0.55% after COVID-19). After the onset of the pandemic, there was no immediate improvement in forecasting model accuracy until two years later; however, these still had not returned to baseline accuracy levels. Conclusion: We were able to identify a TES model that was the most accurate. Most of the models saw an approximate four-fold increase in MAPE after onset of the pandemic. In the months following the most severe waves of COVID-19, we saw improvements in the accuracy of forecasting models, but they were not back to pre-COVID-19 accuracies.

Cannabis Use Patterns and Whole-Blood Cannabinoid Profiles of Emergency Department Patients With Suspected Cannabinoid Hyperemesis Syndrome.

STUDY OBJECTIVES: The objectives of this study were to characterize the detailed cannabis use patterns (eg, frequency, mode, and product) and determine the differences in the whole-blood cannabinoid profiles during symptomatic versus asymptomatic periods of participants with suspected cannabinoid hyperemesis syndrome recruited from the emergency department (ED) during a symptomatic episode. METHODS: This is a prospective observational cohort study of participants with symptomatic cyclic vomiting onset after chronic cannabis use. Standardized assessments were conducted to evaluate for lifetime and recent cannabis use, cannabis use disorder, and cannabis withdrawal symptoms. Quantitative whole-blood cannabinoid testing was performed at 2 times, first when symptomatic (ie, baseline) and at least 2 weeks after the ED visit when asymptomatic. The differences in cannabinoid concentrations were compared between symptomatic and asymptomatic testing. The study was conducted from September 2021 to August 2022. RESULTS: There was a difference observed between delta-9-tetrahydrocannabinol metabolites, but not the parent compound during symptomatic episodes and asymptomatic periods. Most participants (84%) reported using cannabis > once per day (median 3 times per day on weekdays, 4 times per day on weekends). Hazardous cannabis use was universal among participants; the mean cannabis withdrawal discomfort score was 13, indicating clinically significant rates of cannabis withdrawal symptoms with cessation of use. Most participants (79%) previously tried to stop cannabis use, but a few (13%) of them had sought treatment. CONCLUSION: Patients presenting to the ED with cannabinoid hyperemesis syndrome have high cannabis use disorder scores. Further studies are needed to better understand the influence of THC metabolism and concentrations on symptomatic cyclic vomiting.

Cannabinoid hyperemesis syndrome: clinical trajectories and patterns of use three months following a visit to the emergency department.

OBJECTIVES: Cannabinoid hyperemesis syndrome (CHS) is a clinical condition of cyclic vomiting, nausea, and abdominal pain associated with chronic cannabis use. Despite increased recognition of CHS, there are limited details on cannabis use practices and symptoms over time. Understanding what happens in the period surrounding the ED visit, including any changes in symptoms and cannabis use practices following the visit, can help inform the development of patient-centered interventions around cannabis use disorder for patients with CHS. METHODS: A prospective observational cohort (n=39) of patients with suspected CHS recruited from the Emergency Department (ED) at the time of a symptomatic cyclic vomiting episode was followed for three months. Disease progression, cannabis use practices, and health care utilization were monitored. RESULTS: Participants reported high rates of persistent CHS symptoms (abdominal pain, nausea, or cyclic vomiting) in the two-week period immediately following an ED visit with a median duration of 7 days. Cannabis use frequency and quantity were reduced immediately after the ED visit, but most participants returned to pre-ED visit cannabis use patterns within a few days. Recurrent ED visits for cyclic vomiting were reported by 25% of participants who completed follow-up during the three month follow up period. CONCLUSIONS: Participants continued to have ongoing symptoms after the ED visit, but most manage symptoms on their own and do not return to the ED. Longitudinal studies beyond three months are needed to better understand the clinical course of patients with suspected CHS.

The Gender Landscape of Academic Pediatric Emergency Medicine: An Observational Study of Leadership Positions as Described by Fellowship Programs' Online Presence.

