Facility-based approach for the management of acute ST segment elevation myocardial infarction with cardiogenic shock in a rural medical centre: the Durango model.

INTRODUCTION: Cardiogenic shock (CS) complicates 5%-15% of cases of acute myocardial infarction (AMI) with inpatient mortality greater than 40%. The implementation of standardised protocols may improve clinical outcomes in patients with AMI-CS. METHODS AND ANALYSIS: The Durango model is a prospective single-centre registry designed to enable early identification of patients with STEMI-CS to facilitate primary reperfusion therapy with a shock team management algorithm in a rural level II heart attack centre. This prospective registry includes all patients >18 years of age presenting with STEMI with or without CS beginning on 1 February 2023. The primary outcome measures are adherence to model-based documentation of SCAI shock Classification prehospital and in the ED with appropriate STEMI shock alert for AMI and stages C, D, E shock; use of mechanical circulatory support Pre-PCI and door to support time <90 min. ETHICS AND DISSEMINATION: This study was approved by the Institutional Review Board with a waiver of informed consent. The findings will be submitted for publication in a peer-review open access journal on completion of the study. CONCLUSIONS: The Durango model will demonstrate that the implementation of a STEMI shock team can be feasible in a rural medical centre through comprehensive education of a diverse group providers with different levels of experience, continuous model/device proficiency training and performance feedback.

Applying molecular genetic data at different scales to support conservation assessment of European Habitats Directive listed species: A case study of Eurasian otter in Austria.

Evaluating intraspecific genetic structure and diversity is fundamental to assessing a species' conservation status, but direct incorporation of such information into legal frameworks such as the EU's Habitats Directive is surprisingly rare. How genetic structure aligns with EU member state boundaries or biogeographic regions may be very important in designing management plans or achieving legislative goals. The Eurasian fish otter experienced a sharp population decline during the 20th century but is currently re-expanding in several countries. The species is listed under Annex II and IV of the European Habitats Directive, and member states are obliged to assess the species separately across different biogeographic regions. We genotyped 2492 otter spraints across four provinces in Austria, collected between 2017 and 2021. A total of 384 different genotypes were identified, supporting densities along river habitats from 0.1 to 0.47 otters per river km (mean: 0.306), with a resampling-based simulation supporting limited density overestimation at survey lengths of 20 km or more. Three distinct genetic clusters were revealed, two of them presumably reflecting two relict populations whereas the source of the third cluster is unknown. The geographic extent of the three clusters does not coincide with provincial or biogeographic boundaries, both relevant for assessment and management within existing national or European legislative frameworks. We advocate more consideration of genetic structure in the assessment and conservation management planning of species listed in the European Habitats Directive.

Evaluating a species phylogeny using ddRAD SNPs: Cyto-nuclear discordance and introgression in the salmonid genus Thymallus (Salmonidae).

Hybridization and introgression are very common among freshwater fishes due to the dynamic nature of hydrological landscapes. Cyclic patterns of allopatry and secondary contact provide numerous opportunities for interspecific gene flow, which can lead to discordant paths of evolution for mitochondrial and nuclear genomes. Here, we used double digest restriction-site associated DNA sequencing (ddRADseq) to obtain a genome-wide single nucleotide polymorphism (SNP) dataset comprehensive for allThymallus (Salmonidae)species to infer phylogenetic relationships and evaluate potential recent and historical gene flow among species. The newly obtained nuclear phylogeny was largely concordant with a previously published mitogenome-based topology but revealed a few cyto-nuclear discordances. These incongruencies primarily involved the placement of internal nodes rather than the resolution of species, except for one European species where anthropogenic stock transfers are thought to be responsible for the observed pattern. The analysis of four contact zones where multiple species are found revealed a few cases of mitochondrial capture and limited signals of nuclear introgression. Interestingly, the mechanisms restricting interspecific gene flow might be distinct; while in zones of secondary contact, small-scale physical habitat separation appeared as a limiting factor, biologically based reinforcement mechanisms are presumed to be operative in areas where species presumably evolved in sympatry. Signals of historical introgression were largely congruent with the routes of species dispersal previously inferred from mitogenome data. Overall, the ddRADseq dataset provided a robust phylogenetic reconstruction of the genus Thymallus including new insights into historical hybridization and introgression, opening up new questions concerning their evolutionary history.

