Identification of disulfide bond formation between MitoNEET and glutamate dehydrogenase 1.

MitoNEET is a protein that was identified as a drug target for diabetes, but its cellular function as well as its role in diabetes remains elusive. Protein pull-down experiments identified glutamate dehydrogenase 1 (GDH1) as a potential binding partner. GDH1 is a key metabolic enzyme with emerging roles in insulin regulation. MitoNEET forms a covalent complex with GDH1 through disulfide bond formation and acts as an activator. Proteomic analysis identified the specific cysteine residues that participate in the disulfide bond. This is the first report that effectively links mitoNEET to activation of the insulin regulator GDH1.

Emergency department visits after hospital discharge: a missing part of the equation.

STUDY OBJECTIVE: Current methods of measuring hospital readmissions capture only inpatient-to-inpatient hospitalization and ignore return visits to the emergency department (ED) that do not result in an admission. The relative importance of the return ED visit is currently not well established. We conduct this study to characterize the frequency of ED utilization within 30 days of inpatient hospital discharge. METHODS: This was a retrospective cohort study conducted with administrative data from an urban academic center from January 1 to June 30, 2010. We included patient-level and visit-level data from both inpatient and ED databases. All inpatient discharges from January 1 to May 31, 2010, were followed forward to determine whether any ED visits occurred within the subsequent 30 days. Each time a patient was admitted, the 30-day clock was reset on subsequent discharge. RESULTS: There were 15,519 inpatient discharges during the study period, which included 11,976 unique patients. Nearly one quarter (n=3,695; 23.8%) of these discharges resulted in at least 1 ED visit within the subsequent 30 days (total return ED visits=4,077), and more than half of the subsequent ED visits (n=2,204; 54%) did not lead to hospital readmission. CONCLUSION: Excluding a return to the ED misses more than 50% of all returns to the acute level of care after discharge. Inclusion of ED visits as a return to the acute care setting may enhance providers' efforts to identify opportunities to improve care transitions and intervene in a cycle of frequent rehospitalizations.

EMS providers' perceptions of safety climate and adherence to safe work practices.

BACKGROUND: Occupational injuries are an important source of morbidity for emergency medical services (EMS) providers. Previous work has shown that employee perceptions of an organization's commitment to safety (i.e., safety climate) correlate with adherence to safe practices. OBJECTIVE: To assess the association between perceived safety climate and compliance with safety procedures in an urban EMS system with >100,000 calls/year. METHODS: EMS providers were issued a self-administered survey that included questions on demographics, years of experience, perceived safety climate, and adherence to safety procedures. Safety climate was assessed with a 20-item validated instrument. Adherence to safety procedures was assessed with a nine-item list of safety behaviors. Strict adherence to safety procedures was defined as endorsing "agree" or "strongly agree" on 80% of items. The effect of safety climate on compliance with safe practices was estimated using multiple logistic regression. RESULTS: One hundred ninety-six of 221 providers (89%) completed surveys; 74% were male; the median age was 36-40 years; and the median amount of experience was 8 years. One hundred twenty-seven of 196 respondents (65%) reported strict adherence to safe work practice. Factor analysis confirmed the original six-factor grouping of questions; frequent safety-related feedback/training was significantly associated with safe practices (odds ratio [OR] = 2.14, 95% confidence interval [CI] = 1.01-4.51). CONCLUSION: EMS workers perceiving a high degree of perceived safety climate was associated with twofold greater odds of self-reported level of strict adherence to safe work practices. Frequent safety-related feedback/training was the one dimension of safety climate that had the strongest association with adherence to safe workplace behaviors.

A Retrospective Review of Emergency Department Visits That May Be Appropriate for Management in Non-Emergency Settings.