OBJECTIVES: Although many areas of medicine are male dominated, pediatric emergency medicine (PEM) is a female-dominated subspecialty. Despite this, executive leadership within PEM remains male dominated. The aim of this study was to describe the gender landscape of the key positions within academic PEM fellowship programs within the United States, as described by PEM fellowships' online presence. METHODS: Using the 2021-2022 Electronic Residency Application Service American Association of Medical Colleges Pediatric Fellowships ( services.aamc.org/eras/erasstats/par/ ) application service, we were able to identify published information from 84 academic PEM fellowship programs in the United States. Each program's Web site was evaluated to determine which individuals held the position of chief or chair, medical director, and fellowship director. These individuals' genders were then cross-referenced with the National Provider Inventory database. RESULTS: There were 154 executive leadership roles (division chief or medical director) in total. The executive leadership role was significantly different by gender ( z score: 2.54, P < 0.01), with greater male representation (n = 61; 62.9%) among identified executive leadership roles (n = 97). There were significantly more men for the medical director role ( z score: 2.06, P < 0.05). Female representation was greater than male in the fellowship program director role (n = 53; 67.9%) among listed roles ( z score: -3.17, P < 0.001). This gender landscape among key leadership positions was not influenced by the geographic location of the PEM fellowship program. CONCLUSIONS: Although PEM is a female-dominated specialty, executive leadership positions continue to be male dominated. To promote improved gender representation within leadership positions in PEM, PEM fellowship programs must provide consistent and easily accessible executive leadership descriptions within their online storefront.

Focused cardiac ultrasound with mitral annular plane systolic excursion (MAPSE) detection of left ventricular dysfunction.

OBJECTIVES: Detecting reduced left ventricular ejection fraction (LVEF) by an emergency physician (EP) is an important skill. The subjective ultrasound assessment of LVEF by EPs correlates with comprehensive echocardiogram (CE) results. Mitral annular plane systolic excursion (MAPSE) is an ultrasound measure of vertical movement of the mitral annulus, which correlates to LVEF in the cardiology literature, but has not been studied when measured by an EP. Our objective is to determine whether EP measured MAPSE can accurately predict LVEF <50% on CE. METHODS: This is a prospective observational single center study using a convenience sample to evaluate the use of a focused cardiac ultrasound (FOCUS) for patients with possible decompensated heart failure. The FOCUS included standard cardiac views to estimate LVEF, MAPSE, and E-point septal separation (EPSS). Abnormal MAPSE was defined as <8 mm and abnormal EPSS as >10 mm. The primary outcome assessed was the ability of an abnormal MAPSE to predict an LVEF <50% on CE. MAPSE also was compared to EP estimated LVEF and EPSS. Inter-rater reliability was determined by two investigators performing independent blinded review. RESULTS: We enrolled 61 subjects, 24 (39%) had an LVEF <50% on a CE. MAPSE <8 mm had a 42% sensitivity (95% CI 22-63), 89% specificity (95% CI 75-97), and accuracy of 71% for detecting LVEF <50%. MAPSE demonstrated lower sensitivity than EPSS (79% sensitivity [95% CI 58-93], and 76% specificity [95% CI 59-88]) and higher specificity than estimated LVEF (100% sensitivity [95% CI 86-100], 59% specificity [95% CI 42-75]). PPV and NPV for MAPSE was 71% (95% CI 47-88) and 70% (95% CI 62-77) respectively. The ROC for MAPSE <8 mm is 0.79 (95% CI 0.68-0.9). MAPSE measurement interrater reliability was 96%. CONCLUSIONS: In this exploratory study evaluating MAPSE measurements by EPs, we found the measurement was easy to perform with excellent agreement across users with minimal training. A MAPSE value <8 mm had moderate predictive value for LVEF <50% on CE and was more specific for reduced LVEF than qualitative assessment. MAPSE had high specificity for LVEF <50%. Further studies are needed to validate these results on a larger scale.

Emergency unit assessment of seven tertiary hospitals in Nepal using the WHO tool: a cross-sectional study.

