Publications by authors named "Frances S Shofer"

243 Publications

COVID-19 Vaccine Hesitancy Among Patients in Two Urban Emergency Departments.

Acad Emerg Med 2021 Aug 17. Epub 2021 Aug 17.

Department of Emergency Medicine, University of Pennsylvania, USA.

Background: Widespread vaccination is an essential component of the public health response to the COVID-19 pandemic, yet vaccine hesitancy remains pervasive. This prospective survey investigation aimed to measure the prevalence of vaccine hesitancy in a patient cohort at two urban Emergency Departments (EDs) and characterize underlying factors contributing to hesitancy.

Methods: Adult ED patients with stable clinical status (Emergency Severity Index 3-5) and without active COVID-19 disease or altered mental status were considered for participation. Demographic elements were collected, as well as reported barriers/concerns related to vaccination and trusted sources of health information. Data were collected in-person via a survey instrument proctored by trained research assistants.

Results: 1,555 patients were approached, and 1,068 patients completed surveys (completion rate 68.7%). Mean age was 44.1 y (SD 15.5, range 18-93), 61% were female, and 70% were Black. 31.6% of ED patients reported vaccine hesitancy. Of note, 19.7% of the hesitant cohort were healthcare workers. In multivariable regression analysis, Black race (OR 4.24, 95%CI 2.62-6.85) and younger age (age 18-24 y, OR 4.57, 95%CI 2.66-7.86; age 25-35 y, OR 5.71, 95% CI 3.71-8.81) were independently associated with hesitancy, to a greater degree than level of education (high school education or less, OR 2.27, 95%CI 1.23-4.19). Hesitant patients were significantly less likely to trust governmental sources of vaccine information than non-hesitant patients (39.6% vs 78.9%, p<0.001); less difference was noted in the domain of trust towards friends/family (51.1% vs. 61.0%, p=0.004). Hesitant patients also reported perceived vaccine safety concerns and perceived insufficient research.

Conclusions: Vaccine hesitancy is common among ED patients, and more common among Black and younger patients, independent of education level. Hesitant patients report perceived safety concerns and low trust in government information sources, but less so friends or family. This suggests strategies to combat hesitancy may need tailoring to specific populations.
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http://dx.doi.org/10.1111/acem.14376DOI Listing
August 2021

Patient Preference and Risk Assessment in Opioid Prescribing Disparities: A Secondary Analysis of a Randomized Clinical Trial.

JAMA Netw Open 2021 Jul 1;4(7):e2118801. Epub 2021 Jul 1.

Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia.

Importance: Although racial disparities in acute pain control are well established, the role of patient analgesic preference and the factors associated with these disparities remain unclear.

Objective: To characterize racial disparities in opioid prescribing for acute pain after accounting for patient preference and to test the hypothesis that racial disparities may be mitigated by giving clinicians additional information about their patients' treatment preferences and risk of opioid misuse.

Design, Setting, And Participants: This study is a secondary analysis of data collected from Life STORRIED (Life Stories for Opioid Risk Reduction in the ED), a multicenter randomized clinical trial conducted between June 2017 and August 2019 in the emergency departments (EDs) of 4 academic medical centers. Participants included 1302 patients aged 18 to 70 years who presented to the ED with ureter colic or musculoskeletal back and/or neck pain.

Interventions: The treatment arm was randomized to receive a patient-facing intervention (not examined in this secondary analysis) and a clinician-facing intervention that consisted of a form containing information about each patient's analgesic treatment preference and risk of opioid misuse.

Main Outcomes And Measures: Concordance between patient preference for opioid-containing treatment (assessed before ED discharge) and receipt of an opioid prescription at ED discharge.

Results: Among 1302 participants in the Life STORRIED clinical trial, 1012 patients had complete demographic and treatment preference data available and were included in this secondary analysis. Of those, 563 patients (55.6%) self-identified as female, with a mean (SD) age of 40.8 (14.1) years. A total of 455 patients (45.0%) identified as White, 384 patients (37.9%) identified as Black, and 173 patients (17.1%) identified as other races. After controlling for demographic characteristics and clinical features, Black patients had lower odds than White patients of receiving a prescription for opioid medication at ED discharge (odds ratio [OR], 0.42; 95% CI, 0.27-0.65). When patients who did and did not prefer opioids were considered separately, Black patients continued to have lower odds of being discharged with a prescription for opioids compared with White patients (among those who preferred opioids: OR, 0.43 [95% CI, 0.24-0.77]; among those who did not prefer opioids: OR, 0.45 [95% CI, 0.23-0.89]). These disparities were not eliminated in the treatment arm, in which clinicians were given additional data about their patients' treatment preferences and risk of opioid misuse.

Conclusions And Relevance: In this secondary analysis of data from a randomized clinical trial, Black patients received different acute pain management than White patients after patient preference was accounted for. These disparities remained after clinicians were given additional patient-level data, suggesting that a lack of patient information may not be associated with opioid prescribing disparities.

Trial Registration: ClinicalTrials.gov Identifier: NCT03134092.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.18801DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8322998PMC
July 2021

Communicating Guideline Recommendations Using Graphic Narrative Versus Text-based Broadcast Screensavers.

JMIR Hum Factors 2021 Jul 4. Epub 2021 Jul 4.

Center for Emergency Care Policy and Research, University of Pennsylvania, Ravdin Ground3400 Spruce Street, Philadelphia, US.

Background: The use of graphic narratives, defined as stories that use images for narration, is growing in health communication.

Objective: In this study, we describe the design and implementation of a graphic narrative screensaver (GNS) to communicate a guideline recommendation (avoiding low-value acid suppressive therapy (AST) use in hospital inpatients), and examine the comparative effectiveness of the GNS versus a text-based screensaver (TBS) on clinical practice (low-value AST prescriptions) and clinician recall.

Methods: During a two-year period, GNS and TBS were displayed on inpatient clinical workstations. The number of new AST prescriptions were examined in the four quarters before, the three quarters during, and the one quarter after screensavers were implemented. Additionally, an electronic survey was sent to resident physicians one year after the intervention to assess screensaver recall.

Results: Designing an aesthetically engaging graphic that could be rapidly understood was critical in the development of the GNS. The odds of receiving an AST prescription on medicine and medicine subspecialty services after the screensavers were implemented was lower for all 4 quarters (GNS and TBS broadcast together; only TBS broadcast; only GNS broadcast; no AST screensavers broadcast) compared to the quarter prior to implementation (Odds Ratio (OR) 0.85, 95% Confidence Interval (CI) 0.78-0.92; OR 0.89, CI 0.82-0.97; OR 0.87, CI 0.80-0.95; OR 0.81, CI 0.75-0.89, respectively; p<0.0001 for all comparisons). There were no statistically significant decreases for other high volume services such as the surgical services. These declines appear to have begun prior to screensaver implementation. When surveyed about the screensaver content one year later, resident physicians recalled both the GNS and TBS (61% vs 77%, p=0.07), and were more likely to recall the main message of the GNS compared to the TBS (70% vs 2%, p <0.0001).