BACKGROUND: Emergency departments (EDs) continue to struggle with overcrowding, increasing wait times, and a surge in patients with non-urgent conditions. Patients frequently choose the ED for non-emergent medical issues or injuries that could readily be handled in a primary care setting. We analyzed encounters in the ED at the Brooke Army Medical Center-the largest hospital in the Department of Defense-to determine the percentage of visits that could potentially be managed in a lower cost, appointment-based setting. MATERIALS AND METHODS: We conducted a retrospective chart review of patients within our electronic medical record system from September 2019 to August 2020, which represented equidistance from the start of the COVID-19 pandemic, resulting in a shift in ED used based on previously published data. Our study also compared the number of ED visits pre-covid vs. post-covid. We defined visits to be primary care eligible if they were discharged home and received no computed tomography imaging, ultrasound, magnetic resonance imaging, intravenous medications, or intramuscular-controlled substances. RESULTS: During the 12 month period, we queried data on 75,205 patient charts. We categorized 56.7% (n = 42,647) of visits as primary care eligible within our chart review. Most primary-care-eligible visits were ESI level 4 (59.2%). The largest proportion of primary-care-eligible patients (28.3%) was seen in our fast-track area followed by our pediatric pod (21.9%). The total number of ED visits decreased from 7,477 pre-covid to 5,057 post-covid visits. However, the proportion of patient visits that qualified as primary care eligible was generally consistent. CONCLUSIONS: Over half of all ED visits in our dataset could be primary care eligible. Our findings suggest that our patient population may benefit from other on-demand and appointment-based healthcare delivery to decompress the ED.

Innovative Solution for Airway Securement in Combat and Trauma Scenarios.

Airway management is one of the most challenging problems in prehospital combat casualty care. Airway assessment and intervention are second only to hemorrhage control in priority in the initial treatment of trauma patients, and airway compromise continues to account for approximately 1 in 10 preventable battlefield deaths. Combat medics often provide care in no- or low-light conditions, surrounded by the chaos of combat, and with the limited dexterity that accompanies bulky body armor, gloves, and heavy equipment. Far-forward medical care is also limited by available resources, which are often only what a combat medic can fit in the aid bag. Therefore, a procedure such as airway management that currently requires a high degree of skill becomes substantially more complex. Improved airway devices are listed among the top five in a comprehensive list of battlefield research and development priorities by the Defense Health Board, yet the challenge of airway management has received little investment compared to other causes of preventable battlefield death such as exsanguinating hemorrhage and traumatic brain injury.

Myocardial infarction associated with sibutramine use: case report and discussion.

We present the case of a young woman presenting to a military field hospital in Afghanistan with a non-ST-elevation myocardial infarction (NSTEMI) associated with the diet drug sibutramine. We also provide a brief literature review on the association between sibutramine and myocardial infarction.

Rectal Foreign Body Removal in the Emergency Department: A Case Report.

INTRODUCTION: Rectal foreign bodies (RFB) pose a challenge to emergency physicians. Patients are not often forthcoming, which can lead to delays to intervention. Thus, RFBs require a heightened clinical suspicion. In the emergency department (ED), extraction may require creative methods to prevent need for surgical intervention. CASE REPORT: The authors present a case of a successful extraction of a RFB in the ED and review of the literature. CONCLUSION: Retained RFBs are an unusually problematic reason for an ED visit. Thus, it is important for emergency physicians to be comfortable managing such cases appropriately.

Applying a Model of Teamwork Processes to Emergency Medical Services.

INTRODUCTION: Effective teamwork has been shown to optimize patient safety. However, research centered on the critical inputs, processes, and outcomes of team effectiveness in emergency medical services (EMS) has only recently begun to emerge. We conducted a theory-driven qualitative study of teamwork processes-the interdependent actions that convert inputs to outputs-by frontline EMS personnel in order to provide a model for use in EMS education and research. METHODS: We purposively sampled participants from an EMS agency in Houston, TX. Full-time employees with a valid emergency medical technician license were eligible. Using semi-structured format, we queried respondents on task/team functions and enablers/obstacles of teamwork in EMS. Phone interviews were recorded and transcribed. Using a thematic analytic approach, we combined codes into candidate themes through an iterative process. Analytic memos during coding and analysis identified potential themes, which were reviewed/refined and then compared against a model of teamwork processes in emergency medicine. RESULTS: We reached saturation once 32 respondents completed interviews. Among participants, 30 (94%) were male; the median experience was 15 years. The data demonstrated general support for the framework. Teamwork processes were clustered into four domains: planning; action; reflection; and interpersonal processes. Additionally, we identified six emergent concepts during open coding: leadership; crew familiarity; team cohesion; interpersonal trust; shared mental models; and procedural knowledge. CONCLUSION: In this thematic analysis, we outlined a new framework of EMS teamwork processes to describe the procedures that EMS operators employ to convert individual inputs into team performance outputs. The revised framework may be useful in both EMS education and research to empirically evaluate the key planning, action, reflection, and interpersonal processes that are critical to teamwork effectiveness in EMS.

Attitudes and practices regarding influenza vaccination among emergency department personnel.