BACKGROUND: In 2021, the Nepal national emergency care system's assessment (ECSA) identified 39 activities and 11 facility-specific goals to improve care. To support implementation of the ECSA facility-based goals, this pilot study used the World Health Organization's (WHO) Hospital Emergency Unit Assessment Tool (HEAT) to evaluate key functions of emergency care at tertiary hospitals in Kathmandu, Nepal. METHODS: This cross-sectional study used the standardized HEAT assessment tool. Data on facility characteristics, human resources, clinical services, and signal functions were gathered via key informant interviews conducted by trained study personnel. Seven tertiary referral centers in the Kathmandu valley were selected for pilot evaluation including governmental, academic, and private hospitals. Descriptive statistics were generated, and comparative analyses were conducted. RESULTS: All facilities had continuous emergency care services but differed in the extent of availability of each item surveyed. Academic institutions had the highest rating with greater availability of consulting services and capacity to perform specific signal functions including breathing interventions and sepsis care. Private institutions had the highest infrastructure availability and diagnostic testing capacity. Across all facilities, common barriers included lack of training of key emergency procedures, written protocols, point-of-care testing, and ancillary patient services. CONCLUSION: This pilot assessment demonstrates that the current emergency care capacity at representative tertiary referral hospitals in Kathmandu, Nepal is variable with some consistent barriers which preclude meeting the ECSA goals. The results can be used to inform emergency care development within Nepal and demonstrate that the WHO HEAT assessment is feasible and may be instructive in systematically advancing emergency care delivery at the national level if implemented more broadly.

Factors that Predict HPV Vaccination Behavior Among Young Men-Who-Have-Sex-with-Men in the Greater Philadelphia Region.

Human papillomavirus (HPV) is one of the most common sexually transmitted infections in the USA. HPV is acknowledged as one of the leading causes of anal cancer, with an increased risk in men who have sex with men (MSM), when compared to age-matched heterosexual men. This study highlights the various factors that influence and impede HPV vaccination uptake among a multiracial cohort of young-MSM (YMSM). A total of 444 participants aged 18 to 27 in the Greater Philadelphia region completed an online survey. Approximately 75.79% (n = 335) of participants did not receive at least one dose of the HPV vaccine. Having a healthcare provider recommendation (OR = 25.54, 95% CI: 25.54-85.42, p < 0.001) and a one unit increase in experiences of adverse effects of stigma and homophobia (OR = 1.06, 95% CI: 1.01-1.11, p = 0.044) were associated with a greater likelihood of receiving the HPV vaccine uptake. Having a greater number of sexual partners (OR = 0.85, 95% CI: 0.75-0.97, p = 0.014) and having had condomless anal sex in the past 6 months (OR = 0.31, 95% CI: 0.15-0.58, p < 0.001) were associated with a lower odds of HPV vaccine uptake. In conclusion, healthcare provider-focused interventions and educational programs are needed to increase awareness and uptake of the HPV vaccine to mitigate the risks associated with sexual behaviors among this population.

Training program for female community volunteers to combat COVID 19 in rural Nepal.

Female Community Health Volunteers (FCHV) in Nepal have identified lack of appropriate training as a barrier to involvement in the COVID 19 response. With more than 50,000 FCHVs serving rural areas of Nepal, they are instrumental in healthcare and are a major source of information delivery to those with the most limited health-care access in Nepal. This communication describes an innovative training programme to rapidly equip FCHVs with knowledge on COVID 19 response. The ongoing programme leverages partnerships between local municipalities and a local community-based organisation and has rapidly trained more than 300 FCHVs across four districts with a population of 1,000,000, and has plans to expand the training across the country. This training programme is a key example of how local partnerships can be utilised for digital training of FCHVs in remote parts of Nepal and leveraged to strengthen response capacity during the pandemic.

Enhancing the quality of prescribing practices for older adults discharged from the emergency department in Rhode Island.

BACKGROUND: We sought to examine the effectiveness of the Enhancing the Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department (EQUiPPED) medication safety program in three emergency departments (EDs) within the largest health system in Rhode Island (RI) with funding through a quality incentive payment by a private insurance partner. METHODS: This study utilized a quasi-experimental interrupted time series design to implement EQUiPPED, a three-prong intervention aimed at reducing potentially inappropriate medication (PIM) prescriptions to 5% or less per month. We included clinicians who prescribed medications to older ED patients during the pre-and post-intervention periods from July 2018 to January 2021. We determined the monthly rate of PIM prescribing among older adults discharged from the ED, according to the American Geriatrics Society Beers Criteria, using Poisson regression. RESULTS: 247 ED clinicians (48% attendings [n = 119], 27% residents [n = 67], 25% advanced practice providers [n = 61]) were included in EQUiPPED, of which 92% prescribed a PIM during the study period. In the pre-implementation period (July 2018-July 2019) the average monthly rate of PIM prescribing was 9.30% (95% CI: 8.82%, 9.78%). In the post-implementation period (October 2019-January 2021) the PIM prescribing rate decreased significantly to 8.62% (95% CI: 8.14%, 9.10%, p < 0.01). During pre-implementation, 1325 of the 14,193 prescribed medications were considered inappropriate, while only 1108 of the 13,213 prescribed medications in post-implementation were considered inappropriate. The greatest reduction was observed among antihistamines, skeletal muscle relaxants, and benzodiazepines. CONCLUSIONS: EQUiPPED contributed to a modest improvement in PIM prescribing to older adults among clinicians in these RI EDs even in the midst of the COVID-19 pandemic. The quality incentive funding model demonstrates a successful strategy for implementation and, with greater replication, could shape national policy regarding health care delivery and quality of care for older adults.

