Casirivimab/imdevimab treatment for outpatient COVID-19 during a SARS-CoV-2 B1.617.2 (Delta) surge at a community hospital

CONTEXT

Vaccination status has been shown to be linked to patient-centered outcomes in those with COVID-19. However, minimal data have explored the relationship between vaccination status and representation rates after receiving monoclonal antibodies (MABs) the Delta strain of severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) in a community setting.

OBJECTIVES

The authors sought to determine if there was a difference in patient-centered outcomes between those who were vaccinated and unvaccinated after the administration of casirivimab/imdevimab for mild-to-moderate COVID-19 during the time when the Delta strain was most prevalent.

METHODS

A convenience sample of consecutive adults given casirivimab/imdevimab at either an outpatient infusion center or within the emergency department (ED) were included in analysis. Patient demographics, authorized-use qualifiers from the emergency use authorization (EUA), baseline vital signs at the time of infusion, representation rates to a healthcare provider within the hospital's network, and any admissions to the hospital following infusion were all collected from the patient's electronic medical record. Vaccination status was confirmed in both the patient's electronic medical record and the Arizona State Immunization Information System (ASIIS). Analysis was conducted utilizing descriptive statistics, the Mann-Whitney U test for continuous data, and the chi-squared analysis for nominal data.

RESULTS

In total, 743 patients were included in the study, with 585 being unvaccinated and 158 being vaccinated at the time of administration. Those in the vaccinated group were more likely to be older (60.0 vs. 55.0 years; p<0.001) and to have a history of diabetes (18.4% vs. 11.3%; p=0.02), hypertension (39.9% vs. 28.5%; p=0.006), immunosuppression (7.0% vs. 1.4%; p<0.001), and chronic kidney disease (7.0% vs. 3.4%; p=0.05). In the entire sample, 105 (14.1%) patients had an unexpected return visit to either the ED or urgent care at 28 days, with 17 (2.3%) requiring hospitalization. Patients who were vaccinated were more likely to represent for care after casirivimab/imdevimab infusion (20.3% vs. 12.5%; p=0.01), but no difference was noted in hospitalization rates between the two groups (18.8% vs. 15.1%; p=0.15).

CONCLUSIONS

MAB therapy with casirivimab/imdevimab for the outpatient treatment of mild-to-moderate COVID-19 was associated with a low rate of hospitalization. However, those who were vaccinated were more likely to present for unexpected return care at either the ED or urgent care within 28 days of the initial infusion.

A Comparison of Inhaled Epoprostenol in Patients With Acute Respiratory Distress Syndrome and COVID-19-Associated Acute Respiratory Distress Syndrome

Introduction

Acute respiratory distress syndrome (ARDS) and coronavirus disease 2019 (COVID-19)-associated acute respiratory distress syndrome (CARDS) are both characterized by non-cardiogenic pulmonary edema and severe hypoxemia that leads to a high percentage of patients suffering in-hospital mortality. Mechanistically, inhaled epoprostenol (iEPO) has shown a role in the treatment of ARDS and CARDS but little data are available directly comparing the two disease processes. Due to the lack of evidence of iEPO in ARDS and CARDS, the authors sought to compare the pulmonary effects of iEPO for mechanically ventilated patients with CARDS against a case match control of those with ARDS.

Methods

A retrospective cohort of all patients receiving iEPO between January 1, 2020, and February 22, 2022, was reviewed. Patients with ARDS were case-matched in a 2:1 allocation ratio of CARDS to ARDS by the number of medical comorbidities and age +/- 5 years. Clinical data collected included patient demographics, laboratory values, ventilator settings, length of hospitalization, and 28-day mortality. Comparisons of the effectiveness of iEPO between ARDS and CARDS were conducted using the chi-squared statistic for categorical variables and the Mann-Whitney statistic for continuous variables.

Results

A total of 72 patients were included in the final analysis, with 24 having ARDS and 48 CARDS. The number of medical comorbidities was no different for patients with ARDS or CARDs (p = 0.18), though the frequency of patients diagnosed with coronary artery disease (p=0.007), congestive heart failure (p=0.003), chronic obstructive pulmonary disease (p=0.004), and pulmonary hypertension (p=0.004) did vary between the two groups. A moderate but non-significant difference in pre-iEPO partial pressure of oxygen (PaO₂)/fraction of inspired oxygen (FiO₂) ratio was noted between the groups (0.74 vs 0.65; p=0.33). Following iEPO treatment, patients with ARDS showed a greater PaO₂/FiO₂ ratio than those with CARDS (0.87 vs 0.70; p=0.02). CARDS patients who received iEPO had a longer length of stay as compared to those with ARDS (17.5 vs 12.5 days; p=0.01). However, no difference was noted in 28-day mortality between the two groups (14 vs 34; p=0.29).

Conclusion

In this small sample from a single community hospital, a statistically significant improvement in the PaO₂/FiO₂ ratio was noted for both those with ARDS and CARDS. However, those with CARDS who were given iEPO had a longer length of stay without a significant difference in mortality as compared to those with traditional ARDS.

Multisite assessment of emergency medicine resident knowledge of evidence-based medicine as measured by the Fresno Test of Evidence-Based Medicine

CONTEXT

Evidence-based medicine (EBM) is the application of scientific evidence while treating a patient. To date, however, there is very little evidence describing how residents in emergency medicine understand and incorporate EBM into practice.

OBJECTIVES

The aim of this study was to determine EBM theoretical and quantitative knowledge in emergency medicine residents in community hospital-based training programs.

METHODS

A sample of emergency medicine residents from nine hospitals was enrolled to complete a cross-sectional assessment of EBM skills from April 2021 through June 2021. Performance on the Fresno Test of Evidence-Based Medicine (FTEBM) was assessed utilizing descriptive statistics, t tests, and one-way analysis of variance.

RESULTS

A total of 50.8% (124/244) of current emergency medicine residents completed the FTEBM during the study period. No significant difference on FTEBM scores was noted between the different types of medical degrees (DO vs. MD) (p=0.511), holding an advanced research degree (p=0.117), or between each postgraduate year of training (p=0.356). The mean score of those residents who rated their knowledge of EBM as average or higher was 36.0% (32.8-39.1%). The mean score of those residents who rated their programs as having an "average" or higher institutional focus on EBM was 34.9% (32.2-37.6%).

CONCLUSIONS

Participating emergency medicine residents show an incomplete understanding of EBM both in theory and applied computations despite rating themselves as having an average understanding. Emergency medicine residencies would be well suited to implement a standardized EBM curriculum that focuses on longitudinal reinforcement of key concepts needed for the practicing physician.

Characteristics and Outcomes of Patients Presenting to Rural or Urban Emergency Departments with COVID‐19

Background

The Coronavirus disease 2019 pandemic placed unprecedented strain on healthcare workers and hospital systems. While healthcare institutions across the nation all faced high census numbers, hospitals in rural settings are often burdened with less resources than their urban counterparts. Therefore, we hypothesized that receiving care in rural settings would be associated with poorer clinical outcomes.

Objective

To compare the characteristics and outcomes of patients with SARS‐CoV‐2 presenting to urban and rural emergency departments in the American southwest.

Methods

A multisite retrospective chart review of patients admitted to inpatient care due SARS‐CoV‐2 infection from March 1^st, 2020 through January 31^st, 2021 was conducted at three participating hospitals. Abstracted data included patient demographics, intake laboratory values, and patient outcomes. Analysis was conducted using descriptive statistics, the Pearson chi‐square for categorical data, the Mann‐Whitney U test for continuous data, and Kaplan‐Myer for disease progression.

Results

A total of 489 patients with confirmed SARS‐CoV‐2 infection via nasopharyngeal sample were included in the analysis with 57.1% (279/489) presenting to an urban emergency department. Patients admitted in the rural and urban setting showed similar demographics in regard to age (p=0.710), sex (p=0.312), and majority/minority status (p=0.062). Upon presentation, patients in rural settings were more likely to have critically low white blood cell counts (p<0.001), abnormally high hematocrit (p=0.001), and abnormally high aspartate aminotransferase levels (p<0.001) than their urban counterparts. Following admission, urban patients were 2.53 times more likely than rural patients to be transferred to critical care (p<0.001) with the transfer contributing to a reduced hospitalization length of 2.7 days in the urban setting (p=0.002). Rural patients unable to transfer to critical care were 4.95 times more likely to expire than urban patients (p=0.014).