A comprehensive DNA barcode inventory of Austria's fish species.

Austria is inhabited by more than 80 species of native and non-native freshwater fishes. Despite considerable knowledge about Austrian fish species, the latest Red List of threatened species dates back 15 years and a systematic genetic inventory of Austria's fish species does not exist. To fulfill this deficit, we employed DNA barcoding to generate an up-to-date and comprehensive genetic reference database for Austrian fish species. In total, 639 newly generated cytochrome c oxidase subunit 1 (COI) sequences were added to the 377 existing records from the BOLD data base, to compile a near complete reference dataset. Standard sequence similarity analyses resulted in 83 distinct clusters almost perfectly reflecting the expected number of species in Austria. Mean intraspecific distances of 0.22% were significantly lower than distances to closest relatives, resulting in a pronounced barcoding gap and unique Barcode Index Numbers (BINs) for most of the species. Four cases of BIN sharing were detected, pointing to hybridization and/or recent divergence, whereas in Phoxinus spp., Gobio spp. and Barbatula barbatula intraspecific splits, multiple BINs and consequently cryptic diversity were observed. The overall high identification success and clear genetic separation of most of the species confirms the applicability and accuracy of genetic methods for bio-surveillance. Furthermore, the new DNA barcoding data pinpoints cases of taxonomic uncertainty, which need to be addressed in further detail, to more precisely assort genetic lineages and their local distribution ranges in a new National Red-List.

ETC Model: How One Small Dialysis Organization Is Navigating Uncharted Policy Waters.

The ETC model proposes to increase access to home dialysis and transplant for patients with ESRD. Implementation of this model is happening while many dialysis organizations are still suffering the far-reaching effects of the coronavirus disease 2019 (COVID-19) pandemic. In addition, the model has the potential to negatively affect small and independent dialysis organizations disproportionately. It incentivizes home dialysis over transplant and promotes development of new home dialysis programs, rewards achievement over improvement, and places an excessive burden on small and independent dialysis organizations. Advantages of the program include the focus on self-care as an acceptable alternative to home dialysis for some patients and the potential for some organizations to make improvements in care with increased reimbursements. The authors hope that the Centers for Medicare and Medicaid Services will address many of these concerns in updated rulemaking and guidance.

Early adolescents' physical activity and nutrition beliefs and behaviours.

Obesity in early adolescents is a public health concern and presents a risk for poor health outcomes later in life. Early adolescents' beliefs and behaviours of physical activity and healthy eating are not well understood. The purpose of this ethnographic inquiry was to explore the physical activity and healthy eating beliefs and behaviours of early adolescents (n = 15) who attended a community organization in an urban cluster in the Southeastern USA. Data from semi-structured interviews, participant observations and artefact collection were analysed using constant comparative analysis. We learned that five main influences on the early adolescents' healthy eating and physical activity included recognizing benefits of physical activity and healthy eating, family influences, connecting with the community, peer influences, and developing a sense of self. Findings highlight community influences on early adolescents' physical activity and healthy eating beliefs and behaviours that should be taken into account when developing health promotion strategies.

Pharmacological prevention of renal ischemia-reperfusion injury in a rat model.

INTRODUCTION: Renal ischemia-reperfusion injury (IRI) can lead to significant morbidity and mortality. It remains a leading cause of acute kidney injury and is therefore an important issue in trauma and renal transplant surgery. Various pharmaceutical agents have been used in an attempt to dampen the harmful effects of IRI but few have been shown to be useful clinically. Riluzole, Lidocaine and Lamotrigine have been demonstrated to show anti-ischaemic properties in other organs; however, their use has not been tested in the kidneys. We investigated Riluzole, Lidocaine and Lamotrigine for their preventive effects of renal IRI using a rat model. METHODS: Winstar rats (n = 48) were divided into four groups (n = 12 per group)-three treatment groups and one control group. Riluzole, Lidocaine and Lamotrigine were given prior to renal ischemia only (IO) or IRI. The degree of ischemia was measured by glutathione levels and a TUNEL assay was used to measure DNA fragmentation. RESULTS: Riluzole, Lidocaine and Lamotrigine pre-treatment each resulted in statistically higher glutathione levels compared to controls (P = 0.002; P = 0.007 and P = 0.005, respectively). Riluzole and Lidocaine were also effective at preventing depletion of glutathione following IO (P = 0.007 and P = 0.014 respectively), while Lamotrigine was ineffective in IO (P = 0.71). The degree of DNA fragmentation seen on the TUNEL assay was markedly reduced in all three-drug groups in both IO and IRI. DISCUSSION: Riluzole, Lidocaine and Lamotrigine all have anti-ischaemic effects in the rat kidney and can have potential therapeutic implications.