Examining multilevel neighborhood socioeconomic characteristics associated with colorectal cancer screening in Vietnamese Americans residing in Philadelphia County.

Colorectal cancer (CRC) is one of the most predominant cancers in the USA and ranks third among all cancers in incidence and mortality. Vietnamese Americans exhibit persistently lower screening rates compared to the general U.S. population, due to cultural, economic, and environmental barriers. The impact of environmental factors in particular is not well known, and lack of geographical access may be a significant barrier to accessing screening. This study aims to elucidate build and neighborhood environmental factors affecting CRC screening rates among Vietnamese Americans. A total of 517 Vietnamese Americans 50 years and older residing in Philadelphia County were included in the study. Surveys were collected to determine CRC screening behavior and sociodemographic characteristics. Individual neighborhood characteristics, which included the Walk Score, was obtained based on the participant's address. Neighborhood characteristics were calculated using census-tract level data for the social deprivation index, ethnic composition, and presence of hospitals or federally qualified health centers (FQHC). The generalized linear mixed model revealed that residing in an ethnically dense neighborhood was negatively associated with CRC screening (ß = -0.67, SE = 0.29, p = .01), while social deprivation (ß = 0.30, SE = 0.27, p = .27) and presence of FQHCs or hospitals (ß = 0.16, SE = 0.30, p = .58) were not. Individual neighborhood characteristics including the Walk Score (ß = 0.21, SE = 0.26, p = .43) was not associated with CRC screening behavior. Neighborhood characteristics, specifically ethnic density is associated with lower uptake of screening in this population. Future interventions should aim to target specific Vietnamese American and other Asian ethnic neighborhoods that may experience disparities in screening.

Colorectal cancer (CRC) is one of the most common cancers in the USA and ranks third among all cancers as the leading cause of death. CRC screening is key for early detection and better patient outcomes and is recommended for individuals between ages 50 and 75. Vietnamese Americans are an Asian ethnic group that engages in low levels of colorectal cancer screening. This study aimed to determine how the environment plays a role in being able to obtain CRC screenings. A total of 517 Vietnamese Americans aged 50 years and older residing in Philadelphia County were included in the study. This study found that individuals who live in a neighborhood with greater composition of Asians were less likely to have been screened. Other neighborhood characteristics such as neighborhood walkability, social deprivation, and the presence of Federally Qualified Health Centers and Hospitals in one's neighborhood were not linked to screening. Future interventions should aim to target specific Asian neighborhoods that experience disparities in screening.

Empowering Low-Income Asian American Women to Conduct Human Papillomavirus Self-Sampling Test: A Community-Engaged and Culturally Tailored Intervention.