Conclusions: It is feasible to use a graphic narrative embedded in a broadcast screensaver to communicate a guideline recommendation, but further study is needed to determine the impact of graphic narratives on clinical practice.

Clinicaltrial:
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http://dx.doi.org/10.2196/27171DOI Listing
July 2021

Epinephrine plus chest compressions is superior to epinephrine alone in a hypoxia-induced porcine model of pseudo-pulseless electrical activity.

Resusc Plus 2021 Jun 2;6:100110. Epub 2021 Apr 2.

Department of Emergency Medicine, Dartmouth Hitchcock Medical Center, 1 Medical Center Dr #4B, Lebanon, NH 03756, USA.

Aim: Pseudo-pulseless electrical activity (pseudo-PEA) is a global hypotensive ischemic state with retained coordinated myocardial contractile activity and an organized ECG with no clinically detectable pulses. The role of standard external chest compressions (CPR) and its associated intrinsic hemodynamics remains unclear in the setting of pseudo-PEA. We undertook an experimental trial to compare epinephrine alone versus epinephrine with CPR in the treatment of pseudo-PEA.

Methods: Using a porcine model of hypoxic pseudo-PEA, we randomized 12 Yorkshire male swine to resuscitation with epinephrine only (control) (0.0015 mg/kg) versus epinephrine plus standard CPR (intervention). Animals who achieved return of spontaneous circulation (ROSC) were stabilized, fully recovered to hemodynamic and respiratory baseline, and rearrested up to 6 times. Primary outcome was ROSC defined as a sustained systolic blood pressure (SBP) of 60 mmHg for 2 min. Secondary outcomes included time to ROSC, coronary perfusion pressure (CoPP), and end-tidal carbon dioxide (ETCO).

Results: Among 47 events of pseudo-PEA in 12 animals, we observed significantly higher proportion of ROSC when treatment included CPR (14/21 - 67%) compared to epinephrine alone (4/26 - 15%) (p = 0.0007). CoPP, aortic pressures and ETCO were significantly higher, and right atrial pressures were lower in the intervention group.

Conclusions: In a swine model of hypoxia-induced pseudo-PEA, epinephrine plus CPR was associated with improved intra-arrest hemodynamics and higher probability of ROSC. Thus, epinephrine plus CPR may be superior to epinephrine alone in the treatment of patients with pseudo-PEA.
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http://dx.doi.org/10.1016/j.resplu.2021.100110DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8244467PMC
June 2021

Infants at risk for physical disability may be identified by measures of postural control in supine.

Pediatr Res 2021 Jun 26. Epub 2021 Jun 26.

Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA.

Background: Early detection of delay or impairment in motor function is important to guide clinical management and inform prognosis during a critical window for the development of motor control in children. The purpose of this study was to investigate the ability of biomechanical measures of early postural control to distinguish infants with future impairment in motor control from their typically developing peers.

Methods: We recorded postural control from infants lying in supine in several conditions. We compared various center of pressure metrics between infants grouped by birth status (preterm and full term) and by future motor outcome (impaired motor control and typical motor control).

Results: One of the seven postural control metrics-path length-was consistently different between groups for both group classifications and for the majority of conditions.

Conclusions: Quantitative measures of early spontaneous infant movement may have promise to distinguish early in life between infants who are at risk for motor impairment or physical disability and those who will demonstrate typical motor control. Our observation that center of pressure path length may be a potential early marker of postural instability and motor control impairment needs further confirmation and further investigation to elucidate the responsible neuromotor mechanisms.

Impact: The key message of this article is that quantitative measures of infant postural control in supine may have promise to distinguish between infants who will demonstrate future motor impairment and those who will demonstrate typical motor control. One of seven postural control metrics-path length-was consistently different between groups. This metric may be an early marker of postural instability in infants at risk for physical disability.
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http://dx.doi.org/10.1038/s41390-021-01617-0DOI Listing
June 2021

Outcomes of a Survey-Based Approach to Determine Factors Contributing to the Shortage of Occupational Medicine Physicians in the United States.

J Public Health Manag Pract 2021 May-Jun 01;27(Suppl 3):S200-S205

Division of Occupational Medicine (Drs Green-McKenzie, Vearrier, and Emmett) and Department of Emergency Medicine (Drs Green-McKenzie, Emmett, and Shofer), University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Occupational Health at Lima Memorial Health System, Lima, Ohio (Dr Savanoor); University Medical Center of Southern Nevada, Las Vegas, Nevada (Dr Duran); Gadsden County Urgent Care, LLC, Quincy, Florida (Dr Jones); Florida State Hospital, Chattahoochee, Florida (Dr Jones); Department of Emergency Medicine, The University of Mississippi Medical Center, Jackson, Mississippi (Dr Vearrier); and General Occupational Medicine, Mercy Hospital, St Louis, Missouri (Dr Malak).

Context: There is a long-standing shortage of formally trained Occupational & Environmental Medicine (OEM) physicians despite OEM practitioners experiencing high satisfaction and low burnout.

Objective: To explore the root causes of this shortage and suggest potential remedies.

Methods: Cross-sectional surveys were administered to medical students queried regarding OEM training, practicing OEM physicians queried regarding timing of specialty choice, and OEM Train-in-Place (TIP) program graduates queried regarding satisfaction with training.

Results: Of 247 medical student respondents, 70% had heard of OEM, 60% through one lecture. Of the 160 OEM physicians, 17% first became aware of OEM as medical students, and most would have chosen a different path had they heard sooner. Most TIP program trainees reported that they would not have undertaken specialty training without a TIP program (89%).

Conclusions: Strategies to introduce OEM earlier in medical education and TIP programs for mid-career physicians may help overcome persistent shortages of OEM specialists.
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http://dx.doi.org/10.1097/PHH.0000000000001315DOI Listing
March 2021

Effect of CDC Opioid-Prescribing Guidelines in a Community Hospital Emergency Department.

J Public Health Manag Pract 2021 May-Jun 01;27(Suppl 3):S186-S190

Division of Occupational Medicine, Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania. Dr Gumidyala is now at Capital Health in Hamilton, New Jersey.