In the United States, infections related to influenza result in a huge burden to the health care system and emergency departments (EDs). Influenza vaccinations are a safe, cost-effective means to prevent morbidity and mortality. We sought to understand the factors that contribute to the professional and personal influenza vaccination practices of health care workers in the ED setting by assessing their knowledge, attitudes, and practices with regards to the influenza vaccine. A cross-sectional study of all full-time ED staff (nurses, emergency medicine residents, and emergency medicine faculty) at an urban academic medical center in Boston treating > 90,000 ED patients annually, was performed. We examined knowledge, attitudes, and practices regarding personal influenza vaccination and support of an ED-based influenza vaccination program using an anonymous, self-administered questionnaire. Of 130 ED staff, 126 individuals completed the survey (97% response rate). Overall, 69% of respondents reported that they were very or extremely likely to be vaccinated before the coming influenza season. Residents (94%) and attending physicians (82%) were significantly more likely than nurses (42%) to be vaccinated (p < 0.001). Respondents likely to be vaccinated this year were more likely to support a vaccination program for ED patients (80% vs. 55% of those not vaccinated,p < 0.001). Providing regular education on the efficacy of preventive vaccination therapy and dispelling misconceptions regarding adverse effects may reduce barriers to vaccination programs. An educational initiative may result in acceptance of influenza vaccination by ED providers themselves, which could result in increased support for an influenza vaccination program for ED patients.

Stonefish envenomation.

As more Americans travel in greater numbers in search of exotic destinations, they may encounter dangerous marine life that hide in reefs and shallow marine waters. In this case report, we describe a case of stonefish envenomation and provide a review of the literature on management and prevention.

Chemical, thermal, and biological ocular exposures.

Chemical or radiant energy injuries to the eyes are considered ocular burns. The majority of these injuries are occupation-related. Chemical burns are by far more common and represent a true emergency. Thermal and UV injuries are associated with severe pain, but often result in less long-term sequelae than chemical injuries do. The term "biologic exposure" refers to an exposure to human blood or other body fluid. This article describes patterns of these injuries and exposures, with particular emphasis on emergent management and including acute diagnostic and treatment considerations.

Areas of Potential Impact of the Patient Protection and Affordable Care Act on EMS: A Synthesis of the Literature.

INTRODUCTION: This comprehensive review synthesizes the existing literature on the Patient Protection and Affordable Care Act (ACA) as it relates to emergency medical services (EMS) in order to provide guidance for navigating current and future healthcare changes. METHODS: We conducted a comprehensive review to identify all existing literature related to the ACA and EMS and all sections within the federal law pertaining to EMS. RESULTS: Many changes enacted by the ACA directly affect emergency care with potential indirect effects on EMS systems. New Medicaid enrollees and changes to existing coverage plans may alter EMS transport volumes. Reimbursement changes such as adjustments to the ambulance inflation factor (AIF) alter the yearly increases in EMS reimbursement by incorporating the multifactor productivity value into yearly reimbursement adjustments. New initiatives, funded by the Center for Medicare & Medicaid Innovation are exploring novel and cost-effective prehospital care delivery opportunities while EMS agencies individually explore partnerships with healthcare systems. CONCLUSION: EMS systems should be aware of the direct and indirect impact of ACA on prehospital care due to the potential for changes in financial reimbursement, acuity and volume changes, and ongoing new care delivery initiatives.

Self-reported safety belt use among emergency department patients in Boston, Massachusetts.

BACKGROUND: Safety belt use is 80% nationally, yet only 63% in Massachusetts. Safety belt use among potentially at-risk groups in Boston is unknown. We sought to assess the prevalence and correlates of belt non-use among emergency department (ED) patients in Boston. METHODS: A cross-sectional survey with systematic sampling was conducted on non-urgent ED patients age > or = 18. A closed-ended survey was administered by interview. Safety belt use was defined via two methods: a single-item and a multiple-item measure of safety belt use. Each was scored using a 5-point frequency scale. Responses were used to categorize safety belt use as 'always' or less than 'always'. Outcome for multivariate logistic regression analysis was safety belt use less than 'always'. RESULTS: Of 478 patients approached, 381 (80%) participated. Participants were 48% female, 48% African-American, 40% White, median age 39. Among participants, 250 (66%) had been in a car crash; 234 (61%) had a valid driver's license, and 42 (11%) had been ticketed for belt non-use. Using two different survey measures, a single-item and a multiple-item measure, safety belt use 'always' was 51% and 36% respectively. According to separate regression models, factors associated with belt non-use included male gender, alcohol consumption >5 drinks in one episode, riding with others that drink and drive, ever receiving a citation for belt non-use, believing that safety belt use is 'uncomfortable', and that 'I just forget', while 'It's my usual habit' was protective. CONCLUSION: ED patients at an urban hospital in Boston have considerably lower self-reported safety belt use than state or national estimates. An ED-based intervention to increase safety belt use among this hard-to-reach population warrants consideration.

