Sensitivity of systemic inflammatory response syndrome for critical illness among ED patients.

BACKGROUND: Little is known about the diagnostic accuracy of systemic inflammatory response syndrome (SIRS) criteria for critical illness among emergency department (ED) patients with and without infection. Our objective was to assess the diagnostic accuracy of SIRS criteria for critical illness in ED patients. METHODS: This was a retrospective cohort study of ED patients at an urban academic hospital. Standardized chart abstraction was performed on a random sample of all adult ED medical patients admitted to the hospital during a 1-year period, excluding repeat visits, transfers, ED deaths, and primary surgical or psychiatric admissions. The binary composite outcome of critical illness was defined as 24 hours or longer in intensive care or inhospital death. Presumed infection was defined as receiving antibiotics within 48 hours of admission. Systemic inflammatory response syndrome criteria were calculated using ED triage vital signs and initial white blood cell count. RESULTS: We studied 1152 patients; 39% had SIRS, 27% had presumed infection, and 23% had critical illness (2% had inhospital mortality, and 22% had ≥24 hours in intensive care). Of patients with SIRS, 38% had presumed infection. Of patients without SIRS, 21% had presumed infection. The sensitivity of SIRS criteria for critical illness was 52% (95% confidence interval [CI], 46%-58%) in all patients, 66% (95% CI, 56%-75%) in patients with presumed infection, and 43% (95% CI, 36%-51%) in patients without presumed infection. CONCLUSIONS: Systemic inflammatory response syndrome at ED triage, as currently defined, has poor sensitivity for critical illness in medical patients admitted from the ED.

Predictors of early faculty attrition at one Academic Medical Center.

BACKGROUND: Faculty turnover threatens the research, teaching and clinical missions of medical schools. We measured early attrition among newly-hired medical school faculty and identified personal and institutional factors associated with early attrition. METHODS: This retrospective cohort study identified faculty hired during the 2005-2006 academic year at one school. Three-year attrition rates were measured. A 40-question electronic survey measured demographics, career satisfaction, faculty responsibilities, institutional/departmental support, and reasons for resignation. Odds ratios (ORs) and 95 percent confidence intervals (95% CI) identified variables associated with early attrition. RESULTS: Of 139 faculty, 34% (95% CI = 26-42%) resigned within three years of hire. Attrition was associated with: perceived failure of the Department Chair to foster a climate of teaching, research, and service (OR = 6.03; 95% CI: 1.84, 19.69), inclusiveness, respect, and open communication (OR = 3.21; 95% CI: 1.04, 9.98). Lack of professional development of the faculty member (OR = 3.84; 95% CI: 1.25, 11.81); institutional recognition and support for excellence in teaching (OR = 2.96; 95% CI: 0.78, 11.19) and clinical care (OR = 3.87; 95% CI: 1.04, 14.41); and >50% of professional time devoted to patient care (OR = 3.93; 95% CI: 1.29, 11.93) predicted attrition. Gender, race, ethnicity, academic degree, department type and tenure status did not predict early attrition. Of still-active faculty, an additional 27 (48.2%, 95% CI: 35.8, 61.0) reported considering resignation within the 5 years. CONCLUSIONS: In this pilot study, one-third of new faculty resigned within 3 years of hire. Greater awareness of predictors of early attrition may help schools identify threats to faculty career satisfaction and retention.

Employee perception of a mandated helmet policy at Vail Resorts.

OBJECTIVE: The purpose of this study was to measure support for a mandated helmet policy among resort employees along with the impact of such a policy on job satisfaction, and additionally, to measure the prevalence of barriers to helmet use among this population. METHODS: In all, 728 Vail Resort employees were surveyed regarding their opinions on the helmet policy and on general helmet use. RESULTS: The majority of the 728 employees surveyed (66.5%; 95% CI: 63% to 70%) agreed with the helmet policy. Only 18% (95% CI: 16% to 21%) reported a negative effect on job satisfaction. Older employees (>25 years old) were more likely to disagree with the policy (odds ratio [OR] 3.1; 95% CI: 2.2 to 4.3) and report a negative effect on job satisfaction (OR 4.8; 95% CI: 3.0 to 7.6). Skiers were much more likely than snowboarders to report a negative effect on job satisfaction (OR 9.8; 95% CI: 5.2 to 18.1). Among resort employees, ski patrollers were more likely to disagree with the mandate (OR 9.8; 95% CI: 6.8 to 13.9) and report a negative effect on job satisfaction (OR 13.2; 95% CI: 8.3 to 21.). Forty-three percent of participants (95% CI: 39% to 46%) agreed with the statement that wearing a helmet encourages reckless behavior whereas 51.0% (95% CI: 47% to 54%) believed that wearing a helmet limits sensory perception. CONCLUSIONS: A mandatory helmet use policy was supported by most resort employees. However, ski patrollers and older, more experienced employees were more likely to report a negative effect on job satisfaction. Barriers to helmet use continue to persist in the ski industry and represent a target for further educational efforts.