The United States continues to battle the addiction and overdose deaths with the opioid epidemic. Prescription opioids are responsible for more than half of these deaths. This before-after study was conducted to assess the effect of the Centers for Disease Control and Prevention's (CDC's) opioid prescription guidelines. Data were abstracted from electronic health records of adult patients presenting with low back pain seen in the emergency department during the study period. SAS statistical software was used to compare opioid prescription practices before and after the intervention. A total of 1006 patients were included in the analysis. Opioid prescriptions decreased by 11% post-CDC guidelines (45% vs 34%). Of patients receiving opioids (n = 383), there was a 6% reduction in the number of days (<5 days) for which opioids were prescribed post-CDC guidelines (14% vs 8%). CDC guidelines on opioid prescribing were associated with a significant reduction in opioid prescribing in terms of both quantity and length of time prescribed. Public health policies as guidelines may positively influence provider decision making and behaviors.
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http://dx.doi.org/10.1097/PHH.0000000000001317DOI Listing
March 2021

Delays in antibiotic redosing: Association with inpatient mortality and risk factors for delay.

Am J Emerg Med 2021 08 1;46:63-69. Epub 2021 Mar 1.

Department of Emergency Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104, USA. Electronic address:

Objective: Although timely administration of antibiotics has an established benefit in serious bacterial infection, the majority of studies evaluating antibiotic delay focus only on the first dose. Recent evidence suggests that delays in redosing may also be associated with worse clinical outcome. In light of the increasing burden of boarding in Emergency Departments (ED) and subsequent need to redose antibiotic in the ED, we examined the association between delayed second antibiotic dose administration and mortality among patients admitted from the ED with a broad array of infections and characterized risk factors associated with delayed second dose administration.

Methods: We performed a retrospective cohort study of patients admitted through five EDs in a single healthcare system from 1/2018 through 12/2018. Our study included all patients, aged 18 years or older, who received two intravenous antibiotic doses within a 30-h period, with the first dose administered in the ED. Patients with end stage renal disease, cirrhosis and extremes of weight were excluded due to a lack of consensus on antibiotic dosing intervals for these populations. Delay was defined as administration of the second dose at a time-point greater than 125% of the recommended interval. The primary outcome was in-hospital mortality.

Results: A total of 5605 second antibiotic doses, occurring during 4904 visits, met study criteria. Delayed administration of the second dose occurred during 21.1% of visits. After adjustment for patient characteristics, delayed second dose administration was associated with increased odds of in-hospital mortality (OR 1.50, 95%CI 1.05-2.13). Regarding risk factors for delay, every one-hour increase in allowable compliance time was associated with a 18% decrease in odds of delay (OR 0.82 95%CI 0.75-0.88). Other risk factors for delay included ED boarding more than 4 h (OR 1.47, 95%CI 1.27-1.71) or a high acuity presentation as defined by emergency severity index (ESI) (OR 1.54, 95%CI 1.30-1.81 for ESI 1-2 versus 3-5).

Conclusions: Delays in second antibiotic dose administration were frequent in the ED and early hospital course, and were associated with increased odds of in-hospital mortality. Several risk factors associated with delays in second dose administration, including ED boarding, were identified.
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http://dx.doi.org/10.1016/j.ajem.2021.02.058DOI Listing
August 2021

Robot-Based Assessment of HIV-Related Motor and Cognitive Impairment for Neurorehabilitation.

IEEE Trans Neural Syst Rehabil Eng 2021 3;29:576-586. Epub 2021 Mar 3.

There is a pressing need for strategies to slow or treat the progression of functional decline in people living with HIV. This paper explores a novel rehabilitation robotics approach to measuring cognitive and motor impairment in adults living with HIV, including a subset with stroke. We conducted a cross-sectional study with 21 subjects exhibiting varying levels of cognitive and motor impairment. We tested three robot-based tasks - trajectory tracking, N-back, and spatial span - to assess if metrics derived from these tasks were sensitive to differences in subjects with varying levels of executive function and upper limb motor impairments. We also examined how well these metrics could estimate clinical cognitive and motor scores. The results showed that the average sequence length on the robot-based spatial span task was the most sensitive to differences between various cognitive and motor impairment levels. We observed strong correlations between robot-based measures and clinical cognitive and motor assessments relevant to the HIV population, such as the Color Trails 1 (rho = 0.83), Color Trails 2 (rho = 0.71), Digit Symbol - Coding (rho = 0.81), Montreal Cognitive Assessment - Executive Function subscore (rho = 0.70), and Box and Block Test (rho = 0.74). Importantly, our results highlight that gross motor impairment may be overlooked in the assessment of HIV-related disability. This study shows that rehabilitation robotics can be expanded to new populations beyond stroke, namely to people living with HIV and those with cognitive impairments.
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http://dx.doi.org/10.1109/TNSRE.2021.3056908DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7987220PMC
June 2021

Alterations in cerebral and cardiac mitochondrial function in a porcine model of acute carbon monoxide poisoning.

Clin Toxicol (Phila) 2021 Sep 2;59(9):801-809. Epub 2021 Feb 2.

Resuscitation Science Center, Philadelphia, PA, USA.

Objectives: The purpose of this study is the development of a porcine model of carbon monoxide (CO) poisoning to investigate alterations in brain and heart mitochondrial function.

Design: Two group large animal model of CO poisoning.

Setting: Laboratory.

Subjects: Ten swine were divided into two groups: Control ( = 4) and CO ( = 6).

Interventions: Administration of a low dose of CO at 200 ppm to the CO group over 90 min followed by 30 min of re-oxygenation at room air. The Control group received room air for 120 min.

Measurements: Non-invasive optical monitoring was used to measure cerebral blood flow and oxygenation. Cerebral microdialysis was performed to obtain semi real time measurements of cerebral metabolic status. At the end of the exposure, both fresh brain (cortical and hippocampal tissue) and heart (apical tissue) were immediately harvested to measure mitochondrial respiration and reactive oxygen species (ROS) generation and blood was collected to assess plasma cytokine concentrations.

Main Results: Animals in the CO group showed significantly decreased Complex IV-linked mitochondrial respiration in hippocampal and apical heart tissue but not cortical tissue. There also was a significant increase in mitochondrial ROS generation across all measured tissue types. The CO group showed a significantly higher cerebral lactate-to-pyruvate ratio. Both IL-8 and TNFα were significantly increased in the CO group compared with the Control group obtained from plasma. While not significant there was a trend to an increase in optically measured cerebral blood flow and hemoglobin concentration in the CO group.