Conclusion

Patients receiving care for SARS‐CoV‐2 infection in the rural setting often present with more severe clinical profiles and are more likely to experience negative outcomes than their urban counterparts. Rural hospitals should attempt to reduce this discrepancy by developing robust prognostic procedures to minimize critical care bed utilization.

The Impact of Secondary Bacterial Infections in COVID‐19 Patients on Mortality and the Immune Response in the State of Arizona

The literature on COVID‐19 has focused primarily on urban centers and suggest an increased risk of mortality in COVID‐19 patients coinfected with bacteria compared to those solely infected with COVID‐19. In patients screened or admitted to suburban and rural hospitals in Arizona, mortality increased with co‐infection. The impact of bacterial coinfections on the immune response was studied by comparing white blood cell (WBC) and lymphocyte counts as well as the relationship between duration of steroid use and mortality in coinfected COVID‐19 patients investigated.

Multisite Clinical Utilization of Antibiotics among Hospitalized Patients with COVID‐19

Introduction

Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) has infected over 212,000,000 individuals worldwide with a mortality rate of 2.1% as of August 2021. A concerning trend in the treatment of COVID‐19 has emerged wherein hospitalized patients are administered broad spectrum antibiotics to stave off secondary bacterial infection. However, the clinical justification for the use of broad‐spectrum antibiotics for viral respiratory infection remains tenuous. Over administration of these therapies contributes to the growing frequency of antimicrobial resistance, which prior to the pandemic contributed to nearly 700,000 death per year.

Objective

To describe the clinical utilization and efficacy of broad‐spectrum antibiotics among hospitalized patients with SARS‐CoV‐2 within 3 hospital systems in the American southwest.

Methods

A multisite retrospective chart review of patients admitted to inpatient care due SARS‐CoV‐2 infection from March 1^st, 2020 through January 31^st, 2021 was conducted. Abstracted data included patient demographics, laboratory culture results, administered antibiotics, and patient outcomes. Analysis was conducted using descriptive statistics, the Pearson chi‐square for categorical data, and the Mann‐Whitney U test for continuous data.

Results

A total of 489 patients with confirmed SARS‐CoV‐2 infection via nasopharyngeal sample were included in the analysis with 19.2% (94/489) diagnosed with a concurrent bacterial infection. Patients with concurrent bacterial infections were more likely to require critical care (50.0% vs 20.7%; p<0.001) and expire (28.7% vs 14.4%; p<0.001) while hospitalized. Though the rates of secondary bacterial infection were low, 83.4% of all patients were administered at least one broad spectrum antibiotic, with the most common being Azithromycin (60%; 297/489) followed by Ceftriaxone (46.6%; 228/489). Antibiotics were not preferentially administered to patients with concurrent bacterial infection (p=0.1619), nor did it show clinical efficacy for reducing mortality among the entire sample (p=0.190) or those with secondary infection (p=0.191).

Conclusion

The COVID‐19 pandemic has contributed to non‐specific over administration of broad‐spectrum antibiotics, which failed to improve the rate of patient mortality even when afflicted with secondary infection. Over‐administration of these drugs will continue to exacerbate the growing rates of antimicrobial resistance. Clinicians are recommended to apply early empirical approaches when selecting to employ antibiotic therapies.

Results of Lung Cancer Screening in a Rural Setting: A Retrospective Cohort Study

Background

In this study, we aimed to determine the performance of the lung cancer screening (LCS) program using low-dose computed tomography (LDCT) in a rural community.

Methodology

We conducted a retrospective cohort study of patients who underwent LCS at a rural healthcare institution from September 1, 2016, through December 31, 2019, to determine the utilization of screening, rate of positivity, rate of cancer detection, and patient compliance.

Results

A total of 1,474 patients underwent initial LCS, and 1,776 LCS examinations were performed using LDCT. Of 1,776 tests performed, 375 (21.1%) were categorized as positive (Lung CT Screening Reporting and Data System III or higher), with 215 of the 375 (57.6%) being lost to follow-up. A total of 29 malignancies were identified (in 1.6% of all LCS tests) during the study period, with 23 (82.8%) malignancies being low-stage malignancies (stage I or II), 24 (79.3%) malignancies potentially surgical candidates (stage IIIA or less), and five (17.2%) malignancies being non-surgical candidates based on stage (stage IIIB or IV). A total of 28.7% of all patients eligible for repeat screening had at least one repeat annual test. Overall, 9.9% of all patients eligible for two repeat annual tests had a second repeat annual test.

Conclusions

LCS using LDCT is effective in detecting lung cancer in a rural setting. However, compliance with repeat annual screening and recommendations for further workup is low. This may be exacerbated by healthcare and socioeconomic issues prevalent in rural communities. The use of LCS patient coordinators and dedicated tracking software may improve compliance with repeat annual screening and compliance with recommendations when LCS tests are positive.

Analysis of Smoking Behavior in Patients With Peritonsillar Abscess: A Rural Community Hospital's Experience

Background

Peritonsillar abscesses (PTA) are the most common deep space infection of the head and neck. They appear to have an association with a patient’s smoking history but data showing this relationship is sparse and controversial. Currently, no data on this association exists for those who seek care at a rural community emergency department (ED). Based upon the lack of data in this setting, the authors sought to determine the incidence, treatments, and outcomes between smokers and non-smokers with a PTA at a rural community ED.

Methods

A retrospective chart review of all patients undergoing a soft tissue neck computed tomography (CT) scan with or without intravenous contrast was completed from September 25th, 2019 through October 4th, 2021. Patients with a previously diagnosed PTA and those diagnosed via another means (clinical, needle aspiration, etc.), or outside of the ED were excluded from the dataset. Abstracted data included demographics, treatments, and outcomes of each patient. The data were analyzed using the Mann-Whitney test for continuous data and the chi-square test for categorical data.

Results

During the study period, a total of 50 patients were diagnosed with a PTA via soft tissue neck CT. Of those diagnosed, the median age was 40.5 (25.5 - 53.3) years, 15 were female, 38 self-identified as white, and 27 noted a current smoking history. Smokers presented to ED earlier than non-smokers (2.0 vs 4.0 days; p=0.03), but no difference was noted in the size of PTA identified via CT (2.0 vs 1.5 cm; p=0.13). No difference among smokers and non-smokers was noted in corticosteroid therapy either administered in the ED (p = 0.53) or prescribed as an outpatient (p = 0.75), incision and drainage (p = 0.19), outpatient follow-up (p = 0.53), or resolution of the symptoms (p = 0.86). However, more patients in the non-smoking group had an unplanned return to the ED as compared to those who smoked (p=0.02). In those patients who were not discharged from the ED after initial presentation, four were admitted to the hospital and 11 were transferred to a higher level of care.

Conclusion

Although drawn from a limited sample from a single rural community ED, a positive smoking history was more common among patients with a PTA. While there was no statistically significant difference in the overall treatment, a difference was noted for unscheduled return visits to the ED in those without a history of smoking. 

Real World Utilization of Bamlanivimab at a Rural Community Hospital

Introduction

Although there were several proposed treatments for patients that were hospitalized with COVID-19, outpatient treatments for those with mild to moderate illness were limited prior to the emergency use authorization (EUA) of virus-neutralizing monoclonal antibodies. To assess the efficacy of outpatient monoclonal therapy, the investigators assessed the seven, 14, and 28-day emergency department and hospitalization rates of adult patients given bamlanivimab for the treatment of COVID-19 at a community hospital.

Methods

A retrospective chart review was performed of all adult patients given bamlanivimab within the emergency department or an outpatient infusion center from December 2, 2020 through January 8, 2021 for the treatment of mild to moderate COVID-19. Patients were compared to a set of controls who would have qualified for bamlanivimab treatment prior to its authorization in reverse temporal order from November 30, 2020 through August 1, 2020. Abstracted data included patient demographics, allergic reactions, emergency department presentations, and hospitalizations at seven, 14, and 28 days post-infusion due to COVID-19 and any in-hospital mortality in those admitted with a COVID-19 complication. 