Observational studies of patients in the emergency department: a comparison of 4 sampling methods.

STUDY OBJECTIVE: We evaluate the ability of 4 sampling methods to generate representative samples of the emergency department (ED) population. METHODS: We analyzed the electronic records of 21,662 consecutive patient visits at an urban, academic ED. From this population, we simulated different models of study recruitment in the ED by using 2 sample sizes (n=200 and n=400) and 4 sampling methods: true random, random 4-hour time blocks by exact sample size, random 4-hour time blocks by a predetermined number of blocks, and convenience or "business hours." For each method and sample size, we obtained 1,000 samples from the population. Using χ(2) tests, we measured the number of statistically significant differences between the sample and the population for 8 variables (age, sex, race/ethnicity, language, triage acuity, arrival mode, disposition, and payer source). Then, for each variable, method, and sample size, we compared the proportion of the 1,000 samples that differed from the overall ED population to the expected proportion (5%). RESULTS: Only the true random samples represented the population with respect to sex, race/ethnicity, triage acuity, mode of arrival, language, and payer source in at least 95% of the samples. Patient samples obtained using random 4-hour time blocks and business hours sampling systematically differed from the overall ED patient population for several important demographic and clinical variables. However, the magnitude of these differences was not large. CONCLUSION: Common sampling strategies selected for ED-based studies may affect parameter estimates for several representative population variables. However, the potential for bias for these variables appears small.

Investigating Wellness and Burnout Initiatives for Anesthesiology Resident Physicians: Time for Evidence-Based Investigation and Implementation.

Resident physician burnout and well-being are increasingly important and salient topics in medical training. Unfortunately, limited research exists regarding the efficacy of various burnout and wellness interventions for resident physicians. Better characterization of the causes of burnout and the components of well-being must necessarily precede implementation and evaluation of interventions. The authors advocate for an increased role for technology in implementing and studying wellness programming for resident physicians. In addition, they describe an intervention under development at the University of Colorado School of Medicine that uses a "Gratitude Journal" smartphone app to support trainee wellness.

Impact of computerized physician order entry on ED patient length of stay.

OBJECTIVES: We evaluated whether implementation of computerized physician order entry (CPOE) reduces length of stay (LOS) for discharged emergency department (ED) patients. METHODS: Emergency department LOS for discharged and admitted patients were analyzed in a university-affiliated ED before and after introduction of CPOE. Patient demographics and covariates that may affect LOS (mode of arrival, provider staffing, daily census, and admission rate) were measured. RESULTS: The study included 71,188 patients; 49,175 (69%) were discharged from the ED (28, 687 before and 20,488 after CPOE). Length of stay for discharged patients decreased from 198 to 168 minutes (difference of -30; 95% confidence interval [CI], -28 to -33), whereas LOS for admitted patients increased from 405 to 441 minutes (difference of +36; 95% CI, 26-46). After controlling for covariates, CPOE implementation was associated with a 23-minute decrease in LOS for discharged patients (ß = -23 [95% CI, -26 to -19]). CONCLUSION: Implementation of CPOE was associated with a clinically significant (23-minute) decrease in LOS among patients who were discharged from the ED.

Refugee Health During COVID-19 and Future Pandemics.

