Pathways between Adverse Change in Employment and Alcohol Use among U.S. Women during a Global Pandemic: The Moderating Role of Conformity to Masculine Norms.

BACKGROUND: This study examined changes in reported alcohol use among women during the early stages of the COVID-19 pandemic and the relations to adverse changes in employment (e.g. job loss, furlough, reduced pay). Further, this study assessed how the relation between changes in alcohol use and experiencing an adverse change in employment was moderated by four theoretically relevant dimensions of conformity to masculine norms (CMNI, i.e. risk-taking, winning, self-reliance, and primacy of work). METHODS: The sample for the present study is a subset of a survey that was conducted in the spring of 2020 among U.S. adults and includes 509 participants who met the inclusion criteria. We assessed pandemic-related employment change status, changes in reported frequency and quantity of alcohol consumed, and four CMNI dimensions. Relations between these variables were assessed with a multinomial logistic regression path model. RESULTS: Experiencing an adverse change in employment early in the pandemic was related to increased alcohol use when moderated by the CMNI dimension primacy of work. For people higher on primacy of work, an adverse change in employment was associated with a higher likelihood of reporting an increase in frequency, but not quantity, of drinking (rather than a decrease or no change). Not experiencing an adverse change in employment early in the pandemic was associated with an increased likelihood of reporting an increase for quantity but not frequency. CONCLUSION: The results highlight the importance of considering how work-oriented women may be at risk for increasing alcohol use when confronted with changes in work status.

Domains matter: A prospective investigation of traditional feminine gender roles and alcohol use among Latinas.

Scholars suggest traditional feminine gender roles (TFGRs) influence alcohol use among U.S. Latinas, but relevant literature is limited. This two-wave study examined how multi-dimensional internal (i.e., beliefs) and external (i.e., practices) TFGR processes related to drinking among college-bound Latina emerging adults across time. TFGRs characterized by virtue predicted less alcohol engagement, while some TFGR dimensions (e.g., subordinate) predicted more. TFGR practices more strongly predicted cross-sectional alcohol outcomes than TFGR beliefs, although some TFGR beliefs predicted later drinking. These findings highlight the utility of assessing multiple TFGR dimensions and domains to better understand the link between TFGRs and drinking among Latinas.

Understanding ED Buprenorphine Initiation for Opioid Use Disorder: A Guide for Emergency Nurses.

Opioid use disorder is a critical public health problem that continues to broaden in scope, adversely affecting millions of people worldwide. Significant efforts have been made to expand access to medication therapy for opioid use disorder, in particular buprenorphine. As the emergency department is a critical point of access for many patients with opioid use disorder, the initiation of buprenorphine therapy in the emergency department is increasing, and emergency nurses should be familiar with the care of these vulnerable patients. The purpose of this article is to provide a clinical review of opioid use disorder and opioid withdrawal syndrome, medication treatments for opioid use disorder, best clinical practices for ED-initiated buprenorphine therapy, assessment of withdrawal symptoms, discharge considerations, and concerns for special populations. With expanded understanding of opioid use disorder, withdrawal, and available treatments, emergency nurses will be better prepared to deliver and support life-saving treatments for patients and families suffering from this disease. In addition, emergency nurses are well positioned to play an important role in public health advocacy around opioid use disorder, providing critical support for destigmatization and expanded access to safe and efficacious treatments.

The combined relations of gender, enculturation, and depressive symptoms with health risk behaviors in Mexican-Americans: a moderated mediation analysis.

Objectives: The present study investigated the relationships of enculturation and depressive symptoms with health risk behavior engagement in Mexican-American college students and examined how these relationships differed by gender. Previous research has noted consistent gender differences in health risk behavior (e.g. alcohol use, substance use, and risky sexual behavior) among Latina/os, and emphasized the role of U.S. acculturation in this difference. Research examining the role of heritage cultural retention (i.e. enculturation), and including the added influence of mental health variables, such as depressive symptoms, is currently lacking. This study sought to address this gap.Design: A large sample (N = 677) of Mexican-American college students from four universities (located in New York, California, Florida, and Texas) completed an online questionnaire assessing health risk behaviors and corresponding variables.Results: We found that males who endorsed more behavioral enculturation and depressive symptoms were more likely to engage in health risk behavior than all others in the sample. Contrary to previous literature, no relationship was found between behavioral enculturation and health risk behavior in females.Conclusion: The current study found behavioral enculturation to be associated with depressive symptoms, and in turn with health risk behaviors among the males in our sample. Additional research will be needed to identify the mechanism underlying the relationship between enculturation and depressive symptoms as well as between depressive symptoms and risky behavior.

