Targeted rapid testing for SARS-CoV-2 in the emergency department is associated with large reductions in uninfected patient exposure time

Opportunity exists to decrease healthcare-related exposure to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), preserve infection control resources, and increase care capacity by reducing the time to diagnosis of coronavirus disease 2019 (COVID-19). A retrospective cohort analysis was undertaken to measure the effect of targeted rapid molecular testing for SARS-CoV-2 on these outcomes. In comparison with standard platform testing, rapid testing was associated with a 65.6% reduction (12.6 h) in the median time to removal from the isolation cohort for patients with negative diagnostic results. This translated to an increase in COVID-19 treatment capacity of 3028 bed-hours and 7500 fewer patient interactions that required the use of personal protective equipment per week.

Mobile nucleic acid amplification testing (mobiNAAT) for Chlamydia trachomatis screening in hospital emergency department settings

Management of curable sexually-transmitted infections (STI) such as Chlamydia can be revolutionized by highly sensitive nucleic acid testing that is deployable at the point-of-care (POC). Here we report the development of a mobile nucleic acid amplification testing (mobiNAAT) platform utilizing a mobile phone and droplet magnetofluidics to deliver NAAT in a portable and accessible format. By using magnetic particles as a mobile substrate for nucleic acid capture and transport, fluid handling is reduced to particle translocation on a simple magnetofluidic cartridge assembled with reagents for nucleic acid purification and amplification. A mobile phone user interface operating in tandem with a portable Bluetooth-enabled cartridge-processing unit facilitates process integration. We tested 30 potentially Chlamydia trachomatis (CT)-infected patients in a hospital emergency department and confirmed that mobiNAAT showed 100% concordance with laboratory-based NAAT. Concurrent evaluation by a nontechnical study coordinator who received brief training via an embedded mobile app module demonstrated ease of use and reproducibility of the platform. This work demonstrates the potential of mobile nucleic acid testing in bridging the diagnostic gap between centralized laboratories and hospital emergency departments.

Usability characteristics of self-administered computer-assisted interviewing in the emergency department: factors affecting ease of use, efficiency, and entry error

OBJECTIVE

Self-administered computer-assisted interviewing (SACAI) gathers accurate information from patients and could facilitate Emergency Department (ED) diagnosis. As part of an ongoing research effort whose long-range goal is to develop automated medical interviewing for diagnostic decision support, we explored usability attributes of SACAI in the ED.

METHODS

Cross-sectional study at two urban, academic EDs. Convenience sample recruited daily over six weeks. Adult, non-level I trauma patients were eligible. We collected data on ease of use (self-reported difficulty, researcher documented need for help), efficiency (mean time-per-click on a standardized interview segment), and error (self-report age mismatched with age derived from electronic health records) when using SACAI on three different instruments: Elo TouchSystems ESY15A2 (finger touch), Toshiba M200 (with digitizer pen), and Motion C5 (with digitizer pen). We calculated descriptive statistics and used regression analysis to evaluate the impact of patient and computer factors on time-per-click.

RESULTS

841 participants completed all SACAI questions. Few (<1%) thought using the touch computer to ascertain medical information was difficult. Most (86%) required no assistance. Participants needing help were older (54 ± 19 vs. 40 ± 15 years, p<0.001) and more often lacked internet at home (13.4% vs. 7.3%, p = 0.004). On multivariate analysis, female sex (p<0.001), White (p<0.001) and other (p = 0.05) race (vs. Black race), younger age (p<0.001), internet access at home (p<0.001), high school graduation (p = 0.04), and touch screen entry (vs. digitizer pen) (p = 0.01) were independent predictors of decreased time-per-click. Participant misclick errors were infrequent, but, in our sample, occurred only during interviews using a digitizer pen rather than a finger touch-screen interface (1.9% vs. 0%, p = 0.09).

DISCUSSION

Our results support the facility of interactions between ED patients and SACAI. Demographic factors associated with need for assistance or slower interviews could serve as important triggers to offering human support for SACAI interviews during implementation.

CONCLUSION

Understanding human-computer interactions in real-world clinical settings is essential to implementing automated interviewing as means to a larger long-term goal of enhancing clinical care, diagnostic accuracy, and patient safety.

Emergency department (ED) utilization by HIV-infected ED patients in the United States in 2009 and 2010 - a national estimation

OBJECTIVES

The aim of the study was to describe the emergency department (ED) resource utilization patterns of ED visits by patients reported to be HIV-infected in the USA in 2009 and 2010 and to compare them with those of the general ED patient population.