PURPOSE OF REVIEW: This commentary summarizes recent literature pertaining to healthcare challenges and needs during the current pandemic among refugees and asylum seekers residing in a host country. We conducted a literature review to identify barriers to shielding these structurally marginalized populations from the impact of the COVID-19 pandemic. RECENT FINDINGS: Many populations, including refugees, migrants, and asylum seekers, endure structural vulnerabilities in refugee camps and during their resettlement. These structural vulnerabilities include fear of contacting the healthcare system, cultural differences, housing insecurity, food insecurity, discrimination, lack of health insurance, health illiteracy and lack of readily available, and culturally appropriate educational materials. During pandemics, displaced persons suffer disproportionately from poorly managed chronic diseases, economic hardships isolation, and mental illnesses, in addition to the threats posed by the infectious agent. SUMMARY: Underserved groups, including refugee populations, shoulder a disproportionate burden of disease during pandemics. In order to mitigate the impact of preventable chronic illnesses and also reduce the spread of COVID-19 and other easily-transmissible and deadly viruses during pandemics, governments and public health authorities need to implement policies that allow refugees, asylum seekers, and displaced persons to be fully incorporated into their respective healthcare systems, so that they can be supported and protected and to reduce the amplifying networks of transmission.

Ending student mistreatment: early successes and continuing challenges.

Problem: Student mistreatment represents an ongoing challenge for US medical schools. Students experiencing mistreatment may become marginalized and cynical, and they have higher rates of burnout, depression and substance use disorders. Although numerous attempts to eliminate mistreatment have been proposed, best practices remain elusive. We formed a unique student-faculty collaboration (the Ending Mistreatment Task Force) that allowed all voices to be heard and enabled identification of five interventions to reduce mistreatment.Intervention: The EMTF developed and implemented five key interventions: 1) a shared mistreatment definition; 2) measures to increase faculty accountability, including adding professionalism expectations to faculty members' contracts and performance reviews; 3) a Professionalism Office to respond promptly to students' reports of mistreatment and provide feedback to faculty; 4) tools to help teachers provide authentic learning environments for students, while addressing generational misunderstandings; and 5) student-produced videos, helping faculty understand the impact of mistreatment as seen through students' eyes.Context: These interventions occurred at one medical school where mistreatment reports were consistently above national averages.Impact: Over 6 years, the interventions helped reduce the rate of student-reported mistreatment by 36% compared with a 4% decline across all US medical schools.Lessons: The collaborations between students and faculty helped each party identify unexpected misunderstandings and challenges. We learned that students want hard questions, although faculty are often afraid to challenge students for fear of offending them or being reported. We clarified differences between mistreatment and sub-optimal learning environments and openly discussed the pervasive opinion that 'some' mistreatment is important for learning. We also identified ongoing challenges, including the need to solicit residents' perspectives regarding mistreatment and develop proper responses to disrespectful comments directed at patients, family and colleagues. The collaboration reinforced students' and faculty members' shared commitment to upholding a respectful learning and clinical care environment and ending mistreatment.

Case reports describing treatments in the emergency medicine literature: missing and misleading information.

BACKGROUND: Although randomized trials and systematic reviews provide the "best evidence" for guiding medical practice, many emergency medicine journals still publish case reports (CRs). The quality of the reporting in these publications has not been assessed. OBJECTIVES: In this study we sought to determine the proportion of treatment-related case reports that adequately reported information about the patient, disease, interventions, co-interventions, outcomes and other critical information. METHODS: We identified CRs published in 4 emergency medicine journals in 2000-2005 and categorized them according to their purpose (disease description, overdose or adverse drug reactioin, diagnostic test or treatment effect). Treatment-related CRs were reviewed for the presence or absence of 11 reporting elements. RESULTS: All told, 1,316 CRs were identified; of these, 85 (6.5%; 95CI = 66, 84) were about medical or surgical treatments. Most contained adequate descriptions of the patient (99%; 95CI = 95, 100), the stage and severity of the patient's disease (88%; 95CI = 79, 93), the intervention (80%; 95CI = 70, 87) and the outcomes of treatment (90%; 95CI = 82, 95). Fewer CRs reported the patient's co-morbidities (45%; 95CI = 35, 56), concurrent medications (30%; 95CI = 21, 40) or co-interventions (57%; 95CI = 46, 67) or mentioned any possible treatment side-effects (33%; 95CI = 24, 44). Only 37% (95CI = 19, 38) discussed alternative explanations for favorable outcomes. Generalizability of treatment effects to other patients was mentioned in only 29% (95CI = 20, 39). Just 2 CRs (2.3%; 95CI = 1, 8) reported a 'denominator" (number of patients subjected to the same intervention, whether or not successful. CONCLUSION: Treatment-related CRs in emergency medicine journals often omit critical details about treatments, co-interventions, outcomes, generalizability, causality and denominators. As a result, the information may be misleading to providers, and the clinical applications may be detrimental to patient care.

