Comparing Pain Intensity Using the Numeric Rating Scale and Defense and Veterans Pain Rating Scale in Patients Revisiting the Emergency Department.

Objective  To determine the relationship between Numeric Rating Scale (NRS) and Defense and Veterans Pain Rating Scale (DVPRS) as pain intensity measures, we compared pain scores to sociodemographic and treatment data in patients revisiting the emergency department (ED). Methods  After Institutional Review Board approval, 389 adults presenting within 30 days of an index visit were enrolled. Pain scores were classified as follows: 0-3 (mild), 4-7 (moderate), and 8-10 (high). Data were analyzed using descriptive analysis. Wilcoxon rank-sum test measured the association of pain score with gender. Pain scales were correlated using Spearman correlation coefficient. Pain scale association with opioid treatment was tested via ordinal logistic regression controlling for gender, home opioid use, and if ED revisit was for pain. Results  Average patient age was 49. Most patients were African American (68.4%), male (51.2%), and returned for pain (67.0%). As continuous measures, both scales were positively correlated with each other (p<0.0001). Pain score severity categories were distributed differently between the two scales (p=0.0085), decreasing by 8% in patients reporting high pain severity when using DVPRS. For both scales, the proportion of patients (1) administered opioids (p=0.0009 and p≤0.0001, respectively) and (2) discharged with opioids (p=0.0103 and p=0.0417, respectively) increased with pain severity. Discharge NRS (p=0.0001) (OR=3.2, 1.780-5.988) and DVPRS pain score categories (p<0.0001) (OR=2.7, 95% CI=1.63-4.473) were associated with revisits for pain.  Conclusions Our findings demonstrate a link between NRS and administration of opioid medications and suggest that DVPRS may better differentiate between moderate and high levels of pain in the ED setting.

IMPACT survey: IMpaired fecundity in Physicians and Association with Clinical Time.

OBJECTIVE: Studies suggest female physicians experience higher rates of infertility than the general population. The overall objective of this study was to determine the rate of impaired fecundity in a sample of female emergency physicians and compare it to the Centers for Disease Control and Prevention (CDC) National Survey of Family Growth (NSFG) data. Impaired fecundity is defined as physical difficulty in getting pregnant or carrying a pregnancy to live birth. METHODS: We performed a cross-sectional survey of female emergency physicians to determine the rate of impaired fecundity. Survey questions were adapted from the NSFG to allow comparison to the general population. Statistical comparisons were made using contingency tables (with chi-square and tau-c assessments), 1-sample t tests, and independent samples t tests, as appropriate. RESULTS: A total of 2072 women completed the survey with a mean (SD) current age of 38.9 (7.2) years. Data were analyzed for women of childbearing years (15-44 years old as defined by the CDC; n = 1705 [82% total responses]). The rate of impaired fecundity in emergency physicians was 24.9% as compared to the NSFG cohort (12.1%; P < 0.001). Female emergency physicians with impaired fecundity reported working 9.8 overall more clinical hours (95% CI 2.5-17) and 4.5 more night hours (95% CI 0.8-8.2) than those with normal fecundity. CONCLUSION: Female emergency physicians have increased rates of impaired fecundity when compared with a general population cohort. Clinical workload and night shifts are greater in female emergency physicians with impaired fecundity. Research is needed to elucidate work-related impaired fecundity risk factors.

Barriers to Utilizing Social Media Platforms in Emergency Medicine Residency Programs.