METHODS

We identified demographics, HIV infection status, and ED utilization patterns in 2009 and 2010 from a weighted sample of US ED visits using the National Hospital Ambulatory Medical Care Survey, a nationally representative survey. Data on visits by patients aged ≥ 13 years were analysed using procedures for multiple-stage survey data.

RESULTS

In 2009 and 2010, 1 192 535 visits were documented for HIV-infected patients. The estimated annual ED visit rates were 633 per 1000 known HIV-infected persons and 438 per 1000 non-HIV-infected persons [rate difference 195; 95% confidence interval (CI) 194, 197]. While no difference was recorded in the level of acuity between HIV-infected ED patients and general ED patients, the total number of diagnostic/screening services ordered and medications administered in the ED was significantly higher for visits by HIV-infected patients. HIV-infected patients making ED visits also had a longer duration of stays [mean 5.4 h (95% CI 4.6, 6.2 h) vs. 3.6 h (95% CI 3.5, 3.8 h) for HIV-uninfected patients] and were more likely to be admitted [28% (95% CI 22, 34%) vs. 15% (95% CI 14, 16%), respectively] than their non-HIV-infected counterparts.

CONCLUSIONS

ED visits by HIV-infected individuals occur at rates higher than those of visits by the general population, and consume significantly more ED resources than visits by the general population. These national findings represent baseline prior to full implementation of the 2010 Patient Protection and Affordable Care Act.

US national estimation of emergency department utilization by patients given 'HIV/AIDS-related illness' as their primary diagnosis

BACKGROUND

The emergency department (ED) is one of the most frequent sources of medical care for many HIV-infected individuals. However, the characteristics and ED utilization patterns of patients with HIV/AIDS-related illness as the primary ED diagnosis (HRIPD) are unknown.

METHODS

We identified the ED utilization patterns of HRIPD visits from a weighted sample of US ED visits (1993-2005) using the National Hospital Ambulatory Medical Care Survey, a nationally representative survey. Data on visits by patients≥18 years old were analysed using procedures for multiple-stage survey data. We compared the utilization patterns of HRIPD vs. non-HRIPD visits, and patterns across three periods (1993-1996, 1997-2000 and 2001-2005) to take into account changes in HIV epidemiology.

RESULTS

Overall, 492 000 HRIPD visits were estimated to have occurred from 1993 to 2005, corresponding to 5-in-10 000 ED visits. HRIPD visits experienced longer durations of stay (5.2 h vs. 3.4 h; P=0.001), received more diagnostic tests (5.1 vs. 3.3; P<0.001), were prescribed more medications (2.5 vs. 1.8; P<0.001) and were more frequently seen by physicians (99.5%vs. 93.8%; P<0.001) compared with non-HRIPD visits. HRIPD visits were more likely to result in admission [adjusted odds ratio (OR) 7.67; 95% confidence interval (CI) 5.14-11.44]. The proportion of HRIPD visits that required emergent/urgent care or were seen by attending physicians, and the number of diagnostic tests ordered, significantly increased over time (P<0.05), while the wait time (P=0.003) significantly decreased between the second and third study periods (P<0.05).

CONCLUSIONS

Although HRIPD visits were infrequent relative to all ED visits, HRIPD visits utilized significantly more resources than non-HRIPD visits and the utilization also increased over time.

Clinical aspects of diagnosis of gonorrhea and Chlamydia infection in an acute care setting

We found a 10.4% prevalence of unrecognized genital gonorrhea and Chlamydia infection among young adults of an urban emergency department. Intensified detection and treatment policies are needed to prevent continued transmission and complications of sexually transmitted infections.

Unsuspected gonorrhea and chlamydia in patients of an urban adult emergency department: a critical population for STD control intervention

BACKGROUND

Urban emergency departments (EDs) providing services to patients at high risk for sexually transmitted infection may be logical sites for intervention.

GOAL

To determine the prevalence of gonorrhea (GC) and chlamydia (CT) in an adult ED patient population, and to assess risk factors for infection.

STUDY DESIGN

Cross-sectional study of patients aged 18 to 44 in an urban ED, seeking care of any medical nature. Main outcome was positive for GC or CT by urine ligase chain reaction assay.

RESULTS

Test results for GC and/or CT were positive in 13.6% of 434 18 to 31 year-olds and in 1.8% of 221 32 to 44 year-olds. Of 63 infected individuals identified by the study, 15 (23.8%) were treated at the ED visit. Age < or =31 detected 88% of infections. Among 18- to 31-year-old patients, predictive risk factors by multivariate analysis included age <25, >1 sex partner in the past 90 days, and a history of sexually transmitted disease.