BACKGROUND: Asian American women face disproportionate burden of cervical cancer (CC) than non-Hispanic white women in the U.S. The goal of this study was to assess the feasibility and impact of a culturally tailored intervention to promote Human papillomavirus (HPV) self-sampling test among hard-to-reach Asian American women. METHODS: We adopted the community-based participatory research (CBPR) approach to conduct this efficacy study. A total of 156 female participants (56 Chinese, 50 Korean, and 50 Vietnamese) were recruited from community-based organizations (CBOs) in the greater Philadelphia metropolitan area. The intervention components included HPV-related education, HPV self-sampling test kit and instructions, group discussions, and patient navigations, all available in Asian languages. We examined several outcomes, including the completion of HPV self-sampling, HPV-related knowledge, perceived social support, self-efficacy, and comfort with the self-sampling test at post-intervention assessment. RESULTS: The majority of Asian American women had low annual household income (62.3% earned less than $20,000) and low educational attainment (61.3% without a college degree). We found significant increase in participants' knowledge on HPV (baseline: 2.83, post: 4.89, P <.001), social support (baseline: 3.91, post: 4.09, P < .001), self-efficacy (baseline: 3.05, post: 3.59, P < .001), and comfortable with HPV self-sample test (baseline: 3.62, post: 4.06, P < .001). CONCLUSION: To the best of our knowledge, this is the first intervention study that promoted HPV self-sampling test among Asian American women. Our findings showed that CBPR culturally tailored intervention of self-sampling was highly effective in empowering low-income Asian American women to conduct HPV self-sampling tests.

A Multilevel Intervention to Increase HPV Vaccination among Asian American Adolescents.

Human papillomavirus (HPV) is the most common sexually transmitted infection in the US. HPV vaccine is a viable source of prevention against high-risk strains that are likely to cause cancer. However, particularly among racial and ethnic minorities such as Chinese Americans, HPV vaccination rates are suboptimal. The goal of this study was to evaluate the effect of a culturally tailored intervention on HPV vaccine uptake in Chinese Americans. We designed and implemented a multilevel longitudinal pilot study to examine the efficacy of the HPV intervention among Chinese American parents/guardians. We recruited 180 participants from federally qualified health center and community-based clinics that serve predominantly low-income Chinese Americans in Philadelphia. Participants were randomized into an intervention group (n = 110) or a control group (n = 70). The intervention group received an HPV specific intervention, while the control group received a general health intervention. The primary outcome was medical record-confirmed receipt of first shot and completion of HPV vaccine within six months of receiving the interventions. Repeated measure ANOVA was utilized to examine the intervention effect on knowledge between intervention and control groups. Knowledge differed significantly, with participants in the intervention group demonstrating the greatest improvement following the intervention. A multivariable logistic regression was used to examine the association between HPV vaccine initiation and study group assignment. There was a significant effect of provider recommendation, parent's gender, and health insurance status on HPV vaccine uptake. This study demonstrated positive impact of a culturally tailored intervention on HPV vaccination uptake among Chinese Americans.

Multilevel Pathways of Colorectal Cancer Screening Among Low-Income Vietnamese Americans: A Structural Equation Modeling Analysis.

BACKGROUND: Colorectal cancer (CRC) disproportionately affects Vietnamese Americans, especially those with low income and were born outside of the United States. CRC screening tests are crucial for prevention and early detection. Despite the availability of noninvasive, simple-to-conduct tests, CRC screening rates in Asian Americans, particularly Vietnamese Americans, remain suboptimal. The purpose of this study was to evaluate the interplay of multilevel factors - individual, interpersonal, and community - on CRC screening behaviors among low-income Vietnamese Americans with limited English proficiency. METHODS: This study is based on the Sociocultural Health Behavior Model, a research-based model that incorporates 6 factors associated with decision-making and health-seeking behaviors that result in health care utilization. Using a community-based participatory research approach, we recruited 801 Vietnamese Americans from community-based organizations. We administered a survey to collect information on sociodemographic characteristics, health-related factors, and CRC screening-related factors. We used structural equation modeling (SEM) to identify direct and indirect predictors of lifetime CRC screening. RESULTS: Bivariate analysis revealed that a greater number of respondents who never screened for CRC reported limited English proficiency, fewer years of US residency, and lower self-efficacy related to CRC screening. The SEM model identified self-efficacy (coefficient = 0.092, P < .01) as the only direct predictor of lifetime CRC screening. Educational attainment (coefficient = 0.13, P < .01) and health beliefs (coefficient = 0.040, P < .001) had a modest significant positive relationship with self-efficacy. Health beliefs (coefficient = 0.13, P < .001) and educational attainment (coefficient = 0.16, P < .01) had significant positive relationships with CRC knowledge. CONCLUSIONS: To increase CRC screening uptake in medically underserved Vietnamese American populations, public health interventions should aim to increase community members' confidence in their abilities to screen for CRC and to navigate associated processes, including screening preparation, discussions with doctors, and emotional complications.