Paramedic knowledge, attitudes, and training in end-of-life care.

INTRODUCTION: Paramedics often are asked to care for patients at the end of life. To do this, they must communicate effectively with family and caregivers, understand their legal obligations, and know when to withhold unwanted interventions. The objectives of this study were to ascertain paramedics' attitudes toward end-of-life (EOL) situations and the frequency with which they encounter them; and to compare paramedics' preparation during training for a variety of EOL care skills. METHODS: A written survey was administered to a convenience sample of paramedics in two cities: Denver, Colorado and Los Angeles, California. Questions addressed: (1) attitudes toward EOL decision-making in prehospital settings; (2) experience (number of EOL situations experienced in the past two years); (3) importance of various EOL tasks in clinical practice (pronouncing and communicating death, ending resuscitation, honoring advance directives (ADs)); and (4) self-assessed preparation for these EOL tasks. For each task, importance and preparation were measured using a four-point Likert scale. Proportions were compared using McNemar chi-square statistics to identify areas of under- or over-preparation. RESULTS: Two hundred thirty-six paramedics completed the survey. The mean age was 39 years (range 22-59 years), and 222 (94%) were male. Twenty percent had >20 years of experience. Almost all participants (95%; 95% CI = 91-97%) agreed that prehospital providers should honor field ADs, and more than half (59%; 95% CI = 52-65%) felt that providers should honor verbal wishes to limit resuscitation at the scene. Ninety-eight percent of the participants (95% CI = 96-100%) had questioned whether specific life support interventions were appropriate for patients who appeared to have a terminal disease. Twenty-six percent (95% CI = 20-32%) reported to have used their own judgment during the past two years to withhold or end resuscitation in a patient who appeared to have a terminal disease. Significant discrepancies between the importance in practice and the level of preparation during training for the four EOL situations included: (1) understanding ADs (75% very important vs. 40% well prepared; difference 35%: 95% CI = 26-43%); (2) knowing when to honor written ADs (90% very important vs. 59% well-prepared; difference 31%: 95% CI = 23-38%); and (3) verbal ADs (75% very important vs. 54%well-prepared, difference 21%: 95% CI = 12-29%); and (4) communicating death to family or friends (79% very important vs. 48% well prepared, difference 31%: 95% CI = 23-39%). Paramedics' preparation in EOL skills was significantly lower than that for clinical skills such as endotracheal intubation or defibrillation. CONCLUSIONS: There is a need to include more training in EOL care into prehospital training curricula, including how to verify and apply ADs, when to withhold treatments, and how to discuss death with victims' family or friends.

Teaching Hands-Only CPR in Schools: A Program Evaluation in San José, Costa Rica.

BACKGROUND: Hands-only bystander CPR increases survival from out-of-hospital cardiac arrest. Video-based CPR instruction in schools has been proposed as a means to mass-educate laypersons in Hands-only CPR™ (HOCPR), in developed as well as developing countries. OBJECTIVES: The purpose of this study is to determine whether a brief video- and mannequin-based instructional program, developed by the American Heart Association (AHA), is an effective strategy for teaching Costa Rican middle- and high-school age children to learn the steps of HOCPR. METHODS: This study took place in four educational centers that spanned the entire socioeconomic spectrum within the Grand Metropolitan Area of Costa Rica. Three hundred and eight students from the sixth to eleventh grades participated. The intervention included exposure to the AHA "CPR Anytime" video and practice with CPR mannequins. Before and after the intervention, students took a four-question, multiple-choice quiz that measured their knowledge of the correct steps and proper techniques of HOCPR; a separate question assessed their level of comfort "doing CPR on someone with a cardiac arrest." Pre- and post-intervention "percent correct" scores were compared and tested for statistical significance using paired t-tests or the McNemar test as appropriate. Improvement in knowledge and comfort levels were also compared across the different educational centers and compared with similar programs implemented in the United States. RESULTS: The students' overall scores (mean percent correct) on the multiple choice questions more than doubled after training (40.9% ± 1.4% before training vs. 92.5% ± 0.9% after training, p < 0.00001). Improvements were observed in each school, regardless of geographic location or socioeconomic status. Knowledge of the appropriate steps of HOCPR doubled after training (42.2% before training vs. 92.5% after training, p < 0.000001). Post-intervention, a majority (73%) of children reported comfort with performing CPR on an individual who had suffered a cardiac arrest. CONCLUSION: This study demonstrates the effectiveness of the AHA "CPR Anytime" program in teaching HOCPR to school-age children within the Grand Metropolitan Area of Costa Rica. Additional studies are needed to measure longer-term knowledge retention and students' ability to perform CPR in simulated cardiac arrest settings.