Evaluating a Novel Hemodialysis Central Venous Catheter Cap in Reducing Bloodstream Infections: A Quality Improvement Initiative.

PURPOSE: Central line-associated bloodstream infection (CLABSI) is the second leading cause of death in hemodialysis patients. Patients dialyzed via central venous catheters (CVCs) are more susceptible to vascular access-related bloodstream infection (VRBSI), sepsis, and mortality when compared to patients with other dialysis accesses. PATIENTS AND METHODS: A retrospective observational data analysis was conducted from 13 outpatient dialysis clinics in the United States to compare novel chlorhexidine-coated end caps to standard needlefree connectors for differences in CLABSI rates when utilizing CVCs for hemodialysis. There were two periods in this study: in the first study period over a 5-month period (May 2018 to September 2018), data were evaluated from a group of patients undergoing hemodialysis using chlorhexidine end-caps ('chlorhexidine group') as well as a group using standard needlefree connectors ('standard group'). An initial assessment found that a substantial CLABSI rate reduction was seen with use of chlorhexidine-coated end caps; therefore, most patients were switched to chlorhexidine by February 2019 and data continued to be collected till June 2019. The second study period spanned 9 months from October 2018 to June 2019. RESULTS: Across 13 dialysis centers, anonymized health records of 5934 patients who were dialyzed via CVCs between May 2018 and June 2019 were analyzed. The mean age was 61.3 and 47.1% of all patients were female. Study period one included 967 patients with chlorhexidine and 1044 patients with standard end caps, while there were 3647 chlorhexidine and 276 standard patients in the second period. The combined CLABSI rate in the chlorhexidine group was 0.09/1000 CVC days versus 0.63/1000 CVC days in the standard group (p<0.0001). CONCLUSION: Chlorhexidine-coated CVC caps may provide a therapeutic improvement in CVC hemodialysis management.

The rare and enigmatic mayfly Prosopistoma pennigerum (Müller, 1785): Habitat characteristics, recent records from the Volga (Russia) and Vjosa (Albania) rivers, and a proposal for flagship species status.

Nymphs of all 29 described Prosopistoma species share a conspicuous synapomorphy: a round mesonotal shield, the carapace. They occur in the Palaearctic (nine species), the Oriental (12 species) and the Afrotropic as well as Australian regions (six and two species, respectively). Relatively little is known about their ecology, but past and extant distribution patterns indicate an association with undisturbed conditions. Prosopistoma pennigerum is a rare European mayfly with conspicuous nymphs. Formerly common in large rivers, it has been extirpated from central Europe over the last century.This study evaluated general habitat characteristics and human pressures for historical and current records of this rare species. Prosopistoma pennigerum is currently known from only three European rivers, all with gravel substrates, naturally dynamic discharge regimes, summer-warm water temperatures, and little human pressure.This study showed that nymphs from the Vjosa and upper Volga rivers, two relatively natural watercourses 2,000 km apart, are morphologically indistinguishable, and show no variation across a ca. 600-bp fragment of the mitochondrial cytochrome c oxidase I gene.Flagship species were first designated in the 1980s, when charismatic species with high habitat requirements such as the Bengal tiger or the giant panda, but also invertebrates are used to communicate conservation and protection needs. We propose that Europe's rarest mayfly P. pennigerum, with its unusual nymphs and remaining populations in naturally dynamic river courses, can serve as a flagship species promoting the preservation of ecological integrity in European rivers.

Riluzole protects against skeletal muscle ischaemia-reperfusion injury in a porcine model.