Background Residency programs seek to incorporate various social media (SoMe) platforms into their educational curricula, yet little is known regarding the potential roadblocks towards implementation. Our objective was to assess the current utilization of SoMe platforms and identify common barriers to implementation by emergency medicine (EM) residency programs. Methods Members of the Council of Emergency Medicine Residency Directors (CORD) Information Technology (IT) Committee developed an anonymous survey distributed to representatives from EM residency programs using the "CORD Community" internet forum. Descriptive statistics including percentages for numerical data as well as Fisher's exact test for categorical data were used to report results. Results We received 116 individual responses from faculty, fellows, and residents of EM residency programs. The most common institutional, departmental, technological and knowledge barriers identified were restricted access to blogs (12.9%), insufficient protected time (17.2%), insufficient IT support to host the platform (16.4%), and a lack of knowledge among faculty of how to utilize blogs (23.3%) respectively. Ten respondents (8.6%) reported that their programs had not attempted to utilize any SoMe platforms. Community-based programs and smaller programs (<24 residents) were significantly more likely to identify barriers to SoMo use among this cohort. Conclusion Utilization of SoMe platforms for resident education by EM residency programs is increasingly common, but significant obstacles exist on many levels that prevent programs from leveraging these innovations for knowledge translation. This is particularly common for community-based and small residency programs. Awareness of these common barriers will allow institutions and programs to better anticipate and design solutions to overcome these obstacles.

A 6-year retrospective review of pediatric firearm injuries: do patients < 14 years of age differ from those 15-18 years of age?

BACKGROUND: Pediatric firearm injuries are an increasing source of morbidity. Firearm injuries in adolescents are common but not well studied in younger children. The aims were to describe the epidemiology of firearm injuries in patients 0 year to 18 years old, with a case study of patients 14 years or younger for determining shooting characteristics and epidemiologic trends. METHODS: Part 1 obtained data from hospital trauma registry. Inclusion criteria were patients 0 year to 18 years of age presenting from 2005 to 2010 with firearm injury and registry inclusion. Demographic and injury data were extracted. Part 2 included a retrospective review of patients 14 years or younger including hospital and emergency medical services records. Data from the group 0 year to 14 years included shooting and treatment details. Categorical variables were described using counts and percentages. Differences between the groups were assessed using odds ratios (ORs), along with 95%confidence intervals (CIs), extracted from logistic regression models. RESULTS: Registry query resulted in 456 patients (0-18 years), including 78 patients who are 14 years or younger. In the group of 0 to 18 years, 86% were male; 83% were black in the group of 15 to 18 years and 64% in the group 0 to 14 years. Overall death rate was 7%. Patients in the group of 15 years to 18 years were twice more likely (23% vs. 11%) to arrive via car or walk-in compared with the patients in the group of 0 year to 14 years (OR, 2.32;95% CI, 1.07-5.03). Patients in the group of 0 year to 14 years were almost four times more likely to be shot at home compared with those who are 15 years to 18 years (OR, 3.76; 95% CI, 2.29-6.19). Patients in the group of 5 years to 9 years were six times more likely to have multiple injury sites compared with those who are 10 years to 14 years (OR, 6.26; 95% CI, 1.26-31.09). Only 13% had documented child protective services notification. CONCLUSION: Results from this study suggest that firearm injuries differ in younger patients compared with adolescents. The younger subset was more likely to be shot at home versus public settings. Hospital and emergency medical services records lacked important shooting details often found in crime scene reports, which are necessary for the development of effective crime and prevention strategies.

Racial Differences in Blood Lipids Lead to Underestimation of Cardiovascular Risk in Black Women in a Nested observational Study.

BACKGROUND: During screening for enrollment in a clinical trial, we noticed potential racial disparities in metabolic syndrome variables in women who responded to our study advertisement. We designed a nested observational study to investigate whether metabolic syndrome variables differed between non-Hispanic blacks and non-Hispanic whites. METHODS: The cohort comprised of women who have met the preliminary clinical trial criteria (body mass index [BMI] 25-45, age 20-75 years, and no use of lipid-lowering medications or supplements). These women, including 116 blacks and 138 whites, provided fasting blood samples for analysis of serum lipid profile. RESULTS: Blacks had lower mean triglycerides (81.1 ± 3.3 mg/dL vs 140.6 ± 5.9 mg/dL; P < .0001), total cholesterol (176.1 ± 3.6 mg/dL vs 201.6 ± 3.3 mg/dL; P < .0001), and low-density lipoprotein (111.7 ± 3.3 mg/dL vs 128.2 ± 2.9 mg/dL; P < .001) and higher mean BMI (37.2 ± 0.5 vs 35.2 ± 0.5; P < .01) and diastolic blood pressure (82.4 ± 0.8 mmHg vs 79.4 ± 0.7 mmHg; P < .01) than whites. Only 7% of blacks, compared with 41% of whites, had triglycerides ≥150 mg/dL; as a result, fewer black women met metabolic syndrome criteria than white women. Additionally, in women with waist circumference ≥88 cm (N = 215), high-density lipoprotein was higher in blacks than in whites (48.3 ± 1.5 mg/dL vs 44.2 ±1.3 mg/dL; P < .05). CONCLUSIONS: Due to racial differences in blood lipids, current metabolic syndrome criteria may result in underestimation of cardiovascular risk in blacks.