Traditional Gender Roles and the Stress-Alcohol Relationship among Latina/o College Students.

BACKGROUND: Latina/o college students have been shown to engage in more high risk drinking behavior than students from other ethnic minority groups, and are more likely to experience certain negative alcohol related consequences as a result of drinking. Previous research links stress to drinking among college students and indicates drinking occurs within a gendered context. Although this suggests an effect of gender role socialization, studies exploring these relationships among Latina/os are lacking. OBJECTIVES: To explore potential relationships of stress, gender role prescriptions of the heritage culture, and drinking among Latina/o college students. Specifically, to explore potential interactions between stress and multiple dimensions of machismo and marianismo as related to alcohol use. METHOD: Latina/o undergraduates (N = 248) completed a questionnaire. Self-reported stress, quantity of alcohol consumption, and frequency of binge drinking were recorded for all participants. Gender role prescriptions were assessed via endorsement of two dimensions of machismo (men) or two dimensions of marianismo (women). RESULTS: Stress was positively related to general quantity for women. Each dimension of machismo was distinctly related to binge drinking for men. Significant interactions emerged between both machismo and marianismo and stress as related to both alcohol use outcomes. For women, the moderating pattern between marianismo and stress varied according to type of alcohol use. Conclusions/Importance: Gender role beliefs influence the relationship between stress and alcohol use among Latina/o college students. Future research should account for the intersection of gender and culture when considering the stress-alcohol relationship.

A systematic review of smoking cessation interventions in the emergency setting.

STUDY OBJECTIVE: Cigarette smoking remains the leading cause of preventable death in the United States, and tobacco use rates are known to be higher among emergency department (ED) patients than in the general population. Despite recommendations from the Society for Academic Emergency Medicine and the American College of Emergency Physicians, many emergency clinicians remain uncertain about the benefits of providing ED-based smoking cessation interventions. To address this gap in knowledge, we performed a systematic review of cessation interventions initiated in the adult or pediatric ED setting. METHODS: We conducted an electronic search of the MEDLINE and CINAHL databases through February 2014 and hand searched references from potentially relevant articles. We identified eligible studies, evaluated bias and validity, and extracted data and synthesized findings. RESULTS: Seventeen studies underwent critical appraisal, with 13 included in qualitative synthesis. The majority (11/13, 85%) of investigations did not report significant differences in tobacco abstinence between cessation intervention groups. The 2 studies reporting significant differences in cessation both used motivational interviewing-based interventions. Two studies evaluated patient satisfaction with ED-based tobacco cessation interventions, and both reported greater than 90% satisfaction. CONCLUSIONS: Findings indicate that ED visits in combination with ED-initiated tobacco cessation interventions are correlated with higher cessation rates than those reported in the National Health Interview Survey. Clear data supporting the superiority of one intervention type were not identified. Lack of a standardized control group prevented quantitative evaluation of pooled data, and future research is indicated to definitively evaluate intervention efficacy.

Impact of a computerized order set on adherence to Centers for Disease Control guidelines for the treatment of victims of sexual assault.