INTRODUCTION: Skeletal muscle ischaemia-reperfusion injury (IRI) can be a life threatening condition. It is relevant to various aspects of the management of trauma and surgical patients. Currently there lacks a pharmacological agent that can be used to dampen the effects of IRI. Riluzole has been shown to reduce the effects of IRI on various organ systems, but there have yet to be any studies on the effects in IRI of skeletal muscle. Our aim was to investigate the effects of Riluzole on IRI in the skeletal muscle of pigs. METHODS: Twenty-two pigs were randomly divided into groups. Riluzole was administered before ligation of the femoral artery to produce ischaemia in the tibialis anterior muscle in the experimental group but not the control group. The microscopic appearance of muscles were recorded, a TUNEL assay was used to identify DNA damage and glutathione levels were measured. RESULTS: In the Riluzole group, muscle fibres appeared less wavy and less oedematous compared to the control group. The Riluzole group also had less evidence of DNA fragmentation on the TUNEL assay. The glutathione levels in the Riluzole group were also significantly greater than the control group. DISCUSSION: Our findings suggest that Riluzole can potentially reduce the effects of IRI on skeletal muscle. This is potentially due to the ability of Riluzole to block sodium channels, decreasing action potentials and therefore glutamate release. It also acts to decrease intracellular calcium levels, which prevents apoptosis. Riluzole is a promising drug for the prevention of IRI in skeletal muscle, but further research is required.

Sepsis alerts in EMS and the results of pre-hospital ETCO2.

BACKGROUND: Field sepsis alerts have the ability to expedite initial ED sepsis treatment. Our hypothesis is that in patients that meet EMS sepsis alert criteria there is a strong relationship between prehospital end-tidal carbon dioxide (ETCO2) readings and the outcome of diagnosed infection. METHODS: In 2014, our EMS service initiated a protocol requiring hospitals to receive notification of a "sepsis alert" on all suspected sepsis patients. The EMS service transports 70,000 patients/year to a number of urban centers. All patients transported to our major urban teaching hospital by our EMS service in one year in which a sepsis alert was announced were included in this study. The primary outcome variable was diagnosed infection and secondary outcomes were hospital admission, ICU admission and mortality. Positive lactate was defined as >4.0 mmol/L. ROC curve analysis was used to define the best cutoff for ETCO2. RESULTS: 351 patients were announced as EMS sepsis alert patients and transported to our center over a one year period. Positive outcomes were as follows: diagnosed infection in 28% of patients, hospital admission in 63% and ICU admission in 11%. The correlation between lactate and ETCO2 was -0.45. A ROC curve analysis of ETCO2 vs. lactate >4 found that the best cutoff to predict a high lactate was an ETCO2 of 25 or less, which was considered a positive ETCO2 (AUC = 0.73). 27% of patients had a positive ETCO2 and 24% had a positive lactate. A positive ETCO2 predicted a positive lactate with 76% accuracy, 63% sensitivity and 80% specificity. 27% of those with a positive ETCO2 and 44% of those with a positive lactate had a diagnosed infection. 59% of those with a positive ETCO2 and 89% of those with a positive lactate had admission to the hospital. 15% of those with a positive ETCO2 and 18% of those with a positive lactate had admission to the ICU. Neither lactate nor ETCO2 were predictive of an increased risk for diagnosed infection, hospital admission or ICU admission in this patient population. CONCLUSION: While ETCO2 predicted the initial ED lactate levels it did not predict diagnosed infection, admission to the hospital or ICU admission in our patient population but did predict mortality.

Assessing the Prevalence and Predictors of Bullying Among Emergency Medical Service Providers.

Background: Bullying as a stressor in the workplace has been evaluated in numerous settings. It has never been evaluated in the emergency medical service (EMS) environment where bullying can occur from many different sources. The Negative Acts Questionnaire-Revised (NAQ-R) is a 22-question validated tool for evaluating bullying. Our hypothesis was that we could identify a shortened version of the NAQ-R that identifies bullying as accurately as the full screening tool. Methods: This was a cross sectional study of EMS providers in our local EMS transport agency. The local EMS agency transports approximately 50,000 patients per year and is a paramedic level response system. Results on the NAQ-R were on a 5-point Likert scale for each of 22 different categories of bullying that were summed by adding each questions 1-5 response for the 22 questions. Respondents were also categorized as victims or non-victims of bullying based on being positive for any of the 22 types of bullying at least once a week. We performed a binomial decision tree analysis and a cross-validation. Results: Data were collected from 153 providers. Mean age was 33 ± 10 years and 50% were male. Total years in EMS were 8 ± 8 years. NAQ-R summed results in our group ranged between 22 and 88, with an average of 40 ± 15. A NAQ-R score of 33 or less was 91% accurate in identifying non-victims and a score of 45 or more was 94% accurate in identifying victims. The majority at 51% (77/152) of respondents were victims of one or more types of bullying. A combination of five questions was 94% accurate in identifying a victim of bullying among EMS providers. Cross validation resulted in a misclassification risk estimate of 0.12 ± .03. Conclusion: NAQ-R bullying scores in EMS are similar or higher than numbers in other fields. Five questions on the NAQ-R were 94% accurate in identifying victims of bullying in EMS providers.