Conclusions: Low-dose CO poisoning is associated with early mitochondrial disruption prior to an observable phenotype highlighting the important role of mitochondrial function in the pathology of CO poisoning. This may represent an important intervenable pathway for therapy and intervention.
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http://dx.doi.org/10.1080/15563650.2020.1870691DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8326298PMC
September 2021

Early hemodynamic assessment using NICOM in patients at risk of developing Sepsis immediately after emergency department triage.

Scand J Trauma Resusc Emerg Med 2021 Jan 28;29(1):23. Epub 2021 Jan 28.

Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.

Background: One factor leading to the high mortality rate seen in sepsis is the subtle, dynamic nature of the disease, which can lead to delayed detection and under-resuscitation. This study investigated whether serial hemodynamic parameters obtained from a non-invasive cardiac output monitor (NICOM) predicts disease severity in patients at risk for sepsis.

Methods: Prospective clinical trial of the NICOM device in a convenience sample of adult ED patients at risk for sepsis who did not have obvious organ dysfunction at the time of triage. Hemodynamic data were collected immediately following triage and 2 hours after initial measurement and compared in two outcome groupings: (1) admitted vs. dehydrated, febrile, hypovolemicdischarged patients; (2) infectious vs. non-infectious sources. Receiver operator characteristic (ROC) curves were calculated to determine whether the NICOM values predict hospital admission better than a serum lactate.

Results: 50 patients were enrolled, 32 (64 %) were admitted to the hospital. Mean age was 49.5 (± 16.5) years and 62 % were female. There were no significant associations between changes in hemodynamic variables and patient disposition from the ED or diagnosis of infection. Lactate was significantly higher in admitted patients and those with infection (p = 0.01, p = 0.01 respectively). The area under the ROC [95 % Confidence Intervals] for lactate was 0.83 [0.64-0.92] compared to 0.59 [0.41-0.73] for cardiac output (CO), 0.68 [0.49-0.80] for cardiac index (CI), and 0.63 [0.36-0.80] for heart rate (HR) for predicting hospital admission.

Conclusions: CO and CI, obtained at two separate time points, do not help with early disease severity differentiation of patients at risk for severe sepsis. Although mean HR was higher in those patients who were admitted, a serum lactate still served as a better predictor of patient admission from the ED.
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http://dx.doi.org/10.1186/s13049-021-00833-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7842048PMC
January 2021

Elevated inflammatory gene expression in intervertebral disc tissues in mice with ADAM8 inactivated.

Sci Rep 2021 01 19;11(1):1804. Epub 2021 Jan 19.

Department of Orthopedics, University of Maryland, Baltimore, MD, USA.

We found ADAM8 enzymatic activity elevated in degenerative human intervertebral disc (IVD). Here, we examined the discs in ADAM8-inactivation mice that carry a mutation preventing self-activation of the enzyme. Surprisingly, elevated gene expression for inflammatory markers (Cxcl1, IL6) was observed in injured discs of ADAM8 mutant mice, along with elevated expression of type 2 collagen gene (Col2a1), compared with wild type controls. Injured annulus fibrosus of mutant and wild type mice contained a higher proportion of large collagen fibers compared with intact discs, as documented by microscopic examination under circular polarized light. In the intact IVDs, Adam8 mouse AF contained lower proportion of yellow (intermediate) fiber than WT mice. This suggests that ADAM8 may regulate inflammation and collagen fiber assembly. The seemingly contradictory findings of elevated inflammatory markers in mutant mice and excessive ADAM8 activity in human degenerative discs suggest that ADAM8 may interact with other enzymatic and pro-inflammatory processes needed for tissue maintenance and repair. As a future therapeutic intervention to retard intervertebral disc degeneration, partial inhibition of ADAM8 proteolysis may be more desirable than complete inactivation of this enzyme.
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http://dx.doi.org/10.1038/s41598-021-81495-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7815795PMC
January 2021

Low Microcirculatory Perfused Vessel Density and High Heterogeneity are Associated With Increased Intensity and Duration of Lactic Acidosis After Cardiac Surgery with Cardiopulmonary Bypass.

Shock 2021 08;56(2):245-254

Department of Emergency Medicine, Center for Resuscitation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.

Introduction: Lactic acidosis after cardiac surgery with cardiopulmonary bypass is common and associated with an increase in postoperative morbidity and mortality. A number of potential causes for an elevated lactate after cardiopulmonary bypass include cellular hypoxia, impaired tissue perfusion, ischemic-reperfusion injury, aerobic glycolysis, catecholamine infusions, and systemic inflammatory response after exposure to the artificial cardiopulmonary bypass circuit. Our goal was to examine the relationship between early abnormalities in microcirculatory convective blood flow and diffusive capacity and lactate kinetics during early resuscitation in the intensive care unit. We hypothesized that patients with impaired microcirculation after cardiac surgery would have a more severe postoperative hyperlactatemia, represented by the lactate time-integral of an arterial blood lactate concentration greater than 2.0 mmol/L.

Methods: We measured sublingual microcirculation using incident darkfield video microscopy in 50 subjects on intensive care unit admission after cardiac surgery. Serial measurements of systemic hemodynamics, blood gas, lactate, and catecholamine infusions were recorded each hour for the first 6 h after surgery. Lactate area under the curve (AUC) was calculated over the first 6 h. The lactate AUC was compared between subjects with normal and low perfused vessel density (PVD < 18 mm/mm2), high microcirculatory heterogeneity index (MHI > 0.4), and low vessel-by-vessel microvascular flow index (MFIv < 2.6).

Results: Thirteen (26%) patients had a low postoperative PVD, 20 patients (40%) had a high MHI, and 26 (52%) patients had a low MFIv. Patients with low perfused vessel density had higher lactate AUC compared with subjects with a normal PVD (22.3 [9.4-31.0] vs. 2.6 [0-8.8]; P < 0.0001). Patients with high microcirculatory heterogeneity had a higher lactate AUC compared with those with a normal MHI (2.5 [0.1-8.2] vs. 13.1 [3.7-31.1]; P < 0.001). We did not find a difference in lactate AUC when comparing high and low MFIv.

Conclusion: Low perfused vessel density and high microcirculatory heterogeneity are associated with an increased intensity and duration of lactic acidosis after cardiac surgery with cardiopulmonary bypass.
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http://dx.doi.org/10.1097/SHK.0000000000001713DOI Listing
August 2021

A National Survey of U.S. Emergency Medicine Physicians on Their Knowledge Regarding State and Federal Cannabis Laws.

Cannabis Cannabinoid Res 2020 15;5(4):337-339. Epub 2020 Dec 15.

Department of Emergency Medicine, University of Central Florida, Orlando, Florida, USA.

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http://dx.doi.org/10.1089/can.2019.0073DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7759276PMC
December 2020

Robot-based assessment of HIV-related motor and cognitive impairment for neurorehabilitation.

medRxiv 2020 Nov 3. Epub 2020 Nov 3.