BACKGROUND: Care of the sexual assault patient in the Emergency Department can be challenging due to complex pharmacologic interventions, evidence-collection procedures, and concomitant injury. OBJECTIVE: We sought to determine the effect of a standard, computerized order set for the treatment of adult victims of sexual assault on compliance with current Centers for Disease Control and Prevention (CDC) guidelines for the treatment of this population. METHODS: This study utilized a pretest-post-test design to evaluate the implementation of a standardized order set that provided clinicians with treatment recommendations consistent with CDC guidelines. Comparison of the rate of compliance with CDC guidelines before (n = 322) and after (n = 131) implementation of the order set was the primary outcome. Additional analyses examined for differences in compliance based upon evaluation by a sexual assault nurse/forensic examiner (SANE/SAFE), sex, and race. RESULTS: Pre-intervention phase compliance was 14 of 322 cases (4.4%) and post-intervention compliance was 108 of 131 cases (82.4%). This difference was statistically significant, χ(2) = 291.635, df = 1, p < 0.001. Overall, compliance with CDC pharmacologic recommendations was achieved in 122 (26.9%) cases. Evaluation by a SANE/SAFE nurse conferred no statistically significant difference in compliance. No statistically significant differences were noted based upon sex or race. CONCLUSIONS: The implementation of a standard, computerized order set for the treatment of adult victims of sexual assault significantly improved medical provider compliance with CDC treatment guidelines. This research demonstrates that electronic order sets can promulgate evidence-based practices in clinical medicine.

Emergency medical services triage using the emergency severity index: is it reliable and valid?

INTRODUCTION: Efficient communication between emergency medical services (EMS) and ED providers using a common triage system may enable more effective transfers when EMS arrives in the emergency department. We sought (1) to evaluate inter-rater reliability between Emergency Severity Index (ESI) assignments designated by EMS personnel and emergency triage nurses (registered nurses [RNs]) and (2) to evaluate the validity of EMS triage assignments using the ESI instrument. METHODS: This prospective, observational study evaluated inter-rater reliability in ESI scores assigned by prehospital personnel and RNs. EMS providers were trained to use the ESI by the same methods used for nurse training. EMS personnel assigned triage scores to patients independent of assignments by the RN. Inter-rater reliability, differences based on provider experience, and validity of EMS triage assignments (sensitivity and specificity) were evaluated. RESULTS: Seventy-five paired, blinded triages were completed. Overall concordance between EMS providers and RNs was 0.409 (95% confidence interval [CI], 0.256-0.562). Agreement for EMS providers with less experience was 0.519 (95% CI, 0.258-0.780), whereas concordance for those with more experience was 0.348 (95% CI, 0.160-0.536; χ(2) = 1.413, df = 1, P = .235). Sensitivity ranged from 0% to 67.86%. Specificity ranged from 68.09% to 97.26%. CONCLUSIONS: We observed moderate concordance between EMS and RN ESI triage assignments. EMS sensitivity for correct acuity assignment was generally poor, whereas specificity for correctly not assigning a particular level was better. Additional research investigating the potential causes of the poor agreement that we observed is warranted.

Red blood cell transfusion: experience in a rural aeromedical transport service.

INTRODUCTION: The administration of blood products to critically ill patients can be life-saving, but is not without risk. During helicopter transport, confined work space, communication challenges, distractions of multi-tasking, and patient clinical challenges increase the potential for error. This paper describes the in-flight red blood cell transfusion practice of a rural aeromedical transport service (AMTS) with respect to whether (1) transfusion following an established protocol can be safely and effectively performed, and (2) patients who receive transfusions demonstrate evidence of improvement in condition. METHODS: A two-year retrospective review of the in-flight transfusion experience of a single-system AMTS servicing a rural state was conducted. Data elements recorded contemporaneously for each transfusion were analyzed, and included hematocrit and hemodynamic status before and after transfusion. Compliance with an established transfusion protocol was determined through structured review by a multidisciplinary quality review committee. RESULTS: During the study, 2,566 missions were flown with 45 subjects (1.7%) receiving in-flight transfusion. Seventeen (38%) of these transports were scene-to-facility and 28 (62%) were inter-facility. Mean bedside and in-flight times were 22 minutes (range 3-109 minutes) and 24 minutes (range 8-76 minutes), respectively. The most common conditions requiring transfusion were trauma (71%), cardiovascular (13%) and gastrointestinal (11%). An average of 2.4 liters (L) of crystalloid was administered pre-transfusion. The mean transfusion was 1.4 units of packed red blood cells. The percentages of subjects with pre- and post-transfusion systolic blood pressures of <90 mmHg were 71% and 29%, respectively. The pre- and post-transfusion mean arterial pressures were 62 mmHg and 82 mmHg, respectively. The pre- and post- transfusion mean hematocrit levels were 17.8% and 30.4%, respectively. At the receiving institution, 9% of subjects died in the Emergency Department, 18% received additional transfusion within 30 minutes of arrival, 36% went directly to the operating room, and 36% were directly admitted to intensive care. Thirty-one percent of subjects died prior to hospital discharge. There were no protocol violations or reported high-risk provider blood exposure incidents or transfusion complications. All transfusions were categorized as appropriate. CONCLUSIONS: In this rural AMTS, transfusion was an infrequent, likely life-saving, and potentially high-risk emergent therapy. Strict compliance with an established transfusion protocol resulted in appropriate and effective decisions, and transfusion proved to be a safe in-flight procedure for both patients and providers.