Thyroid stimulating hormone testing in ED evaluation of patients with atrial fibrillation and various psychiatric diagnoses.

BACKGROUND: Previous studies of thyroid stimulating hormone (TSH) levels in Emergency Department (ED) patients largely have centered on patients with atrial fibrillation (AF). In our ED patients with AF as well as patients with Psychiatric diagnoses (psych) are screened. The purpose of the present study was to compare TSH levels in the 2 groups. Our hypotheses were that an abnormal TSH and/or AF predicted the need for hospital admission and that TSH is more likely decreased in AF and increased in psych patients. METHODS: Our goal in the study was to compare the use of TSH testing in two ED populations, AF vs. psych patients. The study was a cross sectional cohort of AF vs. psych patients who had TSH levels drawn in the ED over a two year period. Our laboratory ranges were used to determine high vs. low TSH. Two chart examiners collected data after a training process. Charts were reviewed extracting demographic data, TSH levels, outcome (admit vs. discharge), history of AF, thyroid disease, psych diagnoses, presence of CHF, diabetes, hypertension. We compared AF vs. Psych groups using chi square and t-tests for parametric data. Odds ratios were calculated for comparisons between the 2 groups. For non-parametric data Mann Whitney U was used. A logistic regression was performed with the outcome of admission vs. discharge to find predictors of hospital admission. Kappa was calculated for inter-rater agreement. An a priori power analysis showed 80% power with 2 groups of 100 with an absolute difference of 20% between the 2 groups. RESULTS: 252 patients were included, 101 with AF and 152 Psych. Demographics differed in age only with AF patients being older. Mean TSH for AF vs. 2.4 for AF, 2.9 for psych (NS) with no differences in percentages with high or low TSH in the 2 groups. Fifty-three patients had abnormal TSH levels (21%), 27% of AF and 17% of Psych patients (NS). There were significant differences in incidence of CHF, DM, HTN, and tachycardia with more in the AF group (P < 0.001). Significantly more of the psych patients had a history of hypothyroidism (OR 2.28). Our logistic regression showed that taking into account demographics including age, the only predictors of admission were the presence of CHF (aOR 18.6) and having a diagnosis of AF (aOR 4.0). CONCLUSION: There were no differences in TSH levels between the 2 groups. Twenty-one percent had an abnormal level. CHF and AF predicted hospital admission on regression analysis. Many with these AF or Psych diagnoses had abnormal ED TSH levels that could be useful in diagnosis, maintenance, or continuous treatment for their conditions diagnoses.

Bathing Habits in Emergency Department Patients with Cellulitis or Abscess Versus Controls.