Rehabilitation Robotics Lab, Department of Physical Medicine and Rehabilitation, and Department of Bioengineering, University of Pennsylvania, Philadelphia, PA 19104 USA.

There is a pressing need for strategies to slow or treat the progression of functional decline in people living with HIV. This paper explores a novel rehabilitation robotics approach to measuring cognitive and motor impairment in adults living with HIV, including a subset with stroke. We conducted a cross-sectional study with 21 subjects exhibiting varying levels of cognitive and motor impairment. We developed three robot-based tasks trajectory tracking, N-back, and spatial span - to assess if metrics derived from these tasks were sensitive to differences in subjects with varying levels of executive function and upper limb motor impairments. We also examined if these metrics could estimate clinical cognitive and motor scores. The results showed that the average sequence length on the robot-based spatial span task was the most sensitive to differences between subjects' cognitive and motor impairment levels. We observed strong correlations between robot-based measures and clinical cognitive and motor assessments relevant to the HIV population, such as the Color Trails 1 (rho = 0.83), Color Trails 2 (rho = 0.71), Digit Symbol - Coding (rho = 0.81), Montreal Cognitive Assessment - Executive Function subscore (rho = 0.70), and Box and Block Test (rho = 0.74). Importantly, our results highlight that gross motor impairment may be overlooked in the assessment of HIV-related disability. This study shows that rehabilitation robotics can be expanded to new populations beyond stroke, namely to people living with HIV and those with cognitive impairments.
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http://dx.doi.org/10.1101/2020.10.30.20223172DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7654928PMC
November 2020

The management of the poisoned patient using a novel emergency department-based resuscitation and critical care unit (ResCCU).

Am J Emerg Med 2020 10 28;38(10):2070-2073. Epub 2020 Jun 28.

Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States. Electronic address:

Objectives: The Resuscitation & Critical Care Unit (ResCCU) is a novel ED-based ICU designed to provide early critical care services. This study sought to identify characteristics of poisoned patients treated in the ResCCU.

Methods: We conducted a retrospective, single-center case study of poisoned patients over the age of 18 years old over a 16-month period. Patient demographics, drug concentrations, and severity of illness scores were extracted from electronic medical records. Patients were divided into two groups, those who required short term ICU level care (< 24 h) and prolonged ICU care (> 24 h).

Results: A total of 58 ED visits with a tox-related illness were analyzed. There were 24 women (41%) and 34 men (59%). There were 42 patients (72%) who required short term ICU level care and 16 patients (28%) who required prolonged ICU care. In the short-term ICU group, 13 patients (31%) were discharged home directly from the ResCCU, 29 patients (69%) were sent to the inpatient floor, and 1 of the admitted floor patients expired. There were no patients admitted to the floor that required a step-up to the inpatient ICU. 56 patients (97%) were alive at post-admit day 7 and 28, and only 8 (14%) were re-admitted within 30 days.

Conclusions: Patients who were treated in the ED-based ICU for toxicology-related illnesses were frequently able to be either discharged home or admitted to a regular floor after their initial stabilization and treatment, and none that were sent to the floor required an ICU step-up.
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http://dx.doi.org/10.1016/j.ajem.2020.06.068DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7704670PMC
October 2020

Stories to Communicate Individual Risk for Opioid Prescriptions for Back and Kidney Stone Pain: Protocol for the Life STORRIED Multicenter Randomized Clinical Trial.

JMIR Res Protoc 2020 Sep 24;9(9):e19496. Epub 2020 Sep 24.

Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.

Background: Prescription opioid misuse in the United States is a devastating public health crisis; many chronic opioid users were originally prescribed this class of medication for acute pain. Video narrative-enhanced risk communication may improve patient outcomes, such as knowledge of opioid risk and opioid use behaviors after an episode of acute pain.

Objective: Our objective is to assess the effect of probabilistic and narrative-enhanced opioid risk communication on patient-reported outcomes, including knowledge, opioid use, and patient preferences, for patients who present to emergency departments with back pain and kidney stone pain.

Methods: This is a multisite randomized controlled trial. Patients presenting to the acute care facilities of four geographically and ethnically diverse US hospital centers with acute renal colic pain or musculoskeletal back and/or neck pain are eligible for this randomized controlled trial. A control group of patients receiving general risk information is compared to two intervention groups: one receiving the risk information sheet plus an individualized, visual probabilistic Opioid Risk Tool (ORT) and another receiving the risk information sheet plus a video narrative-enhanced probabilistic ORT. We will study the effect of probabilistic and narrative-enhanced opioid risk communication on the following: risk awareness and recall at 14 days postenrollment, reduced use or preferences for opioids after the emergency department episode, and alignment with patient preference and provider prescription. To assess these outcomes, we administer baseline patient surveys during acute care admission and follow-up surveys at predetermined times during the 3 months after discharge.

Results: A total of 1302 patients were enrolled over 24 months. The mean age of the participants was 40 years (SD 14), 692 out of 1302 (53.15%) were female, 556 out of 1302 (42.70%) were White, 498 out of 1302 (38.25%) were Black, 1002 out of 1302 (76.96%) had back pain, and 334 out of 1302 (25.65%) were at medium or high risk. Demographics and ORT scores were equally distributed across arms.

Conclusions: This study seeks to assess the potential clinical role of narrative-enhanced, risk-informed communication for acute pain management in acute care settings. This paper outlines the protocol used to implement the study and highlights crucial methodological, statistical, and stakeholder involvement as well as dissemination considerations.

Trial Registration: ClinicalTrials.gov NCT03134092; https://clinicaltrials.gov/ct2/show/NCT03134092.

International Registered Report Identifier (irrid): DERR1-10.2196/19496.
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http://dx.doi.org/10.2196/19496DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7545334PMC
September 2020

The Impact of Medical Cannabis on Intermittent and Chronic Opioid Users with Back Pain: How Cannabis Diminished Prescription Opioid Usage.

Cannabis Cannabinoid Res 2020 2;5(3):263-270. Epub 2020 Sep 2.

Department of Emergency Medicine, University of Central Florida, Orlando, Florida.