Results

A total of 136 patients received bamlanivimab during the study period with none having an allergic reaction during infusion. In those who received bamlanivimab, 84 (61.8%) patients included were aged 65 years or older. At 28 days, there was a statistically significant reduction in emergency department visits in those who received bamlanivimab (20 vs 36 patients; p = 0.03) but not at seven days (12 vs 20 patients; p = 0.18) or 14 days (17 vs 28 patients; p = 0.11). No statistically significant difference in emergency department returns was noted in those aged 65 years or older at seven (eight vs eight patients; p = 0.70), 14 (11 vs 10 patients; p = 0.83), or 28 days (13 vs 14 patients, p = 0.46). A total of six (4.4%) patients were hospitalized at 28 days following the bamlanivimab infusion with five (83.3%) being aged 65 or older. No statistical difference was noted for decreased hospitalizations at seven (four vs five patients; p = 0.79), 14 (five vs nine patients; p = 0.32), or 28 days (six vs nine patients; p = 0.49) post-infusion. No patients suffered from in-hospital mortality after infusion with bamlanivimab.

Conclusion

Outpatient infusion of bamlanivimab reduced the incidence of those with mild to moderate COVID-19 requiring subsequent care through the emergency department at 28 days but not hospitalizations within this time frame. No statistical difference was noted in either emergency department visits or hospitalizations in those aged 65 or greater who were treated as an outpatient with bamlanivimab for mild to moderate COVID-19. 

Splenic Injury Following Colonoscopy: A Case Report

Introduction

Colonoscopy is a commonly performed outpatient procedure with a low risk of complications. The most common complications seen in the postoperative period include hemorrhage and perforation. Infrequently, splenic injury can occur.

Case Report

A 72-year-old male presented with a one-day history of left upper quadrant pain following colonoscopy. During the procedure he had two polyps removed along the transverse colon near the splenic flexure. There were no complications during the procedure or in the immediate post-operative period. On presentation to the emergency department, abdominal tenderness was present in the left upper quadrant without rebound, rigidity, or guarding. Point-of-care ultrasound of the abdomen demonstrated mixed hypoechoic densities confined to the splenic capsule, and computed tomography of the abdomen and pelvis with intravenous contrast noted a grade II/III splenic laceration without active extravasation. The patient was admitted for serial abdominal examination and labs.

Conclusion

Splenic injury following colonoscopy is a rare complication of colonoscopy. Emergency providers should be aware of this possible complication, and acute management should include basic trauma care and consultation for possible intervention, if warranted.

Incidence of Non-thrombotic Diagnoses Following Venous Duplex Ultrasound at a Community Emergency Department

Background: When used as a diagnostic aid for diagnosing deep vein thrombosis (DVT), venous duplex ultrasound (US) may reveal non-thrombotic findings in those with acute extremity pain. The objective of this study was to determine the prevalence and predictors of non-thrombotic findings on venous duplex US at a community emergency department.

Methods: A retrospective chart review of all adult patients who presented to a community emergency department who underwent either an upper or lower extremity venous duplex US for the evaluation of DVT from June 1, 2019, to September 15, 2020. All US studies were completed by certified sonographers and interpreted by board-certified radiologists. Two trained research assistants manually abstracted patient demographics and US findings. Data were analyzed using the chi-square statistic for categorical variables and the student's independent t-test for continuous variables. Multivariate binomial regression was used to identify independent predictors of non-thrombotic results on venous duplex US.

Results: A total of 1,448 venous duplex US were obtained during the study period with 126 DVTs being diagnosed. A total of 1071 US had no acute abnormality and 252 had non-thrombotic findings. All non-thrombotic findings were found in the lower extremity. Of those with non-thrombotic findings, the most common diagnoses included edema (34.9%, 88/252), Baker’s cyst (22.6%, 57/252), and an unspecified fluid collection (16.3%, 41/252). Patients with non-thrombotic findings were more likely to have a history of atrial fibrillation (p=0.001) or hypertension (p=0.001), be older than the age of 70 (p=0.042), or have a history of using illicit drugs (p=0.003). Females were less likely to have non-thrombotic findings.

Conclusion: In this single-site study, non-thrombotic findings were present in 23.5% of all venous duplex US completed at a community emergency department. These findings are more common in the elderly, those with cardiovascular disorders, and those who have used illicit drugs.

Gender Differences in Language of Standardized Letter of Evaluation Narratives in Osteopathic Emergency Medicine Residency Applicants

Background

The standardized letter of evaluation (SLOE) is used by emergency medicine (EM) faculty during the interview and match process. Data has shown that female allopathic applicants score higher in communal characteristics and have a greater number of ability words in the narrative portion of the SLOE as compared to their male counterparts. 

Objective

To determine if there is a difference in the language used to describe male and female osteopathic applicants within the SLOE. 

Methods

All applicants to a three-year EM residency within a single application cycle were eligible for inclusion. Exclusion criteria included allopathic applicants, applicants without a SLOE, or applicants with a SLOE only from the interviewing program. Data collected included applicant demographics and SLOE narratives. The previously validated Linguistic Inquiry and Word Count (LIWC; Pennebaker Conglomerates, Inc., Austin, TX) product was used to analyze word counts from the narrative portion of each SLOE. Descriptive statistics and t-tests for continuous data were used. 

Results

Of the 577 applicants to the residency program, 318 met inclusion criteria and 33% were female. Females had a higher COMLEX-2 (590 vs 559; p=0.05) as compared to males but no difference was found for the remainder of the baseline demographics. No difference was found for the number of words in the narrative portion of the SLOE between males and females (males = 122 words; females = 127 words; p=0.53). Words within the social (p=0.006), achievement (p=0.007), and standout (p<0.001) categories were more frequent in osteopathic female applicants as compared to males. No statistical differences were detected for the other 13 categories analyzed. 

Conclusion

In this sample of osteopathic applicants, little linguistic difference was noted for the narrative portion of the SLOE. SLOE authors did, however, use more social, achievement, and standout words to describe females as compared to male applicants. 

Real world utilization of REGEN-COV2 at a community hospital

Introduction

Monoclonal antibodies received an Emergency Use Authorization (EUA) from the U.S. Food & Drug Administration for the outpatient treatment of mild to moderate coronavirus disease 2019 (COVID-19). REGN-COV2, casirivimab and imdevimab, has been shown to decrease the viral load and healthcare visits of those with mild to moderate COVID-19 who are treated in the outpatient setting.

Objective

To determine 7- and 14-day emergency department (ED) and hospitalization rates of adult patients given REGN-COV2 for the outpatient treatment of COVID-19 at a community hospital.

Methods

A convenience sample of consecutive adult patients given REGN-COV2 from January 18, 2021 through March 31, 2021 for the outpatient treatment of mild to moderate COVID-19. Abstracted data included patient demographics, allergic reactions, ED presentations and hospitalizations at 7 and 14 days, and in-hospital mortality.

Results

A total of 68 patients with a medain age of 69 years (IQR 57–75.5) and 58.3% being female were given REGEN-COV2 during the study period. No allergic reactions were noted during infusion. Of those infused, 18% (12/68) were infused in the ED and had a median length of stay of 477 min. Following infusion, 10% (7/68) of patients re-presented to the ED and 2% (1/68) were hospitalized for COVID-19 at 14 days. In those aged 65 years or greater, 12% (5/42) of patients re-presented to the ED following infusion. Of those who re-presented to the emergency department, the median age was 72.5 years and the median time from infusion to re-presentation was 2.0 days. No patients suffered in-hospital mortality during the study period.

Conclusion

There was a significant length of stay associated with REGN-COV2 infusion in the emergency department. Following REGN-COV2 infusion, few patients under the age of 65 re-presented to the emergency department at seven and 14 days. However, a large number of patients aged over 65 years re-presented to the ED following infusion.

Accuracy of Weight Estimation Using the Broselow Tape in a Peruvian Pediatric Population

Introduction

The Broselow tape (BT) is a useful pediatric tool for weight estimation and dosing reference during emergency care. Many accuracy studies have been performed for various countries and regions of the world but there is very little information for Latin American countries. The primary objective of the study was to assess the accuracy of the BT in a Peruvian pediatric population.