Thinking about drinking: Acculturation and alcohol-related cognitions among college-bound Latinas.

Objective: This study examined acculturation with positive alcohol expectancies (PAE) and alcohol use intentions among college-bound Latinas using a bidimensional (ie U.S. acculturation/enculturation) and bidomain (ie behaviors/values) acculturation framework. Participants: A total of 298 Latina young adults between 18 and 20 years old were included in this analysis. Methods: Data were collected the summer before participants began college for the first time. We used an online survey to assess acculturation, PAE, and alcohol use expectancies. Results: Path analyses showed that U.S. acculturation values were related to more PAE and alcohol use intentions. U.S. acculturation behaviors were related to more alcohol use intentions, and the pathway was moderated by PAE. There was also an interaction between U.S. acculturation and enculturation behaviors predicting alcohol use intentions. Conclusion: This study sheds light on how acculturating Latina young women think about alcohol use prior to beginning college, which is an opportune window for targeted prevention programs.

Implementing an electronic point-of-care medical record at an organized athletic event: challenges, pitfalls, and lessons learned.

OBJECTIVE: We examined the feasibility of implementing an electronic health record (EHR) at an international running event. DESIGN: Institutional review board-approved observational study. SETTING: An annual international running event supported by an on-site medical facility. PARTICIPANTS: All registered athletes. INTERVENTION: Web-based EHR provided at no cost. Participants were asked to populate it with essential health data. The EHR was accessed for runners requiring medical services. MAIN OUTCOME MEASURES: Obstacles to EHR utilization, reliability of EHR functionality in the field, and ability to correctly match runners to their EHR. RESULTS: Only 320 (5%) of the participants utilized the EHR. Repeated notification, no cost, and ready access proved to be insufficient drivers for use. Lack of reliable Internet connectivity hampered full functionality. "Bib swapping" may pose a risk for participant misidentification with resultant electronic medical error. CONCLUSIONS: Barriers to the successful utilization of an EHR were identified. Despite education and promotion, voluntary participant enrollment was a challenge. Mandatory enrollment will be required if universal EHR adoption is the goal. Internet connectivity needs to be logistically planned. Future efforts should focus on measures to ensure that EHRs are correctly matched to participants. Bib swapping must be eliminated if athletes are to be identified by their assigned numbers.

The knowledge and usage of complementary and alternative medicine by emergency department patients and physicians.

OBJECTIVES: To evaluate Emergency Department (ED) patients' desire to discuss complementary and alternative medicine (CAM) with their emergency physicians, their willingness to try CAM for their presenting complaint, and emergency physicians' attitudes, beliefs, and usage of CAM. METHODS: A written questionnaire asking about CAM knowledge, usage, and interest was administered to a convenience sample of ED patients and put in work mailboxes of emergency physicians at an academic tertiary care referral center with an emergency medicine residency program. RESULTS: Of the 75 patients surveyed, 54.7% stated that they were currently using or had used some form of CAM in the past. Only 24% of patients stated that they would discuss their usage of CAM with their emergency physician. Eighty-one percent of patients thought it was important for their physicians to be educated about CAM, and 85% would be willing to incorporate CAM into the treatment of their presenting complaint. Out of 34 emergency physicians, 28 (82%) completed their surveys. Forty percent of physicians stated that they are currently using or had used some form of CAM in the past. Ninety-six percent of physicians surveyed thought it was important for physicians to be educated about CAM and were willing to discuss CAM with their patients. CONCLUSION: The use and public acceptance of CAM in our study population, for both patients and physicians, was high. Although patients and physicians need more education about CAM, both made it clear that they desire and are willing to discuss CAM with each other.