To determine if cannabis may be used as an alternative or adjunct treatment for intermittent and chronic prescription opioid users. Retrospective cohort study. A single-center cannabis medical practice site in California. A total of 180 patients who had a chief complaint of low back pain were identified (, 10th Revision, code M54.5). Sixty-one patients who used prescription opioids were analyzed. Cannabis recommendations were provided to patients as a way to mitigate their low back pain. Number of patients who stopped opioids and change in morphine equivalents. There were no between-group differences based on demographic, experiential, or attitudinal variables. We found that 50.8% were able to stop all opioid usage, which took a median of 6.4 years (IQR=1.75-11 years) after excluding two patients who transitioned off opioids by utilizing opioid agonists. For those 29 patients (47.5%) who did not stop opioids, 9 (31%) were able to reduce opioid use, 3 (10%) held the same baseline, and 17 (59%) increased their usage. Forty-eight percent of patients subjectively felt like cannabis helped them mitigate their opioid intake but this sentiment did not predict who actually stopped opioid usage. There were no variables that predicted who stopped opioids, except that those who used higher doses of cannabis were more likely to stop, which suggests that some patients might be able to stop opioids by using cannabis, particularly those who are dosed at higher levels. In this long-term observational study, cannabis use worked as an alternative to prescription opioids in just over half of patients with low back pain and as an adjunct to diminish use in some chronic opioid users.
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http://dx.doi.org/10.1089/can.2019.0039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7480723PMC
September 2020

Prevalence of Burnout in Occupational and Environmental Medicine Physicians in the United States.

J Occup Environ Med 2020 09;62(9):680-685

Division of Occupational Medicine (Dr Green-McKenzie, Dr Somasundaram, Dr Lawler, Dr O'Hara); Bayhealth Occupational Medicine, Dover, Delaware (Dr Somasundaram); Sharp Rees-Stealy Medical Group, San Diego (Dr Lawler); EMR CPR, Fremont (Dr O'Hara), California; Epidemiology & Biostatistics (Dr Shofer), Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.

Objective: To determine prevalence and key drivers of burnout in Occupational and Environmental Medicine physicians in the United States.

Methods: A nationwide survey of Occupational Medicine physicians was conducted using the Qualtrics® platform. Burnout, measured by the Maslach Burnout Inventory®, Social Support, and Job Satisfaction were assessed.

Results: The response rate was 46%, the overall burnout prevalence 38%, and most respondents were men (69%). The mean age and mean years in practice were 56 years and 20 years respectively. Physicians working in government/military (48%) and private medical center group settings (46%) were significantly more likely to report burnout, with consultants (15%) reporting the lowest rate.

Conclusions: Although the overall burnout prevalence is lower in Occupational Medicine physicians compared with most specialties, the rate varies significantly by practice setting (15% to 48%) affirming the impact of organizational factors.
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http://dx.doi.org/10.1097/JOM.0000000000001913DOI Listing
September 2020

Improving Emergency Department Patient Experience Through Implementation of an Informational Pamphlet.

J Patient Exp 2020 Apr 22;7(2):225-231. Epub 2019 Feb 22.

Department of Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA.

Objective: Patient satisfaction is emerging as a new health-care metric. We hypothesized that an emergency department (ED) informational pamphlet would significantly improve patient understanding of ED operations and ultimately improve patient satisfaction.

Methods: We performed a prospective study of patients presenting to a single tertiary care center ED from April to July 2017. All patients were given a pamphlet on alternating weeks with regular care on opposite weeks and were surveyed upon ED discharge. The primary outcome was patient satisfaction with ED care. Secondary outcomes included patient understanding of various wait times (test results, consultants), discharge process, who was on the care team and what to expect during the ED visit.

Results: Four hundred ninety-four patients were included in this study and 266 (54%) were in the control group. Of 228 (46%) patients who were given the pamphlet, 116 (51%) were unaware they received it. Of the remaining 112 (49%) patients who remembered receiving the pamphlet, 43 (38%) stated they read it. Among those reading the pamphlet, only two statements were significant: knowing what to expect during the ED visit (88% vs 71%; = 0.012) and waiting time for test results (95% vs 75%; = 0.003) when compared to those who did not receive or read the pamphlet.

Conclusion: An ED informational pamphlet, when utilized by patients, does improve patient understanding of some aspects of the ED visit but does not appear to be the best tool to convey all information. Ultimately, sustained improvement in patient satisfaction is a complex and dynamic issue necessitating a multifactorial approach and other methods should be explored.
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http://dx.doi.org/10.1177/2374373519826246DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7427355PMC
April 2020

TNFAIP8 family gene expressions in the mouse tail intervertebral disc injury model.

JOR Spine 2020 Jun 19;3(2):e1093. Epub 2020 Jun 19.

Department of Physical Medicine & Rehabilitation University of Pennsylvania Philadelphia Pennsylvania USA.

Introduction: The TNF-α-induced protein-8 (TNFAIP8, also known as TIPE) family of molecules comprises four members: TNFAIP8 and TIPEs1-3. Since the first description of these proteins, their roles in fine-tuning inflammation and in directing leukocyte migration have been described in several organ systems. However, their relationship with intervertebral disc (IVD) is unknown.

Materials And Methods: Here, we describe the expression of TNFAIP8 family genes in the nucleus pulposus (NP) and annulus fibrosus (AF) of the normal adult murine IVD. We further describe the expression of these genes in the injured male and female murine IVD.

Results: gene expression was decreased, and gene expression was essentially unchanged, in response to injury. and gene expression was markedly elevated in response to IVD injury, along with those encoding known inflammatory markers (ie, , and ). Additionally, sex-related differences were also observed for some of these genes in intact and injured mouse IVDs. Future studies include examining tissue distribution of TNFAIP8 family proteins and identifying cells that produce them. In addition, examining mice that are deficient in TNFAIP8 molecules, in relation to gene expression, tissue morphology and mouse behavior, may further delineate the roles of these molecules in IVD inflammation and degeneration.
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http://dx.doi.org/10.1002/jsp2.1093DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7323467PMC
June 2020

Discharges "Against Medical Advice" in Patients With Opioid-related Hospitalizations.

J Addict Med 2021 Jan-Feb 01;15(1):49-54

Departments of Internal Medicine and Psychiatry, Tulane University School of Medicine, New Orleans, LA (CJS); Emergency Medicine, Epidemiology & Biostatistics, Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (FSS); National Clinician Scholars Program, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (ML); Emergency Medicine, Center for Addiction Medicine and Policy Director, Division of Medical Toxicology and Addiction Medicine Initiatives, Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (JP).

Objectives: We performed a descriptive analysis of patient and treatment characteristics in premature discharges "against medical advice" (AMA) in a cohort of patients with opioid-related hospitalizations.

Methods: We abstracted data from 1152 opioid related hospitalizations of 928 adult patients in a large academic health system. Using electronic health record data, hospitalizations were categorized as AMA or conventional discharge (CD). To determine differences between AMA and CD regarding treatment characteristics, Fisher exact test, t tests, ANOVA, and logistic regression were performed.