Medical school faculty discontent: prevalence and predictors of intent to leave academic careers.

BACKGROUND: Medical school faculty are less enthusiastic about their academic careers than ever before. In this study, we measured the prevalence and determinants of intent to leave academic medicine. METHODS: A 75-question survey was administered to faculty at a School of Medicine. Questions addressed quality of life, faculty responsibilities, support for teaching, clinical work and scholarship, mentoring and participation in governance. RESULTS: Of 1,408 eligible faculty members, 532 (38%) participated. Among respondents, 224 (40%; CI95: 0.35, 0.44) reported that their careers were not progressing satisfactorily; 236 (42%; CI95: 0.38, 0.46) were "seriously considering leaving academic medicine in the next five years." Members of clinical departments (OR = 1.71; CI95: 1.01, 2.91) were more likely to consider leaving; members of inter-disciplinary centers were less likely (OR = 0.68; CI95: 0.47, 0.98). The predictors of "serious intent to leave" included: Difficulties balancing work and family (OR = 3.52; CI95: 2.34, 5.30); inability to comment on performance of institutional leaders (OR = 3.08; CI95: 2.07, 4.72); absence of faculty development programs (OR = 3.03; CI95: 2.00, 4.60); lack of recognition of clinical work (OR = 2.73; CI95: 1.60, 4.68) and teaching (OR = 2.47; CI95: 1.59, 3.83) in promotion evaluations; absence of "academic community" (OR = 2.67; CI95: 1.86, 3.83); and failure of chairs to evaluate academic progress regularly (OR = 2.60; CI95: 1.80, 3.74). CONCLUSION: Faculty are a medical school's key resource, but 42 percent are seriously considering leaving. Medical schools should refocus faculty retention efforts on professional development programs, regular performance feedback, balancing career and family, tangible recognition of teaching and clinical service and meaningful faculty participation in institutional governance.

The effect of FDA approval of a generic competitor to OxyContin (oxycodone HCl controlled-release) tablets on the abuse of oxycodone.

Controversy exists concerning whether abuse of oxycodone will increase after the introduction of generic controlled-release (CR) oxycodone. We evaluated the effect of FDA approval of generic CR oxycodone on the misuse/abuse of oxycodone, hydrocodone, methadone and morphine utilizing data from eight poison control centers (PCC). PCC intentional exposure (IE) reason codes were used as measures of abuse. Opioid-specific quarterly IE rates (per 100,000 population and per 10,000 patients) were calculated for 1 year before and after approval (March 24, 2004). Changes in regression slopes (1 year before to 1 year after) and in IE rates (1 quarter before to 1 quarter after) were analyzed using Poisson regression. The regression slopes for oxycodone, methadone and morphine did not change after approval but decreased significantly for hydrocodone. None of the prescription opioids' IE rates significantly increased after approval. When changes in oxycodone's IE rates were compared to the other opioids, no statistically significant differences were found, indicating a lack of time-opioid interaction. These results did not vary when population rates or patient rates were used. PCC data indicate that approval of generic CR oxycodone was not followed by an immediate unfavorable effect on the misuse/abuse of oxycodone.

Barriers and Facilitators to Community CPR Education in San José, Costa Rica.