Reduced use of occult bacteremia blood screens by emergency medicine physicians using immunization registry for children presenting with fever without a source.

OBJECTIVES: This study examined whether utilization of the Florida State Health Online Tracking System (SHOTS) immunization registry to determine Haemophilus influenzae type B and heptavalent pneumococcal conjugate (PCV7) vaccine status impacts the protocolized decision to perform a screening blood draw for occult bacteremia (OB) in young children. METHODS: A convenience sample of children 6 to 24 months of age presenting to the pediatric emergency department with fever of greater than 39°C without a source was enrolled. Physicians were trained to use the SHOTS immunization registry and reviewed the emergency department's fever protocol. A "preregistry" workup plan was documented for each patient based on clinical history, immunization status before accessing SHOTS, and physical examination. A "postregistry" workup plan was then documented based on the SHOTS record. Demographic and registry data were recorded. RESULTS: Preregistry workup plans indicated OB screening blood draws for 100% (n = 91; 95% confidence interval [CI], 96-100) of patients with unconfirmed immunization status. Of those 91 children, 58% (n = 53; 95% CI, 55-61) were documented in SHOTS as having received their primary conjugate vaccine series at ages 2, 4, and 6 months. Registry access reduced the percentage of screening blood draws from 100% (n = 91) to 42% (n = 38; 95% CI, 37-53; P < 0.001). CONCLUSIONS: The state immunization registry is an adjunctive tool to caregiver recall, which can be used by emergency medicine practitioners to confirm completion of the primary conjugate vaccine series before making the decision to perform blood screens for OB in children aged 6 to 24 months who present with fever without a source.

A Mediterranean-style low-glycemic-load diet improves variables of metabolic syndrome in women, and addition of a phytochemical-rich medical food enhances benefits on lipoprotein metabolism.

BACKGROUND: The high prevalence of metabolic syndrome (MetS) has highlighted the need for effective dietary interventions to combat this growing problem. OBJECTIVE: To assess the impact of a Mediterranean-style low-glycemic-load diet (control arm, n = 44) or the same diet plus a medical food containing phytosterols, soy protein, and extracts from hops and acacia (intervention arm, n = 45) on cardiometabolic risk variables in women with MetS. METHODS: In this 12-week, 2-arm randomized trial, baseline, week 8 and 12, fasting blood samples were drawn to measure plasma lipids, apolipoproteins, and homocysteine. Dietary records were also collected and analyzed. RESULTS: There were decreases in fat and sugar intake (P < .001 for both) and increases in docosahexaenoic acid and eicosapentaenoic acid intake (P < .001 for both) over time, consistent with the prescribed diet. Regarding MetS variables, there were decreases in waist circumference, systolic and diastolic blood pressure, and plasma triglycerides in all subjects (P < .001 for all) with no differences between arms. Plasma low-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol, apolipoprotein (apo) B, and apo B/apo A1 were reduced over time but to a greater extent in the intervention arm (P < .05 for all), indicating the medical food had a greater effect in altering lipoprotein metabolism. Further, medical food intake was associated with reduced plasma homocysteine (P < .01) compared to the control arm. CONCLUSION: A Mediterranean-style low-glycemic-load diet effectively reduces the variables of MetS. Addition of the medical food results in a less atherogenic lipoprotein profile and lower plasma homocysteine.