Results: 74 / 1152 (6%) of opioid-related hospitalizations were discharged AMA. Hospitalizations that resulted in AMA discharge had shorter median length of stay (AMA vs CD 3.5 vs 5.5 days, P < 0.001) and received fewer of any type of opioid agonist treatment (AMA vs CD 73% vs 84%, P = 0.03). Although the number of hospitalizations in which methadone was administered did not differ between the AMA and CD groups, hospitalizations that resulted in AMA had more dose reductions and lesser quantities of methadone overall before discharge. Buprenorphine use was low overall in AMA and CD (0% and 2.1%, respectively).

Conclusion: In this sample of opioid related hospitalizations, admissions that resulted in AMA discharge had fewer opioid agonist administrations and lower methadone dosing. These findings support efforts to initiate opioid agonist therapy during hospital admissions, and further studies should determine whether this practice mitigates AMA discharges.
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http://dx.doi.org/10.1097/ADM.0000000000000688DOI Listing
June 2021

Severe Impairment of Microcirculatory Perfused Vessel Density Is Associated With Postoperative Lactate and Acute Organ Injury After Cardiac Surgery.

J Cardiothorac Vasc Anesth 2021 Jan 14;35(1):106-115. Epub 2020 May 14.

Department of Emergency Medicine, Center for Resuscitation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.

Objective: Resuscitation after cardiac surgery needs to address multiple pathophysiological processes that are associated with significant morbidity and mortality. Functional microcirculatory derangements despite normal systemic hemodynamics have been previously described but must be tied to clinical outcomes. The authors hypothesized that microcirculatory dysfunction after cardiac surgery would include impaired capillary blood flow and impaired diffusive capacity and that subjects with the lowest quartile of perfused vessel density would have an increased postoperative lactate level and acute organ injury scores.

Design: Prospective, observational study.

Setting: A single, tertiary university cardiovascular surgical intensive care unit.

Participants: 25 adults undergoing elective cardiac surgery requiring cardiopulmonary bypass.

Intervention: Sublingual microcirculation was imaged using incident dark field microscopy before and 2 to 4 hours after surgery in the intensive care unit.

Measurements And Main Results: Compared with baseline measurements, postoperative vessel-by-vessel microvascular flow index (2.9 [2.8-2.9] v 2.5 [2.4-2.7], p < 0.0001) and perfused vessel density were significantly impaired (20.7 [19.3-22.9] v 16.3 [12.8-17.9], p < 0.0001). The lowest quartile of perfused vessel density (<12.8 mm/mm) was associated with a significantly increased postoperative lactate level (6.0 ± 2.9 v 1.8 ± 1.2, p < 0.05), peak lactate level (7.6 ± 2.8 v 2.8 ± 1.5, p = 0.03), and sequential organ failure assessment (SOFA) score at 24 and 48 hours.

Conclusion: In patients undergoing cardiac surgery, there was a significant decrease in postoperative microcirculatory convective blood flow and diffusive capacity during early postoperative resuscitation. Severely impaired perfused vessel density, represented by the lowest quartile of distribution, is significantly related to hyperlactatemia and early organ injury.
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http://dx.doi.org/10.1053/j.jvca.2020.04.045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7666105PMC
January 2021

Ex vivo use of cell-permeable succinate prodrug attenuates mitochondrial dysfunction in blood cells obtained from carbon monoxide-poisoned individuals.

Am J Physiol Cell Physiol 2020 07 6;319(1):C129-C135. Epub 2020 May 6.

Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

The purpose of this study was to evaluate a new pharmacological strategy using a first-generation succinate prodrug, NV118, in peripheral blood mononuclear cells (PBMCs) obtained from subjects with carbon monoxide (CO) poisoning and healthy controls. We obtained human blood cells from subjects with CO poisoning and healthy control subjects. Intact PBMCs from subjects in the CO and Control group were analyzed with high-resolution respirometry measured in pmol O per second per 10 PBMCs. In addition to obtaining baseline respiration, NV118 (100 μM) was injected, and the same parameters of respiration were obtained for comparison in PBMCs. We measured mitochondrial dynamics with microscopy with the same conditions. We enrolled 37 patients (17 in the CO group and 20 in the Control group for comparison) in the study. PMBCs obtained from subjects in the CO group had overall significantly lower respiration compared with the Control group ( < 0.0001). There was a significant increase in respiration with NV118, specifically with an increase in maximum respiration and respiration from complex II and complex IV ( < 0.0001). The mitochondria in PBMCs demonstrated an overall increase in net movement compared with the Control group. Our results of this study suggest that the therapeutic compound, NV118, increases respiration at complex II and IV as well as restoration of mitochondrial movement in PBMCs obtained from subjects with CO poisoning. Mitochondrial-directed therapy offers a potential future strategy with further exploration in vivo.
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http://dx.doi.org/10.1152/ajpcell.00539.2019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7468892PMC
July 2020

Functional Deficits in Mice Expressing Human Interleukin 8.

Comp Med 2020 06 20;70(3):205-215. Epub 2020 Apr 20.

Department of Physical Medicine and Rehabilitation, Perelman School of Medicine, University of Pennsylvania; Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania; Corporal Michael J Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania.

We showed previously that inflammatory mediators, including IL8, in intervertebral disc tissues from patients with discogenic back pain may play a key role in back pain. To investigate the molecular mechanism of IL8 signaling in back pain, we generated a mouse model that conditionally expresses human (h) IL8. We hypothesized that hIL8 levels affect mouse activity and function. Briefly, hIL8 cDNA was inserted into the pCALL2 plasmid, linearized, and injected into mouse embryos. Resulting pCALL2-hIL8 mice were then bred with GDF5-Cre mice to express the transgene in cartilage and intervertebral disc (IVD) tissues. Functional capacities including nest-making and other natural behaviors were measured. Both male and female mice expressing hIL8 showed lower nesting scores than did littermates that did not express hIL8 ( = 14 to 16 per group). At 28 wk of age, mice expressing hIL8 ( = 35) spent more time immobile and eating during each night than littermate controls ( = 33). Furthermore, hIL8-expressing mice traveled shorter distances and at a lower average speed than littermate controls. Thus, in an initial effort to investigate the relationship between this chemokine and mouse behavior, we have documented changes in normal activities in mice conditionally expressing hIL8.
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http://dx.doi.org/10.30802/AALAS-CM-19-000049DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7287389PMC
June 2020

Influence of Genetic Background and Sex on Gene Expression in the Mouse () Tail in a Model of Intervertebral Disc Injury.

Comp Med 2020 04 10;70(2):131-139. Epub 2020 Mar 10.