Methods

This was a retrospective cross-sectional study of 1,160 children aged two to 19 years from three outpatient clinics in La Libertad, Lima, and Iquitos, Peru. Patient height and weight were measured and compared with the weight and color zone generated by the 2017 edition of the BT. Accuracy was estimated by statistical comparison of mean absolute percent differences, error within 10% (EW10), and color zone agreement.

Results

Comparison of mean differences between measured weight (MW) and estimated BT weight shows that the BT underestimates actual weight for all color zones in this population. Likewise, the Bland-Altman plot of agreement between estimated and measured weights shows an overall underestimation, or bias, equal to 1.60 kg. The overall percent difference was -7.84% with differences gradually increasing for weights over 10 kg. In terms of accuracy, the overall error within 10% was 62.8%.

Conclusion

The BT underestimates the actual weight of Peruvian pediatric patients in all color categories, particularly in children with higher body mass indexes. Underestimation of weight may lead to the use of non-therapeutic medication doses or incorrect equipment sizes and, subsequently, ineffective resuscitation.

Impact of the COVID-19 Pandemic on Emergency Department Transfers to a Higher Level of Care

Introduction

During the coronavirus disease 2019 (COVID-19) pandemic, a reduction in emergency department (ED) visits was seen nationally according to the US Centers for Disease Control and Prevention. However, no data currently exists for the impact of ED transfers to a higher level of care during this same time period. The primary objective of the study was to determine whether the COVID-19 pandemic affected the rate of non-COVID-19 transfers from a rural community ED.

Methods

We completed a retrospective chart review of all ED patients who presented to Kingman Regional Medical Center in Kingman, Arizona, from March 1–June 31, 2019 and March 1–June 31, 2020. To ensure changes were not due to seasonal trends, we examined transfer rates from the same four-month period in 2019 and 2020. Patients were included in the study if they were transferred to an outside facility for a higher level of care not related to COVID-19.

Results

Between the time periods studied there was a 25.33% (P = 0.001) reduction in total ED volume and a 21.44% (P = 0.009) reduction in ED transfers to a higher level of care. No statistical difference was noted in ED transfer volume following adjustment for decreased ED volumes. Transfers for gastroenterology (45%; P = 0.021), neurosurgery (29.2%; P = 0.029), neurology (76.3%; P < 0.001), trauma (37.5%; P = 0.039), urology (41.8%; P = 0.012), and surgery (56.3%; P = 0.028) all experienced a decrease in transfer rates during the time period studied. When gender was considered, males exhibited an increased rate of transfers to psychiatric facilities (P = 0.018).

Conclusion

Significant reductions in both ED volume and transfers have coincided with the emergence of the COVID-19 pandemic. Further research is needed to determine how the current pandemic has affected patient care.

The seroprevalence of SARS-CoV-2 in a rural southwest community

Context

The true prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), has been difficult to determine due to limited testing, inconsistent symptom severity, and asymptomatic infections. Systematic investigation of the prevalence of SARS-CoV-2 has been limited to urban environments and large academic centers. Limited data on the seroprevalence of SARS-CoV-2 is available for those who live in a rural community setting, leaving rural practitioners to extrapolate the epidemiology of COVID-19 to a nonhomogeneous population.

Objective

To determine the seroprevalence of SARS-CoV-2 in a community setting. The secondary objective of this study was to describe the difference in infection rate and reverse transcription polymerase chain reaction (RT-PCR) testing in the same rural community.

Methods

A prospective convenience sample of community members and healthcare workers from the Kingman, Arizona area were tested for SARS-CoV-2-specific antibodies using a lateral flow immunoassay with the VITROS Anti-SARS-CoV-2 IgG test (Ortho-Clinical Diagnostics, Inc.) from September 28, 2020 to October 09, 2020. Upon recruitment, participants were asked to complete a demographic survey assessing socioeconomic status, comorbidities, and COVID-19 symptoms in the preceding two months. Following enrollment, a retrospective chart review was completed to determine the percentage of patients who had undergone previous SARS-CoV-RT-PCR testing.

Results

A total of 566 participants were included in the final analysis: 380 (67.1%) were women, 186 (32.9%) were men, a majority (458; 80.9%) self-identified as White, and 303 (53.5%) were employed as healthcare professionals. Seroprevalence of SARS-CoV-2 was found to be 8.0% (45 of 566) across the sample and 9.9% (30 of 303) in healthcare workers. No statistical difference in seroprevalence was found between men and women, healthcare workers and other participants, amongst racial groups, by socioeconomic status, by comorbid conditions, or by education level. Among the participants, 108 (19.1%) underwent previous RT-PCR testing. Of the 45 patients who were antibody positive, 27 (60%) had received a previous RT-PCR test, with 20 (44.4%) testing positive for SARS-CoV-2. Participants with symptoms of anosmia/ageusia (p<0.001), chest congestion (p=0.047), fever (p=0.007), and shortness of breath (p=0.002) within the past two months were more likely to have antibodies to SARS-CoV-2.

Conclusion

Only 8% of 566 participants in this rural community setting were found to have antibodies for SARS-CoV-2. A large minority (18; 40%) of patients testing seropositive for SARs-CoV-2 had never received a prior test, suggesting that the actual rates of infection are higher than publicly available data suggest. Further large-scale antibody testing is needed to determine the true prevalence of SARS-CoV-2 in the rural setting.

National Institutes of Health Funding in Internal Medicine: Analysis of Physicians Receiving an R01 Grant Between 2008 and 2017

Introduction As the world's largest funding source for biomedical research, the National Institutes of Health (NIH) supports physician-scientists with a discipline-specific R01 grant. Recently, scholarly activity disparities regarding investigator degree and gender have been highlighted in the medical literature among allopathic and osteopathic investigators of various medical backgrounds. We aimed to assess trends in internal medicine NIH R01 grants over the past decade. Methodology Internal medicine R01 funding was retrospectively obtained from a centralized online NIH database encompassing 2008 through 2017. Principal investigators (PIs) were then categorized by gender and academic degree(s). Two-way analysis of variance was used to analyze NIH grant funding trends over the time period studied. Results A total of 5,089 NIH R01s were awarded to internal medicine PIs, with an average value per grant of $469,270. Awardees were predominantly male (71.5%, 3,639/5,089). Most awards were issued to PIs with an MD degree (62.4%, 3,173/5,089), followed by PhD degree (36.3%, 1,845/5,089). DOs accounted for five awards over the time period studied (0.15%). MDs were awarded higher funding than PhDs ($466,494 and $421,576, p < 0.001), and females were awarded higher amounts than males ($462,771 and $444,868, p < 0.001). Investigators who held a second degree received more funding than PIs with a single degree ($476,693 and $439,693, p < 0.001). Conclusion In the decade under investigation, both gender and degree disparities existed within NIH R01 funding for PIs in the field of internal medicine, and osteopathic representation accounted for a paucity of R01 funding.

Remdesivir for the Treatment of Severe COVID-19: A Community Hospital's Experience

Context

Following the emergence of the novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), researchers sought safe and effective treatment modalities. Remdesivir is currently being evaluated for clinical efficacy and safety in patients with COVID-19.

Objective

To describe the clinical outcomes of COVID-19 patients following treatment with remdesivir at a community hospital.

Methods

A retrospective review of medical records was conducted in August 2020 for all patients given remdesivir while hospitalized for severe COVID-19 between May 1 and August 19, 2020. A convenience sample of consecutive patients with treatment including remdesivir, antibiotics, convalescent plasma, dexamethasone, or a combination of multiple drugs was included in the analysis. Patients receiving remdesivir were administered a 5-day treatment course. Patients with a glomerular filtration rate of less than 30 mL/min, those with liver function tests 5 times the normal reference range, and those who were pregnant were excluded from treatment with remdesivir. Differences in between men and women were detected with χ2 and independent samples t tests. The degree to which presenting symptoms influenced patient outcomes was analyzed with a stepwise logistic regression.