A Bidimensional Examination of Machismo in Relation to Risky Sexual Cognitions and Behavior among Latino College Men.

Objective: College students and Latina/o individuals are disproportionately affected by adverse consequences related to risky sex, highlighting the importance of examining sociocultural factors related to risky sexual variables among Latina/o college students. We explored the link between machismo (a bidimensional form of masculinity often ascribed to Latino men) and risky sexual outcomes among Latino college men. Methods: Latino college men responded to an online study assessing two dimensions of machismo, and risky sexual cognitions (eg, risky sexual intentions) and behavior (eg, condom use). Results: Among our findings, a hypermasculine dimension of machismo predicted greater intentions to engage in risky sex, and more positive condom use attitudes. A dimension of machismo characterized by respect and chivalry predicted more frequent condom use. Conclusions: These findings indicate the relation between machismo and risky sex among Latino college men is complex, underscoring the need for sociocultural considerations in culturally tailored collegiate sexual-risk prevention programs.

Performance of endotracheal intubation and rescue techniques by emergency services personnel in an air medical service.

BACKGROUND: Literature spanning the last two decades has identified potential harm associated with out-of-hospital endotracheal intubation performed by ground paramedics. Previous researchers have reported intubation success rates of 66% to 97% in the air medical setting. OBJECTIVE: To examine the success of endotracheal intubation and rescue techniques performed by air medical personnel during the first eight years of operation of the air ambulance service. METHODS: This study was a retrospective survey of health records utilizing data from LifeFlight of Maine's airway procedure quality review database, covering the first eight years of system encounters. RESULTS: During the study period, 369 intubation encounters occurred. Rapid-sequence intubation medications were administered in 345 (93.5%) cases. Flight personnel successfully performed endotracheal intubation in 340 (92.1%) encounters. Unsuccessful intubations were managed with an alternative definitive airway, rescue airway, or bag-valve-mask. Laryngeal mask airway (n = 11) was the most commonly used rescue airway device. CONCLUSIONS: During the first eight years of operation of this air medical transport system, flight personnel were able to successfully perform endotracheal intubation in 92.1% of cases.

Unintentional ingestion of ziprasidone in a 22-month-old.

Unintentional ingestions are a common presentation to the emergency department in the pediatric population. However, very few ingestions of an atypical antipsychotic, such as ziprasidone, have been described in the emergency medicine literature. While the prevalence of these newer antipsychotics increases in the general population, emergency physicians can expect to see more patients with accidental or intentional overdoses. Many emergency physicians may be unfamiliar with the presentation, initial workup, and expected clinical course of such an overdose. We describe a case of an unintentional ingestion of ziprasidone tablets in a 22-month-old girl who presented to the emergency department with somnolence, drooling, and poor tone.

Smoking expectancies and health perceptions: An analysis of Hispanic subgroups.

Research suggests different patterns of cigarette smoking behaviors across Hispanic subgroups. However, research examining differences in known cognitive correlates of smoking behavior (e.g., beliefs about smoking and perceived consequences of smoking) is lacking. The purpose of this study was two-fold. First, given the dearth of research examining cigarette smoking across Hispanic subgroups, we sought to replicate previous findings related to disparities in smoking behavior across four subgroups (i.e., Mexican American, Puerto Rican, Cuban American, and Dominican American). Second, we sought to extend previous work by examining Hispanic subgroup differences across a range of smoking-related cognitive factors (i.e., positive and negative beliefs, perceived health risks, and perceived social consequences). This study used data from 1021 Hispanic individuals from four universities in the U.S. (i.e., Texas, California, New York, Florida) in a project funded by the American Legacy Foundation. Results indicated that Cuban Americans reported more current smoking than any other subgroup and the most positive beliefs about smoking, although Puerto Ricans endorsed the fewest negative beliefs about smoking out of all the groups. There were also differences across subgroups on some perceived health risks of smoking (e.g., Cubans were most likely to believe that smoking was a risk factor for diabetes) and perceived social consequences of smoking (e.g., Mexican Americans were less likely to perceive negative social consequences from not smoking). This study underscores the need to account for heterogeneity within the Hispanic population in tobacco research to more effectively inform future research and prevention practices.