Brief interventions to reduce harmful alcohol use among military personnel: lessons learned from the civilian experience.

Unhealthy alcohol use is among the leading causes of morbidity and mortality in the United States. Among military personnel, service members between the ages 18 and 25 had a 27.3% prevalence of heavy drinking in the previous 30 days, compared to 15.3% among civilians in the same age group. In the civilian world, > 100 million patients are treated in U.S. emergency departments (ED) annually; 7.9% of these visits are alcohol related. Alcohol is associated with a broad range of health consequences that may ultimately present in the ED setting: traumatic injuries (e.g., motor vehicle crashes, intentional violence, falls); environmental injuries (e.g., frostbite); cardiovascular problems (e.g., hypertension, dilated cardiomyopathy); gastrointestinal disorders (e.g., hepatitis, pancreatitis, gastrointestinal bleeding); neurological problems (e.g., encephalopathy, alcohol withdrawal, withdrawal seizures), as well as psychological problems (e.g., depression, suicide). Seminal work has been done to create behavioral interventions for at-risk drinkers. These motivational interventions have been found to be successful in encouraging clients to change their risky behaviors. We present such a technique, called the Brief Negotiated Interview as performed in a civilian ED setting, in hopes of adapting it for use in the military context. Military health care providers could easily adapt this technique to help reduce risky levels of alcohol consumption among service members, retirees, or military dependents.

An observational study of safety belt use among taxi drivers in Boston.

STUDY OBJECTIVE: Although safety belt legislation exists for drivers in Massachusetts, there is an exemption for taxicab drivers. According to the most recent data from the Governor's Highway Safety Bureau, the observed safety belt use rate of drivers in Massachusetts is 64%. However, the safety belt use among taxicab drivers in Boston is unknown. METHODS: An observational study was conducted to assess the prevalence of safety belt use among taxicab drivers in Boston. We compared our findings with state-level data obtained from the Governor's Highway Safety Bureau. Research staff made observations of taxicabs arriving at various sites within Boston (Logan Airport, Back Bay subway entrance, Government Center, and a hospital in Boston). The methodology used in this study was adapted from MASS-Safe, the Traffic Safety Research Program of the Governor's Highway Safety Bureau. In brief, research staff assessed the use of shoulder safety belts worn by taxicab drivers in Boston. Researchers observed traffic flow coming from a single direction at each observation site. These observers were instructed to include only taxicabs in motion, approaching in the nearest lane to the sidewalk. RESULTS: Two hundred fifty taxicabs were observed during the study period. Of these, 247 taxicab drivers were men (98.9%), whereas 3 were women (1.2%). Overall, 17 of 250 taxicab drivers (6.8%; 95% confidence interval 3.9% to 9.7%) wore safety belts, whereas 233 (93.2%) did not. CONCLUSION: The safety belt use among taxicab drivers in Boston is 6.8%, markedly lower than the state-level safety belt use of other drivers in Massachusetts. Stronger safety belt use legislation in Massachusetts may help to improve safety belt use among taxi drivers in Boston.

Hot topics in international emergency medicine.

The Global Burden of Disease report published in 1996 predicted that by 2020 the majority of illness burden globally will be from in-juries, mental illness, and chronic diseases. Patients with many of the disorders leading the list frequently require emergent care. This article provides a brief literature-based introduction to these and other important topics relevant to international development of emergency medicine.

Self-reported provider safety in an urban emergency medical system.