Departments of Physical Medicine and Rehabilitation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Departments of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Translational Musculoskeletal Research Center, Corporal Michael J Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania.

To facilitate rational experimental design and fulfill the NIH requirement of including sex as a biologic variable, we examined the influences of genetic background and sex on responses to intervertebral disc (IVD) injury in the mouse tail. The goal of this study was to compare gene expression and histologic changes in response to a tail IVD injury (needle puncture) in male and female mice on the DBA and C57BL/6 (B6) backgrounds. We hypothesized that extracellular matrix gene expression in response to IVD injury differs between mice of different genetic backgrounds and sex. Consistent changes were detected in gene expression and histologic features after IVD injury in mice on both genetic backgrounds and sexes. In particular, expression of and was higher in the injured IVD of DBA mice than B6 mice. Conversely, expression was higher in B6 mice than DBA mice. Sex-associated differences were significant only in B6 mice, in which expression was greater in male mice than in female. Histologic differences in response to injury were not apparent between DBA and B6 mice or between males and females. In conclusion, mouse tail IVD showed sex- and strain-related changes in gene expression and histology after needle puncture. The magnitude of change in gene expression differed with regard to genetic background and, to a lesser degree, sex.
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http://dx.doi.org/10.30802/AALAS-CM-19-000034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7137552PMC
April 2020

The practical knowledge, experience and beliefs of US emergency medicine physicians regarding medical Cannabis: A national survey.

Am J Emerg Med 2020 09 30;38(9):1952-1954. Epub 2020 Jan 30.

University of Central Florida, Orlando, FL, United States of America.

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http://dx.doi.org/10.1016/j.ajem.2020.01.059DOI Listing
September 2020

Feedback With Performance Metric Scorecards Improves Resident Satisfaction but Does Not Impact Clinical Performance.

AEM Educ Train 2019 Oct 20;3(4):323-330. Epub 2019 May 20.

Department of Emergency Medicine Columbia University College of Physician and Surgeons New York NY.

Objectives: The Emergency Medicine Milestone Project, a framework for assessing competencies, has been used as a method of providing focused resident feedback. However, the emergency medicine milestones do not include specific objective data about resident clinical efficiency and productivity, and studies have shown that milestone-based feedback does not improve resident satisfaction with the feedback process. We examined whether providing performance metric reports to resident physicians improves their satisfaction with the feedback process and their clinical performance.

Methods: We conducted a three-phase stepped-wedge randomized pilot study of emergency medicine residents at a single, urban academic site. In phase 1, all residents received traditional feedback; in phase 2, residents were randomized to receive traditional feedback (control group) or traditional feedback with performance metric reports (intervention group); and in phase 3, all residents received monthly performance metric reports and traditional feedback. To assess resident satisfaction with the feedback process, surveys using 6-point Likert scales were administered at each study phase and analyzed using two-sample t-tests. Analysis of variance in repeated measures was performed to compare impact of feedback on resident clinical performance, specifically patient treatment time (PTT) and patient visits per hour.

Results: Forty-one residents participated in the trial of which 21 were randomized to the intervention group and 20 in the control group. Ninety percent of residents liked receiving the report and 74% believed that it better prepared them for expectations of becoming an attending physician. Additionally, residents randomized to the intervention group reported higher satisfaction (p = 0.01) with the quality of the feedback compared to residents in the control group. However, receiving performance metric reports, regardless of study phase or postgraduate year status, did not affect clinical performance, specifically PTT (183 minutes vs. 177 minutes, p = 0.34) or patients visits per hour (0.99 vs. 1.04, p = 0.46).

Conclusions: While feedback with performance metric reports did not improve resident clinical performance, resident physicians were more satisfied with the feedback process, and a majority of residents expressed liking the reports and felt that it better prepared them to become attending physicians. Residency training programs could consider augmenting feedback with performance metric reports to aide in the transition from resident to attending physician.
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http://dx.doi.org/10.1002/aet2.10348DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6795364PMC
October 2019

The Triage of Older Adults with Physiologic Markers of Serious Injury Using a State-Wide Prehospital Plan.

Prehosp Disaster Med 2019 Oct 13;34(5):497-505. Epub 2019 Sep 13.

Department of Emergency Medicine, University of North Carolina, Chapel Hill, North CarolinaUSA.

Introduction: In January of 2010, North Carolina (NC) USA implemented state-wide Trauma Triage Destination Plans (TTDPs) to provide standardized guidelines for Emergency Medical Services (EMS) decision making. No study exists to evaluate whether triage behavior has changed for geriatric trauma patients.

Hypothesis/problem: The impact of the NC TTDPs was investigated on EMS triage of geriatric trauma patients meeting physiologic criteria of serious injury, primarily based on whether these patients were transported to a trauma center.

Methods: This is a retrospective cohort study of geriatric trauma patients transported by EMS from March 1, 2009 through September 30, 2009 (pre-TTDP) and March 1, 2010 through September 30, 2010 (post-TTDP) meeting the following inclusion criteria: (1) age 50 years or older; (2) transported to a hospital by NC EMS; (3) experienced an injury; and (4) meeting one or more of the NC TTDP's physiologic criteria for trauma (n = 5,345). Data were obtained from the Prehospital Medical Information System (PreMIS). Data collected included proportions of patients transported to a trauma center categorized by specific physiologic criteria, age category, and distance from a trauma center.

Results: The proportion of patients transported to a trauma center pre-TTDP (24.4% [95% CI 22.7%-26.1%]; n = 604) was similar to the proportion post-TTDP (24.4% [95% CI 22.9%-26.0%]; n = 700). For patients meeting specific physiologic triage criteria, the proportions of patients transported to a trauma center were also similar pre- and post-TTDP: systolic blood pressure <90 mmHg (22.5% versus 23.5%); respiratory rate <10 or >29 (23.2% versus 22.6%); and Glascow Coma Scale (GCS) score <13 (26.0% versus 26.4%). Patients aged 80 years or older were less likely to be transported to a trauma center than younger patients in both the pre- and post-TTDP periods.

Conclusions: State-wide implementation of a TTDP had no discernible effect on the proportion of patients 50 years and older transported to a trauma center. Under-triage remained common and became increasingly prevalent among the oldest adults. Research to understand the uptake of guidelines and protocols into EMS practice is critical to improving care for older adults in the prehospital environment.
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http://dx.doi.org/10.1017/S1049023X19004825DOI Listing
October 2019

Nursing updates as a means to improve patient satisfaction.

Am J Emerg Med 2020 02 6;38(2):404-406. Epub 2019 Aug 6.

Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.

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http://dx.doi.org/10.1016/j.ajem.2019.158388DOI Listing
February 2020
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