CONCLUSION

This study identified a high prevalence of GC and CT in patients seeking ED services. Many of these infections were clinically unsuspected. These data demonstrate that the ED is a high-risk setting and may be an appropriate site for routine GC and CT screening in 18- to 31-year-old patients.

A decision guideline for emergency department utilization of noncontrast head computed tomography in HIV-infected patients

OBJECTIVE

To determine which neurologic signs or symptoms are predictive of new focal lesions on head CT in HIV-infected patients.

METHODS

Prospective study with convenience sample enrollment of HIV-infected patients who presented to a large inner-city university-based ED over an 11-month period. Patients were assessed using a standardized neurologic evaluation to ascertain whether they had developed new or changed neurologic signs or symptoms. Patients with any new or changed neurologic findings had a head CT scan in the ED. The association between individual complaints or findings and new focal lesions on head CT was assessed by univariate analysis, and sensitivity, specificity, and positive predictive values were calculated. Stepwise logistic regression analysis was then carried out to estimate the relative risk for those variables independently associated with new focal lesions on CT scans. A decision guideline was developed incorporating those variables.

RESULTS

One hundred ten patients were identified as having new or changed neurologic signs or symptoms and had a head CT done in the ED. Twenty-seven patients (24%) had focal lesions on head CT, of which 19 (18%) were identified as new focal lesions; eight of these (7%) demonstrated a mass effect. Clinical findings most strongly associated with new focal findings on head CT were: 1) new seizure, relative risk (RR) = 73.5, 95% CI = 6.2 to 873.0; 2) depressed or altered orientation, RR = 39.1, 95% CI = 4.6 to 330.0; and 3) headache, different in quality, RR = 27.0, 95% CI = 3.2 to 230.1. Use of these three findings as a screen for ordering head CT in the ED would have identified 95% (18/19) of the patients with new focal intracranial lesions, and resulted in a 53% reduction in the number of head CTs ordered in the ED. Inclusion of one additional parameter (prolonged headache, > or =3 days), would have resulted in identification of 100% of all new focal lesions, with a 37% reduction in the number of head CTs ordered. Among those patients with new focal findings, 74% required emergent management (i.e., seizure control, IV antibiotics, IV steroids or surgery). The most common intracranial lesion among patients with CD4 counts less than 200 cells/microL was toxoplasmosis, while cerebrovascular accidents (ischemic or hemorrhagic) were most common in those with CD4 counts greater than 200 cells/microL.

CONCLUSION

Specific clinical signs and symptoms were associated with the presence of new intracranial lesions in a group of HIV-infected patients who presented to the ED with neurologic complaints. These clinical findings can be incorporated into guidelines for determining the need for emergent head CT. Validation and widespread application of these guidelines could result in limiting the use of emergent neuroimaging to a more well-defined HIV-infected patient population.

Construction of defined polytopic integral transmembrane proteins. The role of signal and stop transfer sequence permutations

Signal and stop transfer sequences are discrete regions within a polypeptide chain able to initiate or terminate translocation of the protein across the membrane of the endoplasmic reticulum. We have investigated the role of these topogenic sequences in the biogenesis of polytopic transmembrane proteins. Plasmids encoding various patterns of well-characterized signal and stop transfer sequences fused to a set of topogenically inert passenger domains were constructed. These molecules were expressed by transcription-translation in a cell-free system or by microinjection of transcripts into Xenopus oocytes. The observed orientation with respect to the membrane was dependent on the order of signal and stop transfer sequences in the coding region. These results were used to test the hypothesis that a protein can achieve polytopic transmembrane orientation using combinations of simple topogenic sequences. We conclude that some (but not all) patterns of signal and stop transfer sequences confer polytopic orientation to proteins across the membrane of the endoplasmic reticulum.

Uncoupling translocation from translation: implications for transport of proteins across membranes

The segregation of secretory proteins into the cisternae of the endoplasmic reticulum (ER) is normally tightly coupled to their synthesis. This feature distinguishes their biogenesis from that of proteins targeted to many other organelles. In the examples presented, translocation across the ER membrane is dissociated from translation. Transport, which is normally cotranslational, may proceed in the absence of chain elongation. Moreover, translocation across the ER membrane does not proceed spontaneously since, even in the absence of protein synthesis, energy substrates are required for translocation. These conclusions have been extended to the cotranslational integration of newly synthesized transmembrane proteins.