OBJECTIVE: Cellulitis is a leading cause of emergency department (ED) visits, with more than 200 cases per 100,000 people per year. Although many risk factors have been identified, including edema, skin breakdown, and penetrance of the skin, there are few data available on whether personal hygiene habits (bathing and clean clothes) are associated with increased risk for soft tissue infection. Studies looking at chlorhexidine baths in the intensive care unit to prevent soft tissue infections have shown conflicting and limited efficacy. Our objective was to determine whether poor personal hygiene, as manifested in poor bathing habits, a lack of access to clean clothes, or frequent needle self-injections, are associated with cellulitis or abscesses. METHODS: The research is a cross-sectional cohort study of patients with either cellulitis, soft tissue abscess, or both (cases) versus a control group of patients with abdominal pain without prior surgeries in a large, urban ED in a convenience sampling. We asked about bathing habits, access to clean clothing, and skin breaks from intravenous (IV) drug use as risk factors. The two groups were compared using descriptive statistics, and a regression analysis was performed to determine the characteristics that are predictive of soft tissue infections. The study was powered at 0.8 to detect a 20% difference in adequate bathing habits with 100 per group. RESULTS: In an approximate 1-year study period, 108 cases were identified and compared with 104 abdominal pain controls selected at random from patients presenting to the same ED. In the cellulitis/abscess group the mean age was 47 and 81% were men, and in the control group the mean age was 45 and 39% were men. There were significantly more men in the cellulitis/abscess group (Diff 22%, 95% confidence interval [CI] 8-34, P < 0.01). Seventy percent (76 of 108) of cases versus 58% (80 of 104) of controls bathed daily (odds ratio [OR] 1.7, 95% CI 0.98-3.1, not significant). There was a significant difference between the two groups in laundry habits: 66% (71 of 108) of cases versus 42% (44 of 104) of controls did not have access to clean laundry daily (adjusted OR [AOR] 2.5, 95% CI 1.4-5.0, P < 0.01). The most profound and significant difference was noted between cases and controls regarding the use of IV drugs, in which 20 of 108 cases (19%) used IV drugs versus 3 of 104 controls (3%, P < 0.01). Finally, 35 of 108 (32%) of our cases had a history of infections, whereas only 5 of 104 (5%) of the controls had cellulitis or an abscess previously (P < 0.01). On regression analysis significant predictors of soft tissue infection were history of skin infection (AOR 7.0) and not cleaning clothes daily (AOR 2.5). CONCLUSIONS: There was no significant difference in bathing habits, but there was a significant difference in laundry habits between the case and control groups. Our study further confirms that IV drug use is a risk factor for cellulitis and no access to clean clothes daily was significantly related to the development of cellulitis. Failing to obtain daily showers was not associated with an increase in infection.

Explaining negative refraction without negative refractive indices.

Negative refraction through a triangular prism may be explained without assigning a negative refractive index to the prism by using array theory. For the case of a beam incident upon the wedge, the array theory accurately predicts the beam transmission angle through the prism and provides an estimate of the frequency interval at which negative refraction occurs. The hypotenuse of the prism has a staircase shape because it is built of cubic unit cells. The large phase delay imparted by each unit cell, combined with the staircase shape of the hypotenuse, creates the necessary conditions for negative refraction. Full-wave simulations using the finite-difference time-domain method show that array theory accurately predicts the beam transmission angle.

Inferring phylogenetic structure, hybridization and divergence times within Salmoninae (Teleostei: Salmonidae) using RAD-sequencing.

Phylogenetic studies focusing on Salmonidae have revealed significant obstacles in trying to clarify some interspecific relationships within the Salmoninae subfamily, due to a limited number of markers typed, conflicting phylogenetic signals and ancient hybridization events. To infer reliable phylogenetic relationships, evaluate several putative scenarios of ancient hybridization, and estimate divergence times within Salmoninae, we applied restriction-site associated DNA sequencing (RAD-seq) to 43 samples, including 26 genetic lineages across 21 species, largely representing the subfamily, with an emphasis on the genus Salvelinus. We identified 28,402 loci and 28,363 putatively unlinked SNPs, which were used in downstream analyses. Using an iterative k-means partitioned dataset and a Maximum Likelihood approach; we generated a well-supported phylogeny, providing clear answers to several previous phylogenetic uncertainties. We detected several significant introgression signals, presumably ancient, in the genus Salvelinus. The most recent common ancestor of Salmonidae dates back to approximately 58.9MY ago (50.8-64 MY) and the crown age of Salmoninae was estimated to be 37.7 MY (35.2-40.8 MY) using a Bayesian molecular dating analysis with a relaxed molecular clock. The divergence among genera of the subfamily occurred between the late Eocene and middle of the Miocene (≈38-11 MY) such as the divergence between the genus Oncorhynchus and Salvelinus, which we estimated to 21.2 MY ago (95% HPD: 19.8-23.0 MY), while species diversification took place mainly during the Neogene (≈22-1.5 MY), with more than half of these events occurring in the last 10 MY.

Implementation of electronic charting is not associated with significant change in physician productivity in an academic emergency department.