INTRODUCTION: Emergency Medical Service (EMS) personnel often respond to dangerous scenes and encounter hostile individuals without police support. No recent data describes the frequency of physical or verbal assaults or which providers have increased fear for their safety. This information may help to guide interventions to improve safety. Our objective was to describe self-reported abuse and perceptions of safety and to determine if there are differences between gender, shift, and years of experience in a busy two-tiered, third service urban EMS system. METHODS: This was a secondary analysis of an anonymous, cross-sectional work safety survey of EMS providers. This survey included demographics, years of experience, history of verbal and physical assault, safety behavior following an assault and perceptions of safety. Descriptive statistics were generated. RESULTS: Eighty-nine percent (196/221) of EMS providers completed the survey. Most were male (72%) and between the ages of 25 and 50 years (66%). The majority of providers had worked in this service for more than five years (54%), and many for more than ten years (37%). Verbal assaults were reported by 88% (172/196, 95% CI [82.4%-91.6%]). Although 80% (156/196, 95% CI [73.4%-84.6%]) reported physical assaults, only 40% (62/156, 95% CI [32.4%-47.6%]) sought medical care and 49% (76/156, 95% CI [41%-56.6%]) reported the assault to police. The proportion of those who sought medical care and reported the assault to the police was not the same across years of experience (p<0.0001). Fear for personal safety was reported by 68% (134/196, 95% CI [61.6%-74.5%]). There was no statistical difference in assault by gender; however, females feared more for their safety compared to men (38/50, 76% v 96/142, 68%, p=0.02). The proportion of those who have ever been physically assaulted was not the same across shift worked (p=0.01). CONCLUSION: The majority of EMS providers surveyed reported an assault and certain groups had a higher rate of assault. Most assaults were not reported to the police and medical care was infrequently sought following an event. The majority of providers reported feeling fear for their personal safety. Further research into enhancing safety mechanisms is needed.

War-related psychological sequelae among emergency department patients in the former Republic of Yugoslavia.

BACKGROUND: Residents of the Republic of Serbia faced civil war and a NATO-led bombing campaign in 1999. We sought to assess the burden of metal health dysfunction among emergency department (ED) patients presenting for care three years post-war in Serbia. METHODS: This study was conducted during July and August 2002 at two sites: a university hospital ED in Belgrade, Serbia and an ED in a remote district hospital serving a Serbian enclave in Laplje Selo, Kosovo. Investigators collected data on a systematic sample of non-acute patients presenting to the ED. All respondents completed a structured questionnaire assessing demographics and symptoms of post-traumatic stress disorder (PTSD) (using the Harvard Trauma Questionnaire), and major depression (using the Center for Epidemiologic Studies Depression Scale). RESULTS: A total of 562 respondents participated (310 in Belgrade, 252 in Laplje Selo); the response rate was 83.8%, 43% were female, and mean age was 37.6 years (SD = 13.4). Overall, 73 (13.0%) participants had symptoms consistent with PTSD, and 272 (49.2%) had symptoms consistent with depression. Sixty-six respondents had both disorders (11.9%). In separate multivariable logistic regression models, predictors of PTSD were refugee status and residence in Laplje Selo, and predictors of depression were older age, current unemployment, and lower social support. CONCLUSIONS: Three years post-war, symptoms of PTSD and major depression in Serbia remained a significant public health concern, particularly among refugees, those suffering subsequent economic instability, and persons living in rural, remote areas.

Mental health status among ethnic Albanians seeking medical care in an emergency department two years after the war in Kosovo: a pilot project.

STUDY OBJECTIVE: The long-term psychological effects of war are under appreciated in clinical settings. Describing the postwar psychosocial burden on medical care can help direct public health interventions. We performed an emergency department (ED)-based assessment of the mental health status of ethnic Albanian patients 2 years after the North Atlantic Treaty Organization-led bombing of Serbia and Kosovo in 1999. METHODS: This study was conducted July 30, 2001, to August 30, 2001, in the ED of a hospital in Pristina, Kosovo. Investigators collected data through systematic sampling of every sixth nonacute ED patient presenting for care; 87.7% of patients agreed to participate. Respondents completed a structured questionnaire, including demographic characteristics, the Short Form-36, and the Harvard Trauma Questionnaire. RESULTS: All 306 respondents were ethnic Albanians; mean age was 39 years (SD 17.9 years). Of respondents, 58% had become refugees during the war. Two hundred ninety-six (97%) reported experiencing at least one traumatic event during the war; the average number of traumatic events encountered by participants was 6.6. Forty-three (14%) reported symptoms that met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for posttraumatic stress disorder; mean Short Form-36 Mental Component Summary score was 42.1 (SD 12.5). Separate multivariable linear regression models confirmed our belief that older age, female sex, less than a high school education, and having experienced a greater number of traumatic events would be associated with more posttraumatic stress disorder symptoms and lower Mental Component Summary scores. CONCLUSION: Mental health problems among ED patients in Kosovo, particularly among specific vulnerable populations, are a significant public health concern 2 years after the conflict.