Results

Among the 76 patients who received remdesivir, the mean (95% confidence interval, CI) age was 63 years (59.8-66.2). Thirty-six (47.4%) were men and 40 (52.6%) were women. Forty-nine (64.5%) were White and 27 (35.5%) were nonWhite. The majority of patients (54; 71.1%) had at least 1 comorbid condition, with hypertension being the most common (43; 56.6%). The mean (95% CI) length of stay for patients who received remdesivir was 10.09 days (8.6-11.6) and the mean (95% CI) duration of oxygen therapy was 9.42 days (8.0-10.8). A total of 14 (18.4%) patients given remdesivir were admitted to the intensive care unit (ICU) with an mean (95% CI) length of stay of 9.29 days (5.6-13.0). Women administered remdesivir were more likely to be admitted to the ICU (11 [27.5%] vs 3 [8.3%]; P=.031). The mortality rate was 14 patients (18.4%), with no statistically significant difference observed between men (5; 13.9%) and women (9; 22.5%; P=.33). No significant difference was seen amongst sexes for duration of oxygen therapy (men, 8.0 days [6.2-9.8] vs women, 10.76 days [8.8-12.8]; P=.051) or length of stay (men, 8.61 days [6.7-10.5] vs women, 11.43 days [9.3-13.5]; P=.058). There was no statistically significant difference in pooled racial groups (White vs nonWhite) for in-hospital mortality, number admitted to the ICU, days spent in the ICU, duration of oxygen use, or length of stay.

Conclusion

Remdesivir may show clinical efficacy for the treatment of severe COVID-19 in a community setting. Although this was a small-scale study with limited patients, it represents a point of reference for the use of remdesivir at other community hospitals.

Morel-Lavallée Lesion Following a Low-speed Injury: A Case Report

Introduction

Soft tissue injuries are a common presenting complaint seen in the emergency department following trauma. However, internal degloving injuries are not commonly seen by the emergency provider.

Case Report

A 57-year-old male presented with right lower extremity pain, bruising, and swelling after a low-speed bicycle accident five days prior. Physical examination revealed an edematous and ecchymotic right lower extremity extending from the mid-thigh distally. Computed tomography of the thigh demonstrated a hyperdense foci within the fluid collection suggesting internal hemorrhage and internal de-gloving suggestive of a Morel-Lavallée lesion.

Discussion

The Morel-Lavallée lesion is a post-traumatic soft tissue injury that occurs as a result of shearing forces that create a potential space for the collection of blood, lymph, and fat. First described in 1853 by French physician Maurice Morel-Lavallée, this internal degloving injury can serve as a nidus of infection if not treated appropriately. Magnetic resonance imaging has become the diagnostic modality of choice due to its high resolution of soft tissue injuries. Treatment has been focused on either conservative management or surgical debridement after consultation with a surgeon.

Conclusion

The emergency physician should consider Morel-Lavallée lesions in patients with a traumatic hematoma formation to avoid complications that come from delayed diagnosis.

Miller-Fisher Syndrome: A Case Report and Review of the Literature

Introduction

Neurological complaints are a common presenting symptom seen by the emergency physician. However, the Miller-Fisher variant of Guillain-Barré syndrome is a rare cause of neurological complaints seen in the emergency department.

Case Report

A 26-year-old male presented with dysphonia and bilateral hand and feet paresthesia after a recent diarrheal illness. Examination revealed the absence of tricep, brachioradialis, patellar and Achilles tendon reflexes bilaterally, and difficulty with phonation. Lumbar puncture revealed the presence of anti-GQ1b antibodies, and the patient was diagnosed with Miller-Fisher variant of Guillain-Barré.

Discussion

Miller-Fisher syndrome is an acute, autoimmune response that typically follows either an upper respiratory or diarrheal illness. Typically associated with dysfunction of cranial nerves three, four, and six, Miller-Fisher syndrome may present with facial paralysis, opthalmoplegia, arefexia, or ataxia. Lumbar puncture with the presence of anti-GQ1b antibodies is indicative. Treatment could include supportive respiratory care, intravenous immunoglobulin therapy, or plasmapheresis.

Conclusion

Miller-Fisher syndrome is a rare form of Guillain-Barré syndrome that the emergency provider should include in the differential when faced with a patient with cranial nerve dysfunction.

Secondary Syphilis

Case Presentation

A 40-year-old male presented the the emergency department (ED) due to a diffuse body rash after a sexual encounter. Examination revealed a maculopapular rash that included the palms and soles of the feet bilaterally. A rapid plasma reagin was positive, and the patient was treated with 2.4 million units of benzathine benzylpenicillin intramuscularly.

Diagnosis

Secondary syphilis can mimic many disease processes but classically presents as a painless macular rash on the palms of the hands and soles of the feet. Diagnosis is based upon clinical examination coupled with serological testing. Emergency department management should include 2.4 million units of benzathine benzylpenicillin intramuscularly and mitigation strategies.

Management of deep vein thrombosis in the emergency department

Deep vein thrombosis (DVT) can present with a variety of nonspecific signs and symptoms, and can involve the upper or lower extremities. Management of patients with DVT has changed markedly over the last 10 years, moving from hospital admission for initiation of anticoagulation to outpatient management. Diagnosis requires a risk stratification process involving clinical decision rules, D-dimer testing, and ultrasonography. Once the diagnosis is confirmed, the patient should be engaged in shared decision-making regarding treatment options. Recurrent DVT, as well as managing DVT in pregnant women, the elderly population, and patients with malignancies are also discussed.

A Case Report of Pulmonary Sarcoidosis: An Uncommon Cause of Chest Pain

INTRODUCTION

Chest pain is one of the most common causes of emergency department visits on an annual basis and carries a high degree of morbidity and mortality if managed inappropriately.

CASE REPORT

A 36-year-old male presented with four months of left-sided chest pain with dyspnea on exertion. Physical examination and laboratory values were within normal limits. Chest radiograph depicted diffuse interstitial nodular opacities throughout the lungs bilaterally with bilateral perihilar consolidations. Computed tomography of the chest demonstrated mid and upper lung nodularity with a perilymphatic distribution involving the central peribronchial vascular regions as well as subpleural and fissural surfaces causing conglomerate in the upper lobes centrally with associated hilar and mediastinal lymphadenopathy. The next day the patient underwent bronchoscopy with endotracheal ultrasound and transbronchial biopsies and pathology revealed non-necrotizing, well-formed granulomas embedded in dense hyaline sclerosis consistent with sarcoidosis.

DISCUSSION

Sarcoidosis is a multi-system granulomatous disease characterized by noncaseating granulomas on pathology. The worldwide epidemiology of sarcoidosis is currently unknown due to many patients being asymptomatic. However, patients may present with a persistent cough, dyspnea, or chest pain. Emergency department management should be aimed at minimizing long-term sequelae of the disease through obtaining labs and imaging after specialist consultation and arranging urgent follow-up.

CONCLUSION

Although not one of the six high-risk causes of chest pain, sarcoidosis should be included in the differential to minimize the risk of long-term morbidity associated with advanced forms of the disease.

Medical Degree Disparity Among Authors of Original Research in Pediatric Journals: A Four-Year Follow-Up

Introduction and Objective: Scholarly activity is a major component of residency training and the accreditation process for graduate medical education. In 2014, Accreditation Council for Graduate Medical Education and the American Association of Colleges of Osteopathic Medicine announced a single accreditation system with the transition beginning July 1, 2015. Previous data before the transition had shown that osteopathic physicians rarely published original research in three high-impact pediatric journals. The objective of this study is to determine if there is a degree disparity between osteopathic and allopathic physicians among authors who publish original research manuscripts in three high-impact pediatric journals after the beginning of the transition to a single graduate medical education accreditation system. 

Methods: Degree designation for the first and senior authors of original research manuscripts was reviewed for the Journal of Pediatrics (J Pediatr), Pediatrics, and JAMA Pediatrics (JAMA Pediatr) for the years 2016, 2017, 2018, and 2019. Inter-rater reliability was calculated by the kappa coefficient, and data were analyzed with descriptive statistics and simple linear regression. 

Results: A total of 3,252 manuscripts and 4,068 authors were reviewed with 0.98% of all authors being osteopathic physicians. A total of 1.65% of first authors and 0.41% of senior authors were osteopathic physicians. For those with a dual degree, a total of 1.03% of first, and 0.41% of senior authors were osteopathic physicians. No statistical trend could be established for increased first, senior, dual-degree first, or dual-degree senior osteopathic physician authorship.