Ophthalmic diagnoses in the ED: herpes zoster ophthalmicus.

The epidemiology, pathophysiology, and clinical presentation of herpes zoster ophthalmicus in the emergency department is discussed with an emphasis on the identification of the numerous potential ocular complications. Emergency physicians need to be able to recognize the clinical features of herpes zoster ophthalmicus and initiate appropriate therapy and referral.

An example of medical device-based projection of clinical trial enrollment: Use of electrocardiographic data to identify candidates for a trial in acute coronary syndromes.

BACKGROUND: To identify potential participants for clinical trials, electronic health records (EHRs) are searched at potential sites. As an alternative, we investigated using medical devices used for real-time diagnostic decisions for trial enrollment. METHODS: To project cohorts for a trial in acute coronary syndromes (ACS), we used electrocardiograph-based algorithms that identify ACS or ST elevation myocardial infarction (STEMI) that prompt clinicians to offer patients trial enrollment. We searched six hospitals' electrocardiograph systems for electrocardiograms (ECGs) meeting the planned trial's enrollment criterion: ECGs with STEMI or > 75% probability of ACS by the acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI). We revised the ACI-TIPI regression to require only data directly from the electrocardiograph, the e-ACI-TIPI using the same data used for the original ACI-TIPI (development set n = 3,453; test set n = 2,315). We also tested both on data from emergency department electrocardiographs from across the US (n = 8,556). We then used ACI-TIPI and e-ACI-TIPI to identify potential cohorts for the ACS trial and compared performance to cohorts from EHR data at the hospitals. RESULTS: Receiver-operating characteristic (ROC) curve areas on the test set were excellent, 0.89 for ACI-TIPI and 0.84 for the e-ACI-TIPI, as was calibration. On the national electrocardiographic database, ROC areas were 0.78 and 0.69, respectively, and with very good calibration. When tested for detection of patients with > 75% ACS probability, both electrocardiograph-based methods identified eligible patients well, and better than did EHRs. CONCLUSION: Using data from medical devices such as electrocardiographs may provide accurate projections of available cohorts for clinical trials.

Triage of geriatric patients in the emergency department: validity and survival with the Emergency Severity Index.

STUDY OBJECTIVE: We evaluate the validity of the Emergency Severity Index (version 3) (ESI) triage algorithm in a geriatric emergency department (ED) population and determine the association between ESI categorization and survival. METHODS: Validity was assessed using a retrospective analysis of hospitalization, ED length of stay, and observed resource use compared with resource utilization estimated at triage by the ESI. Survival analysis was conducted for the same cohort. The study was exempted by the hospital institutional review board, and the requirement for informed consent was waived. RESULTS: During the investigation, 1,087 patients older than 65 years were registered in the ED. Six patients were identified as direct admissions, and 152 were found to be repeat visitors, leaving 929 subject visits for analysis. In this cohort, hospitalization was associated with ESI triage assignment (Kendall's tau-b=-0.476; 95% confidence interval [CI] -0.524 to -0.425). The area under the receiver operating characteristic curve for the predictive ability of the ESI for hospitalization was 0.77 (95% CI 0.748 to 0.806). Length of stay was associated with ESI assignment (Kruskal-Wallis test, P=.000). The relationship between triage categorization and resource utilization was significant (Spearman's correlation=-0.683; 95% CI -0.716 to -0.647). ESI categorization was associated with vital status at 1 year (Kaplan-Meier chi2 67.85; df=4; P=.0000). CONCLUSION: When used to triage patients older than 65 years, the ESI algorithm demonstrates validity. Hospitalization, length of stay, resource utilization, and survival were all associated with ESI categorization in this cohort.