OBJECTIVES: To compare physician productivity and billing before and after implementation of electronic charting in an academic emergency department (ED). MATERIALS AND METHODS: This retrospective, blinded, observational study compared the 6 months pre-implementation (January to June 2012) with the 6 months post-implementation 1 year later (January to June 2013). Thirty-one ED physicians were recruited, with each physician acting as his/her own control in a before-after design. Productivity was measured via total number of encounters and "productivity index" defined as worked relative value units divided by the clinical full-time equivalent. Values for charges, encounters, and productivity index were determined during each study period and separately for procedures, observational stays, and critical care. RESULTS: No differences were found for total productivity index per month (758 [623-876] pre-group vs. 756 [673-886] post-group; P = 0.30). There was, however, a 9% decrease in total encounters per month (138 [101-163] pre-group vs. 125 [99-159] post-group; P = 0.01). Significant decreases were seen across all observation stay categories. Conversely, significant increases were seen across all critical care categories. There was no difference in total charges per month. DISCUSSION: This is one of few studies to demonstrate minimal disruption in physician productivity after transitioning to electronic documentation. The reasons for these findings are likely multi-factorial. CONCLUSION: In this study, implementation of electronic charting was not associated with decreases in productivity or billing for total ED care, but may be associated with increases for critical care and decreases for observational stays.

Patients Given Take Home Medications Instead of Paper Prescriptions Are More Likely to Return to Emergency Department.

Objective: The aim of this study was to compare the 30-day emergency department (ED) return rate between patients given a Take Home Medication pack (THM) versus a standard paper prescription (SPP) prior to discharge. Methods: This was an observational, prospective cohort study in an urban, university-affiliated, level I trauma center. Patients were identified through daily pharmacy reports. Consecutive adult patients discharged from the ED with either a THM or equivalent SPP were included. For each patient, baseline characteristics including age, gender, primary care provider (PCP), primary language, ethnicity, marital status, and insurance status were recorded from the electronic medical record (EMR). Review of the EMR was used to determine whether patients returned to the ED within 30 days and whether the return visit was for all-causes or for the same complaint targeted by the THM or SPP from the index visit. Similarly, visits to other providers in the health system within 30 days were recorded. Results: A total of 711 patients were included in the study, with 268 receiving a THM and 443 receiving a SPP. In comparison with the SPP group, the THM group was more likely to have an all-cause return (Relative Risk [RR] = 1.7, P < .01). Variables associated with increased odds of returning to the ED within 30 days included study group (adjusted Odds Ratio [aOR]: 1.7), male gender (aOR: 1.6), African American ethnicity (aOR: 3.0), public insurance (aOR: 3.3), and institutional financial assistance (aOR: 5.0). The difference between study groups for index visit complaint-specific returns was not significant. Conclusions: Patients receiving a THM demonstrated a higher all-cause return rate than patients receiving a SPP. A randomized study is needed evaluating the effect of THM on return ED visits.

Cross-Sectional Study of the Relation of Health Literacy to Primary Language and Emergency Department Length of Stay.

OBJECTIVES: The primary aim of this study was to determine whether emergency department (ED) length of stay (LOS) or primary language was related to the degree of health literacy of patients. METHODS: Adult English-speaking and Spanish-speaking patients were recruited for the study. Participants completed the Newest Vital Sign (NVS) tool (English and Spanish versions), a 6-question validated scale. Patients with NVS scores of 0 to 3 were considered to be at risk for limited health literacy, whereas those with adequate health literacy were defined as scoring a 4 to 6. After completion of their ED visit, a retrospective chart review was performed to identify the patient's ED LOS (time from registration to time of disposition) and ED disposition. In addition, 2 single-item questions were compared with the NVS for validity. RESULTS: Participants included 250 English-speaking and 257 Spanish-speaking subjects. Per the NVS, 71% (359 of 507) of all patients had limited health literacy. By language group, significantly more Spanish-speaking than English-speaking patients had limited health literacy (93% vs 48%, diff 45%, 95% confidence interval 37-51). There was no significant difference in LOS between the limited health literacy group and adequate health literacy group (medians 440 vs 461 min). The 2 single-item questions had fair validity in comparison to the NVS scale (κ 0.2-0.3). CONCLUSIONS: There was a significant difference in health literacy based on language, with 93% of all Spanish-speaking patients in our sample having limited health literacy. We found no significant difference in ED LOS between patients with limited health and adequate health literacy in an academic urban ED setting.