Conclusion: Osteopathic physicians continue to be underrepresented as first and senior authors in original publications in the three high-impact pediatric journals as compared to their allopathic counterparts. 

National Institutes of Health Funding in Obstetrics and Gynecology: Analysis of R01 Grants by Degree and Gender

INTRODUCTION

Limited data currently exist regarding the demographics of principal investigators (PIs) in obstetrics and gynecology (OBGYN), who have received an R01 grant from the National Institutes of Health (NIH).

OBJECTIVE

This study investigated funding differences among gender and advanced degree for PIs in the disciplines of OBGYN.

METHODS

Retrospective data were collected from the NIH Research Portfolio Online Reporting Tools Expenditures and Results (RePORTER) tool to identify OBGYN PIs who received an R01 grant between 2008 and 2017.  Results: Between 2008 and 2017, the NIH awarded 263 R01 grants totaling $113,326,883 in funding to investigators in OBGYN. Male PIs and PIs holding a non-medical degree were awarded the majority of R01 grants (52.47% and 55.51%, respectively). Zero osteopathic (Doctor of Osteopathic Medicine [DO]) physicians were awarded an R01 grant in OBGYN during this time period. Females were awarded larger dollar amounts than males ($449,556 vs $414,003, p=0.04). Allopathic (Doctor of Medicine [MD]) physicians were awarded larger grants than scientists holding a non-medical degree ($467,849 vs $401,291, p<0.01). Both male and female MD physicians were awarded more dollars per grant as compared with PIs holding a non-medical degree (p=0.01 and p<0.01, respectively).

CONCLUSIONS

Between 2008 and 2017, a degree disparity was found to exist for investigators who received an NIH R01 grant in OBGYN. Females and investigators holding an MD degree were awarded larger total grants than their male and non-physician counterparts. Further research needs to be undertaken to understand the degree disparity and recent funding trends by the NIH.

Diet-induced Ketoacidosis in a Non-diabetic: A Case Report

Introduction

Anion gap metabolic acidosis is a common disorder seen in the emergency department. The differential can include toxicological, renal, endocrine, infectious, and cardiogenic disorders. Ketosis, however, is one of the rarer causes of metabolic acidosis seen by the emergency physician in developed nations.

Case Report

A 53-year-old female presented after starting a low-carbohydrate ketogenic diet for weight loss. She reported xerostomia, nausea with abdominal pain and a 17-pound weight loss over the previous 22 days. Labs revealed an anion-gap metabolic acidosis with ketosis. She was treated with 5% dextrose in normal saline and a sliding scale insulin coverage. Her anion gap corrected during her hospital course and was discharged on hospital day three.

Discussion

The ketogenic diet typically consists of a high-fat, adequate protein and low carbohydrate diet that has previously been thought to be relatively safe for weight loss. However, when carbohydrates are completely removed from the diet an overproduction of ketones bodies results in ketoacidosis. Treatment should be aimed at halting the ketogenic process and patient education.

Conclusion

Although rarely included in the differential for metabolic acidosis, diet-induced ketosis should be included by the emergency physician when faced with a patient who recently changed their eating patterns.

Impact of a Pharmacist-driven Methicillin-resistant Staphylococcus aureus Polymerase Chain Reaction Nasal Swab Protocol on the De-escalation of Empiric Vancomycin in Patients with Pneumonia in a Rural Healthcare Setting

Introduction

Pneumonia caused by methicillin-resistant Staphylococcus aureus (MRSA) carries a high rate of morbidity and mortality. Many clinicians empirically treat those at risk of developing MRSA pneumonia with vancomycin. Several studies have identified a high negative predictive value of the MRSA polymerase chain reaction (PCR) nasal swab test in lower respiratory tract infections, suggesting it can be used to guide the de-escalation of empiric anti-MRSA therapy.

Objective

To evaluate the impact of a pharmacist-driven MRSA PCR nasal swab protocol on the de-escalation of empiric vancomycin in patients with pneumonia in a rural healthcare setting. Secondarily, to assess the rate of hospital length of stay, the rate of vancomycin-associated acute kidney injury, and in-hospital mortality after pharmacist-driven de-escalation of empiric vancomycin in patients with pneumonia. 

Methods

A retrospective, single-center, pre-post cohort study was conducted in patients after the implementation of a pharmacist-driven protocol allowing pharmacists to obtain nasal swabs and PCR testing for MRSA in those on empiric vancomycin therapy for suspected MRSA pneumonia. Based on negative test results, pharmacists recommended a de-escalation of empiric vancomycin to the physician. Patients were included if they were adults at least 18 years of age, had a physician diagnosis of suspected or confirmed pneumonia, and initiated on at least one dose of intravenous vancomycin within 48 hours of admission.

Results

A total of 79 patients were identified for inclusion in the pre-protocol group (n=32) or post-protocol group (n= 47). The mean duration of vancomycin therapy in the pre-protocol group was 3.1 days as compared to 1.7 days in the post-protocol group for a 1.4 days reduction (p=0.044). There was no significant impact on the number of vancomycin cases de-escalated within 24 hours (p=0.14) but there was a significant reduction at 48 hours (p=0.01). Protocol implementation was associated with a reduction in the average length of hospitalization (8 versus 5.20 days, p=0.006). Neither group had a vancomycin-associated acute kidney injury or in-hospital mortality.

Conclusion

Among patients with suspected MRSA pneumonia, a pharmacist-driven MRSA PCR nasal swab protocol resulted in a significant reduction of empiric vancomycin duration of therapy without an adverse impact on clinical outcomes in a rural healthcare setting.

Disseminated Gonorrhea

Sexually transmitted infections have risen sharply over the last decade in the United States. The incidence of gonorrhea has risen to 172 reported cases per 100,000 people over the past year. This likely represents an under-representation due to many cases going unreported. Disseminated gonorrhea can present with nonspecific symptoms including arthralgia, cutaneous lesions, or tenosynovitis. Diagnosis is based upon a degree of high clinical suspicion and serology. Emergency department treatment includes ceftriaxone and azithromycin.

Patterns of Recent National Institutes of Health Funding in Family Medicine: Analysis Using the NIH Research Portfolio Online Reporting Tools Expenditures and Results System

Introduction Despite a call for increased research by family-medicine physicians, there is no data on the demographics of those awarded a National Institutes of Health (NIH) R01 grant.  Objective The purpose of the study was to assess recent NIH R01 funding trends over the last decade in family medicine. Methods  A retrospective analysis of NIH R01 grant funding in family medicine was conducted by extracting demographic data from the NIH's Research Portfolio Online Reporting Tools Expenditures and Results (RePORTER) database from 2008 through 2017. Demographics were reported as percentages, and comparisons of the groups were performed by the t-test.  Results  From 2008 to 2017, the NIH awarded 139 R01 grants to principal investigators (PI) in family medicine. Males comprised 51.80% of all awardees, and those holding a doctorate of medicine (MD) made up 43.88% of the awardees. No one holding a Doctorate of Osteopathic Medicine (DO) degree received an NIH R01 grant during the timeframe studied. A total of 81.97% of all MDs held a dual degree. When gender and degree were considered, no statistical difference was observed for the total amount of dollars awarded.  Conclusion For the years studied, a disparity related to medical degrees was noted for those family-medicine physicians who received an NIH R01 grant. However, no gender disparity was observed.

Medical Degree Disparity Among Authors of Original Research in Pediatric Journals

INTRODUCTION

Research and scholarly output are integral parts of residency training for both residents and faculty. With the transition to a single accreditation system, scholarly activity and output of osteopathic physicians have garnered significant interest. Previous research has shown that osteopathic physicians in emergency medicine and obstetrics and gynecology infrequently publish original research in high impact journals.

OBJECTIVE

To determine whether there is a disparity between osteopathic and allopathic physicians among authors who publish original research manuscripts in three high-impact pediatric journals.

METHODS

The medical degree designation of the first and senior author (last author) and any advanced degree either author may have obtained were retrieved from the Journal of Pediatrics (J Pediatr), Pediatrics, and JAMA Pediatrics (JAMA Pediatr) for the years 2000, 2005, 2010 and 2015. Data was analyzed using simple descriptive statistics and linear regression.