BACKGROUND: Bystander cardiopulmonary resuscitation (CPR) improves survival after prehospital cardiac arrest. While community CPR training programs have been implemented across the US, little is known about their acceptability in non-US Latino populations. OBJECTIVES: The purpose of this study was to identify barriers to enrolling in CPR training classes and performing CPR in San José, Costa Rica. METHODS: After consulting 10 San José residents, a survey was created, pilot-tested, and distributed to a convenience sample of community members in public gathering places in San José. Questions included demographics, CPR knowledge and beliefs, prior CPR training, having a family member with heart disease, and prior witnessing of a cardiac arrest. Questions also addressed barriers to enrolling in CPR classes (cost/competing priorities). The analysis focused on two main outcomes: likelihood of registering for a CPR class and willingness to perform CPR on an adult stranger. Odds ratios and 95% CIs were calculated to test for associations between patient characteristics and these outcomes. RESULTS: Among 371 participants, most were male (60%) and <40 years old (77%); 31% had a college degree. Many had family members with heart disease (36%), had witnessed a cardiac arrest (18%), were trained in CPR (36%), and knew the correct CPR steps (70%). Overall, 55% (95% CI, 50-60%) indicated they would "likely" enroll in a CPR class; 74% (95% CI, 70-78%) would perform CPR on an adult stranger. Cardiopulmonary resuscitation class enrollment was associated with prior CPR training (OR: 2.6; 95% CI, 1.6-4.3) and a prior witnessed cardiac arrest (OR: 2.0; 95% CI, 1.1-3.5). Willingness to perform CPR on a stranger was associated with a prior witnessed cardiac arrest (OR: 2.5; 95% CI, 1.2-5.4) and higher education (OR: 1.9; 95% CI, 1.1-3.2). Believing that CPR does not work was associated with a higher likelihood of not attending a CPR class (OR: 2.4; 95% CI, 1.7-7.9). Fear of performing mouth-mouth, believing CPR is against God's will, and fear of legal risk were associated with a likelihood of not attending a CPR class and not performing CPR on a stranger (range of ORs: 2.4-3.9). CONCLUSION: Most San José residents are willing to take CPR classes and perform CPR on a stranger. To implement a community CPR program, barriers must be considered, including misgivings about CPR efficacy and legal risk. Hands-only CPR programs may alleviate hesitancy to perform mouth-to-mouth. Schmid KM , Mould-Millman NK , Hammes A , Kroehl M , Quiros García R , Umaña McDermott M , Lowenstein SR . Barriers and facilitators to community CPR education in San José, Costa Rica. Prehosp Disaster Med. 2016;31(5):509-515.

Perspectives on Tiered Older Driver Assessment in Primary Care Settings.

PURPOSE OF THE STUDY: Widespread screening of older drivers, with in-depth evaluation only of those who screen positive ("tiered assessment"), might efficiently balance driver safety and mobility. To inform program development, we sought to examine the perspectives of older drivers and clinicians on the concept of tiered assessment in primary care settings. DESIGN AND METHODS: Iterative focus groups and interviews with 33 community-dwelling current drivers aged ≥65 years and 8 primary care providers. We used inductive and deductive theme analysis to explore driver and clinician perspectives and to identify barriers and facilitators to establishing a tiered older driver assessment program in primary care settings. RESULTS: Four dominant themes emerged. Two themes addressed the overall concept: (a) support for the concept of tiered older driver assessment and (b) concerns about the consequences of older driver assessment and how these could affect program viability. Two themes addressed screening: (c) tension inherent in using a generalized approach to the highly individualized issue of driving and (d) logistical considerations for screening in primary care settings. IMPLICATIONS: Standardized older driver screening and referral might improve clinician-driver communication, but screening should occur in a context that includes personalized mobility counseling.

Student drivers: a study of fatal motor vehicle crashes involving 16-year-old drivers.