RESULTS

In total, 2232 manuscripts and 4296 authors were reviewed with 0.58% (25/4296) of all authors being osteopathic physicians. A total of 0.81% (18/2232) of first authors and 0.34% (7/2064) of senior authors were osteopathic physicians. For those with a dual degree, a total of 0.64% (5/777) of first and 0.33% (3/904) of senior authors were osteopathic physicians. No statistical trend could be established for increased first (p=0.24), senior (p=0.16), dual degree first (p=0.08) or dual degree senior (p=0.06) osteopathic physician authorship. Likewise, no statistical trend for increased authorship could be established for any Doctor of Osteopathic Medicine (DO) authorship role in the three journals over the time period studied.

CONCLUSION

Very few osteopathic physicians have served as either the first or senior author in published original research manuscripts for the Journal of Pediatrics, Pediatrics, or JAMA Pediatrics for the years studied. Also, no statistical trend could be established for increased osteopathic physician publication over the same years.

Tethered Cord Syndrome

Tethered spinal cord syndrome refers to signs and symptoms of motor and sensory dysfunction related to increased tension on the spinal cord due to its abnormal attachment; it has classically been associated with a low-lying conus medullaris. Treatment is primarily surgical and has varying degrees of results. Although rarely diagnosed in the emergency department, the emergency physician must be aware of the disease in patients presenting with signs and symptoms concerning for cauda equina syndrome.

Patterns of Recent National Institutes of Health (NIH) Funding in General Surgery: Analysis Using the NIH RePORTER System

Introduction: The National Institutes of Health (NIH) is the world’s largest funding source for research, and the R01 grant is seen as a stepping stone to future granting opportunities for the physician-scientist. Recently, both a gender and degree disparity in scholarly activity has been highlighted in the medical literature. 

Objective: To assess NIH R01 funding trends in general surgery over the last decade.

Methods: A retrospective review of general surgery funding was extracted from the NIH’s Research Portfolio Online Reporting Tools Expenditures and Results database from 2008 through 2017. All principal investigators (PIs) were categorized by gender and academic degree(s). Linear regression analysis assessed NIH grant funding trends over time and comparisons of groups were completed with the t-test.

Results: From 2008 to 2017, the NIH awarded 600 R01 grants and $272,669,397 to PIs in general surgery. The majority of R01 grants were awarded to males (76.33%; p < 0.01) and those holding a Doctorate of Medicine (MD) degree (58.33%; p < 0.01). No Doctorate of Osteopathic Medicine (DO) had received an NIH R01 grant during the time studied. No statistically significant trend could be established for the number of R01 grants awarded over time (p = 0.33), grants awarded to males or females over time (p = 0.73 and p = 0.18), or for those holding an MD or other type of degree over time (p = 0.30 and p = 0.39). Also, no statistically significant trend was established for increased grant funding over time (P = 0.88) but females and those holding an other type of degree (Doctorate in Philosophy (PhD), Doctorate in Science (DSc), Master of Public Health (MPH), etc.) experienced an increase in the total dollar amount of funding over the time studied (p < 0.01 and p < 0.01). 

Conclusion: For the years studied, a gender and degree disparity exists for those receiving an NIH R01 grant in general surgery. However, an increase in total grant funding has been seen for both females and non-physician scientists over from 2008 through 2017. 

A National Evaluation of Scholarly Activity Requirement in Osteopathic EM Residency Programs: Survey of EM Program Directors

OBJECTIVES

The objectives of the study were to determine the percentage of osteopathic emergency medicine (EM) residencies that require an original research project to meet the American Osteopathic Association requirement, describe the resources available to the residents and faculty members to complete their projects, and determine resident and faculty research productivity.

METHODS

This was a cross-sectional online survey of program directors from osteopathic EM residency programs. Participants were asked about demographics and specifics related to their program's research curriculum, which included resources, outcomes, and challenges.

RESULTS

The response rate was 48.21% (27/56) of program directors from EM residencies. The majority (82.77%) of respondents were from a community-based EM program, had a requirement that a research project be completed before graduation from residency (87.5%), and did not have a research associate program to assist in recruiting patients (83.33%). A physician research director was noted to lead the department in 53.57% of respondents, whereas 70.83% noted having a statistician on staff. A total of 2.91% of program faculty had received federal grant funding, and 13.88% had a research study indexed in PubMed. EM programs that had a physician-led research director were more likely to have core faculty with federal funding, articles indexed in PubMed, residents who submit their research for publication, and residents with competitive grants, as compared with programs without a research director. Program directors noted that analyzing data, designing a study, and generating a hypothesis were the biggest challenges to conducting research in the residency.

CONCLUSIONS

Osteopathic EM residencies significantly differ from their allopathic counterparts in their research curriculum, capabilities, and outcomes.

Medical Degree Disparity Among Authors in Obstetrics and Gynecology Journals

Context

With the transition to a single accreditation system for graduate medical education, the scholarly activity among core faculty in osteopathic and allopathic residency programs has come under scrutiny. Currently, major differences in scholarly activity requirements exist between core faculty in obstetrics and gynecology residencies accredited by the Accreditation Council for Graduate Medical Education and those accredited by the American Osteopathic Association.

Objective

To determine whether there is a disparity between osteopathic and allopathic physicians among authors with original research published in 4 high-impact obstetrics and gynecology journals during 4 select years.

Methods

The authors reviewed Obstetrics & Gynecology (Obstet Gynecol), the American Journal of Obstetrics and Gynecology (Am J Obstet Gynecol), Fertility and Sterility (Fertil Steril), and Menopause for the degree designation of the first and senior (last) author of each original manuscript for the years of 2000, 2005, 2010, and 2015. Data were analyzed using simple descriptive statistics and linear regression.

Results

In total, 3311 articles and 5909 authors were reviewed. Of these authors, 0.80% (47) had a DO degree. Of 1692 authors with dual advanced degrees, only 0.53% (9) had a DO degree. On subgroup analysis of each journal, 0.87% (13 of 1494) of identified authors in Obstet Gynecol, 1.03% (21 of 2038) in Am J Obstet Gynecol, 0.44% (9 of 2030) in Fertil Steril, and 2.20% (4 of 347) in Menopause were osteopathic physicians. During the years studied, no statistically significant trend could be established for first or senior author publication by osteopathic physicians over time, for all 4 journals or for any individual journal.

Conclusion

Very few osteopathic physicians have served as either the first or the senior author in articles published in Obstet Gynecol, Am J Obstet Gynecol, Fertil Steril, or Menopause during the years studied, and no trend was seen for increased publication by osteopathic physicians in these journals over time.

Comparison of intubation devices in level C personal protective equipment: A cadaveric study

BACKGROUND

With the advancement of chemical, biological and nuclear warfare and the reemergence of infectious diseases, the possibility of intubating in personal protective equipment has become increasingly more real to the emergency physician. Human cadaveric models have been found to simulate real world conditions better than mannequins. The aim of the study was to determine the first pass success rate and average time to successful intubation while wearing Personal Protective Equipment (PPE). Secondarily, subjects were asked to rank their choice of a primary and back up device, as well as the most common encountered barriers using PPE.

METHODS

Emergency medicine residents and pre-hospital providers were enrolled in a double randomized sequence to either intubation with direct laryngoscopy (DL), video laryngoscopy (VL), or the Supraglottic Airway Laryngopharyngeal Tube (SALT) in a cadaveric model while wearing level C PPE or without PPE.

RESULTS

First pass success rate was 96% without PPE and 58% while wearing PPE when all devices were considered (p≤0.001). Time to intubation while wearing PPE was 35.0s while no PPE was 22.2s (p=0.012). While wearing PPE both DL and VL were found to allow for a faster intubation as compared to the SALT (23.0s and 18.8s; p=0.002 and p=0.006 respectively). No statistical difference was noted in intubations without PPE. Participants indicated the most common barrier to successful intubation included visibility while wearing hoods (73.7%). Furthermore, 52.6% of participants indicated they would choose DL as the primary method to intubate with if wearing PPE while 47.4% would choose VL.

CONCLUSION

There is a statistically significant difference in first pass success and time to successful intubation while wearing and not wearing PPE in human cadaveric models.

Takotsubo Cardiomyopathy Presenting as Wellens' Syndrome

Takotsubo cardiomyopathy, also known as apical ballooning syndrome and stress cardiomyopathy, is a transient systolic and diastolic left ventricular dysfunction with a variety of cardiac wall-motion abnormalities that is increasingly being associated with significant morbidity and mortality. Wellens’ syndrome is an electrocardiographic (ECG) pattern in a pain-free patient that is indicative of critical occlusion of the left anterior descending coronary artery requiring immediate cardiac catheterization. The authors report a case of a patient presenting with ECG findings consistent with Wellens’ syndrome that was later found to have Takotsubo cardiomyopathy with angiographically normal coronary arteries on cardiac catheterization after a seizure.

Difference in R01 Grant Funding Among Osteopathic and Allopathic Emergency Physicians over the Last Decade

Introduction

Receiving an R01 grant from the National Institutes of Health (NIH) is regarded as a major accomplishment for the physician researcher and can be used as a means of scholarly activity for core faculty in emergency medicine (EM). However, the Accreditation Council for Graduate Medical Education requires that a grant must be obtained for it to count towards a core faculty member’s scholarly activity, while the American Osteopathic Association states that an application for a grant would qualify for scholarly activity whether it is received or not. The aim of the study was to determine if a medical degree disparity exists between those who successfully receive an EM R01 grant and those who do not, and to determine the publication characteristics of those recipients.

Methods

We queried the NIH RePORTER search engine for those physicians who received an R01 grant in EM. Degree designation was then determined for each grant recipient based on a web-based search involving the recipient’s name and the location where the grant was awarded. The grant recipient was then queried through PubMed central for the total number of publications published in the decade prior to receiving the grant.

Results

We noted a total of 264 R01 grant recipients during the study period; of those who received the award, 78.03% were allopathic physicians. No osteopathic physician had received an R01 grant in EM over the past 10 years. Of those allopathic physicians who received the grant, 44.17% held a dual degree. Allopathic physicians had an average of 48.05 publications over the 10 years prior to grant receipt and those with a dual degree had 51.62 publications.

Conclusion

Allopathic physicians comprise the majority of those who have received an R01 grant in EM over the last decade. These physicians typically have numerous prior publications and an advanced degree.

Evidence-based management of potassium disorders in the emergency department [digest]

Hypokalemia and hyperkalemia are the most common electrolyte disorders managed in the emergency department. The diagnosis of these potentially life-threatening disorders is challenging due to the often vague symptomatology a patient may express, and treatment options may be based upon very little data due to the time it may take for laboratory values to return. This review examines the most current evidence with regard to the pathophysiology, diagnosis, and management of potassium disorders. In this review, classic paradigms, such as the use of sodium polystyrene and the routine measurement of serum magnesium, are tested, and an algorithm for the treatment of potassium disorders is discussed. [Points & Pearls is a digest of Emergency Medicine Practice].

Evidence-Based Management Of Potassium Disorders In The Emergency Department

Hypokalemia and hyperkalemia are the most common electrolyte disorders managed in the emergency department. The diagnosis of these potentially life-threatening disorders is challenging due to the often vague symptomatology a patient may express, and treatment options may be based upon very little data due to the time it may take for laboratory values to return. This review examines the most current evidence with regard to the pathophysiology, diagnosis, and management of potassium disorders. In this review, classic paradigms, such as the use of sodium polystyrene and the routine measurement of serum magnesium, are tested, and an algorithm for the treatment of potassium disorders is discussed.

Cryptosporidium parvum Infection Following Contact with Livestock

CONTEXT

Scours, or calf diarrhea, is an infectious gastrointestinal disease commonly found in the calves of dairy farms. It primarily presents with diarrhea that can be life threatening to the animal and is also contagious and threatening to the other livestock. Cryptosporidium is one of the major causes of scours and can be transmitted to humans via fecal-oral route, resulting in diarrheal illnesses. Cryptosporidiosis infection usually occurs as a waterborne outbreak with the potential to affect many people at once.

CASE REPORT

We report a case of a 24-year-old female farmer who presented to the emergency department with diarrhea after taking care of ill cattle with similar symptoms. Fecal cultures were positive for Cryptosporidium parvum. Given the patient was immunocompetent, no further treatment was warranted.

CONCLUSION

Confirmed cases should be reported, however, treatment is only recommended in children and immunocompromised adults. Clinicians should educate patients on the importance of proper hygiene and handling techniques in order to decrease transmission and recurrence of the protozoan infection.

Authorship Trends of Emergency Medicine Publications over the Last Two Decades

Introduction

With the recent merger of the American Osteopathic Association (AOA) and the Accreditation Council for Graduate Medical Education (ACGME) a heightened pressure for publication may become evident. Our objective was to determine whether there was a gap in the type of both medical degree designation and advanced degree designation among authorship in three United States-based academic emergency medicine journals.

Methods

We reviewed the Journal of Emergency Medicine, Academic Emergency Medicine and Annals of Emergency Medicine for the type of degree designation that the first and senior authors had obtained for the years 1995, 2000, 2005, 2010 and 2014.

Results

A total of 2.48% of all authors held a degree in osteopathic medicine. Osteopathic physician first authors contributed to 3.26% of all publications while osteopathic physician senior authors contributed 1.53%. No statistical trend could be established for the years studied for osteopathic physicians. However, we noted an overall trend for increased publication for allopathic senior authors (p=0.001), allopathic first authors with a dual degree (p=0.003) and allopathic senior authors with a dual degree (p=0.005). For each journal studied, no statistical trend could be established for osteopathic first or senior authors but a trend was noted for allopathic first and senior authors in the Journal of Emergency Medicine (p-value=0.020 and 0.006). Of those with dual degrees, osteopathic physicians were in the minority with 1.85% of osteopathic first authors and 0.60% of osteopathic senior authors attaining a dual degree. No statistical trend could be established for increased dual degree publications for osteopathic physicians over the study period, nor could a statistical trend be established for any of the journals studied.

Conclusion

Very few osteopathic physicians have published in the Journal of Emergency Medicine, Academic Emergency Medicine or Annals of Emergency Medicine over the last two decades. Despite a trend for increased publication by allopathic physicians in certain journals, there appears to be no trend for increased publication of osteopathic physicians in emergency medicine.

Patient and Health-Care Provider Interpretation of do not Resuscitate and do not Intubate

BACKGROUND

Advance directives and end of life care are difficult discussions for both patients and health-care providers (HCPs). A HCP requires an accurate understanding of advanced directives to educate patients and their family members to allow them to make an appropriate decision. Misinterpretations of the do not resuscitate (DNR), do not intubate (DNI), and the Physicians Orders for Life-Sustaining Treatment (POLST) form result in ineffective communication and confusion between patients, family members, and HCPs.

METHODOLOGY

An anonymous, multiple choice online and paper survey was distributed to patients, family members of patients (PFMs), and HCPs from December 12, 2012 to March 6, 2013. Data regarding demographics, the accuracy of determining the correct definition of DNR and DNI, the familiarity of the POLST form and if a primary care physician had discussed advanced directives with the participants were collected.

RESULTS

A total of 687 respondents participated in the survey. Patients and PFMs could not distinguish the definition of DNR (95% confidence interval [CI] [1.453-2.804]) or DNI (95% CI (1.216-2.334)) 52% of the time while HCPs 35% and 39% of the time (P < 0.0005). Regarding the POLST form, 86% of patients and PFMs and 50% of HCPs were not familiar with the POLST form. Sixty-nine percent of patients and family members reported that their primary care physician had not discussed advance directives with them. Twenty-four percent of patients and family members reported that they had previous health-care experience and this was associated with increased knowledge of the POLST form (P < 0.0005). An association was also seen between the type of HCP taking the survey and the ability to correctly identify the correct definition of DNR (P < 0.0005).

CONCLUSION

Discussion of end of life care is difficult for patients and their family members. Often times multiple discussions are required in order to effectively communicate the definition of DNR, DNI, and the POLST form. Education of patients, family members, and HCPs is required to bridge the knowledge gap of advance directives.