STUDY OBJECTIVE: Motor vehicle crashes are the leading cause of death for US teenagers, accounting for 40% of fatalities. The purpose of this study was to compare novice (aged 16 years) and experienced (aged 25 to 49 years) drivers involved in fatal motor vehicle crashes with respect to crash characteristics and driver behaviors. METHODS: This cross-sectional study of fatal motor vehicle crashes in Colorado used data from the Fatality Analysis Reporting System (1995 to 2001). Driver and crash variables were compared in the 2 age groups using separate logistic regression models, adjusted for sex, geographic locale, and year. RESULTS: Two thousand four hundred twenty fatal motor vehicle crashes were included; 158 fatalities (6.5%) were novice drivers. Novice drivers were more likely to have been speeding (odds ratio [OR] 1.87, 95% confidence interval [CI] 1.34 to 3.08); driving recklessly (OR 4.78, 95% CI 3.31 to 6.92); charged with a traffic violation (OR 3.08, 95% CI 2.20 to 4.31); in a single-vehicle (OR 1.84, 95% CI 1.32 to 2.57), rollover (OR 1.36, 95% CI 0.97 to 1.91) or run-off-the-road (OR 1.54, 95% CI 1.03 to 2.30) crash; and carrying 2 (OR 4.52, 95% CI 2.75 to 7.41) or more (OR 4.07, 95% CI 2.49 to 6.55) passengers. Safety belt nonuse was high for novice (48%) and experienced (42%) drivers (OR 1.19, 95% CI 0.86 to 1.67). Novice drivers had older cars (mean difference 1.5 years, 95% CI 0.37 to 2.57 years). Novice drivers were less likely to be involved in crashes caused by alcohol (OR 0.24, 95% CI 0.14 to 0.41) or adverse weather (OR 0.37, 95% CI 0.19 to 0.75) and to be driving a sport utility vehicle (OR 0.62, 95% CI 0.39 to 0.97). CONCLUSION: Fatal motor vehicle crashes involving novice drivers are characterized by speeding, recklessness, single-vehicle and rollover crashes, and traffic law violations, suggesting that novice drivers bear considerable responsibility for their fatal crashes. Moreover, almost half of 16-year-old drivers involved in fatal motor vehicle crashes were not wearing their safety belts. These data may prove useful in strengthening graduated licensing laws and in improving drivers' education courses and public safety campaigns.

Emergency contraception: what do our patients know?

STUDY OBJECTIVE: Unintended pregnancy is a major medical, social, and public health problem. Emergency contraceptive pills can prevent 75% to 85% of unintended pregnancies if administered within 72 hours of intercourse. We perform this study to measure knowledge, attitudes, practices, and perceived needs about emergency contraception in a sample of women seeking emergency department (ED) care. METHODS: This was a prospective survey of women presenting to an inner-city ED during an 8-week study period. Women who were aged 18 to 45 years, English speaking, and not critically ill and who presented during 56 randomly generated 4-hour time blocks were eligible. Trained research assistants administered a 20-question survey that included questions on current sexual and contraceptive practices and knowledge, acceptance, and preferences about postcoital contraception. RESULTS: Two hundred thirty-two women met eligibility criteria; 158 (68%) women agreed to participate. Participants and nonparticipants were similar in age, race, ethnicity, and insurance status. The participants' mean age was 30 years. Twenty-five percent were married, whereas 49% had never married and 25% were separated or divorced. Fifty-two percent (95% confidence interval [CI] 44% to 60%) reported at least 1 previous unintended pregnancy; 28% (95% CI 21% to 35%) had 1 or more previous elective abortions. Of women who had been sexually active in the past month, half (47%) reported unprotected intercourse during that time. Among all respondents, 122 (77%; 95% CI 71% to 84%) had heard of emergency contraception as a way of preventing pregnancy after unprotected intercourse. Of these respondents, one fourth to one half did not have enough knowledge to use emergency contraceptive pills effectively. Fifty-seven percent of women were willing to use emergency contraceptive pills in the future, and 16 women said they would consider a change in regular contraception to emergency contraceptive pills if widely available. CONCLUSION: Sexually active women seeking ED care have high rates of unintended pregnancy and abortion. There is broad acceptance of emergency contraceptive pills to prevent pregnancy, but knowledge of availability, timing, and proper use is limited. Emergency contraceptive pills are a safe, effective, and low-cost primary preventive and emergency care intervention, and information about their use should be made available to ED patients. Patients should be advised not to abandon their use of barrier or other traditional contraceptives.

A positive domestic violence screen predicts future domestic violence.

The objective of this study was to determine if a brief screen for domestic violence (DV) predicts future violence. We conducted a cohort study of adult women who presented to an inner-city emergency department during an 8-week study period. Participants were screened for DV using the Partner Violence Screen (PVS). At 4 months, follow-up telephone interviews were conducted: rates of verbal and physical violence were measured using the modified Conflict Tactics Scale. Relative risks of violent events (physical and verbal) were calculated. Of the 215 women who enrolled, 36 (16%) had an initial screen positive for DV. Ninety-six women participated in the follow-up phase; of these women, 9% had screened positive for DV. At 4 months, women with DV were 11.3 times more likely to experience physical violence and 7.3 times more likely to experience verbal aggression. The study's screen identified women at high risk for subsequent physical violence and verbal aggression.