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Introduction The 2016 Clinical Learning Environment Review established that experiential patient safety curricula for residents are uncommon. Moreover, these curricula do not incorporate non-technical skills linked to safety, such as situational awareness (SA). We developed an in-situ patient safety simulation exercise incorporating core SA concepts and subsequently assessed exercise feasibility and acceptability, and measured residents' safety SA. Methods A simulation scenario and mock chart were designed, incorporating 16 patient safety hazards. Residents at two institutions reviewed the chart and had 10 minutes in an emergency department room with the simulated scenario to document identified hazards, followed by a facilitated debriefing. Pre- and post-exercise surveys were completed. We used regression analyses to compare exercise performance and survey responses by training year, and measures of proportional difference and association for survey responses. Results This study included 76 of 104 eligible residents (73.1%). Around 56.5% initially reported being comfortable identifying hazards. During the exercise, hazards requiring higher SA were identified less frequently. Senior residents identified more hazards (OR 2.26; 95%CI 1.56-3.28) (mean 8.28, SD1.45); 93.4% expressed satisfaction with the session, and residents reporting comfort increased significantly (89.5%, p<0.001). Conclusion In-situ simulation incorporating SA concepts feasibly provides experiential safety education and enhances resident comfort with safety issues. Visible hazards were often identified; those requiring information synthesis were usually missed, suggesting a need for developing more robust resident SA. While interns demonstrated the poorest performance, senior residents only identified 50% of errors, indicating that patient safety education enhancing SA should begin early and continue longitudinally.

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Objective: To report the effectiveness of the antimicrobial stewardship program (ASP) in a long-term care (LTC) facility, by analyzing the change in antimicrobial consumption and cost and multidrug resistance (MDR) rates over a 5-year period. Method: A prospective interventional study was conducted at a 106-bed facility (nursing home: 100 beds and an intensive care unit (ICU): 6 beds). The ASP was designed and led by a multidisciplinary team including an infectious disease consultant, two clinical pharmacists, a clinical microbiologist, and an infection control preventionist. Five key performance indicators were monitored: (1) intravenous (IV)-to-oral switch rate, (2) consumption of restricted IV antimicrobials (raw consumption and defined daily doses (DDD) index), (3) cost of restricted IV antimicrobials, (4) antimicrobial sensitivity profiles, and (5) MDR rate among hospital-acquired infections (MDR-HAI). Result: A ∼5.5-fold enhancement of the IV-to-oral switch and a 40% reduction in the overall consumption of restricted IV antimicrobials were observed. Regarding the cost, the cumulative cost saving was estimated as 5.64 million SAR (US$1.50 million). Microbiologically, no significant change in antimicrobial sensitivity profiles was observed; however, a large-size reduction in the MDR-HAI rate was observed, notably in ICU where it declined from 3.22 per 1,000 patient days, in 2015, to 1.14 per 1,000 patient days in 2020. Interestingly, the yearly overall MDR rate was strongly correlated with the level of antimicrobial consumption. Conclusion: The implementation of a multidisciplinary ASP in LTC facilities should be further encouraged, with emphasis on physicians' education and active involvement to enhance the success of the strategy.

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BACKGROUND: Dialysis patients who miss treatments are twice as likely to visit emergency departments (EDs) compared to adherent patients; however, prospective studies assessing ED use after missed treatments are limited. This interdisciplinary pilot study aimed to identify social determinants of health (SDOH) associated with missing hemodialysis (HD) and presenting to the ED, and describe resource utilization associated with such visits. METHODS: We conducted a prospective observational study with a convenience sample of patients presenting to the ED after missing HD (cases); patients at local dialysis centers identified as HD-compliant by their nephrologists served as matched controls. Patients were interviewed with validated instruments capturing associated risk factors, including SDOH. ED resource utilization by cases was determined by chart review. Chi-square tests and ANOVA were used to detect statistically significant group differences. RESULTS: All cases visiting the ED had laboratory and radiographic studies; 40% needed physician-performed procedures. Mean ED length of stay (LOS) for cases was 17 h; 76% of patients were admitted with average LOS of 6 days. Comparing 25 cases and 24 controls, we found no difference in economic stability, educational attainment, health literacy, family support, or satisfaction with nephrology care. However, cases were more dependent on public transport for dialysis (p = 0.03). Despite comparable comorbidity burdens, cases were more likely to have impaired mobility, physical limitations, and higher severity of pain and depression. (p < 0.05). CONCLUSIONS: ED visits after missed HD resulted in elevated LOS and admission rates. Frequently-cited SDOH such as health literacy did not confer significant risk for missing HD. However, pain, physical limitations, and depression were higher among cases. Community-specific collaborations between EDs and dialysis centers would be valuable in identifying risk factors specific to missed HD and ED use, to develop strategies to improve treatment adherence and reduce unnecessary ED utilization.

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INTRODUCTION: Acute blood loss represents a leading cause of death in both civilian and battlefield trauma, despite the prioritization of massive hemorrhage control by well-adopted trauma guidelines. Current Tactical Combat Casualty Care (TCCC) and Tactical Emergency Casualty Care (TECC) guidelines recommend the application of a tourniquet to treat life-threatening extremity hemorrhages. While extremely effective at controlling blood loss, the proper application of a tourniquet is associated with severe pain and could lead to transient loss of limb function impeding the ability to self-extricate or effectively employ weapons systems. As a potential alternative, Innovative Trauma Care (San Antonio, Texas USA) has developed an external soft-tissue hemostatic clamp that could potentially provide effective hemorrhage control without the aforementioned complications and loss of limb function. Thus, this study sought to investigate the effectiveness of blood loss control by an external soft-tissue hemostatic clamp versus a compression tourniquet. HYPOTHESIS: The external soft-tissue hemostatic clamp would be non-inferior at controlling intravascular fluid loss after damage to the femoral and popliteal arteries in a normotensive, coagulopathic, cadaveric lower-extremity flow model using an inert blood analogue, as compared to a compression tourniquet. METHODS: Using a fresh cadaveric model with simulated vascular flow, this study sought to compare the effectiveness of the external soft-tissue hemostatic clamp versus the compression tourniquet to control fluid loss in simulated trauma resulting in femoral and posterior tibial artery lacerations using a coagulopathic, normotensive, cadaveric-extremity flow model. A sample of 16 fresh, un-embalmed, human cadaver lower extremities was used in this randomized, balanced two-treatment, two-period, two-sequence, crossover design. Statistical significance of the treatment comparisons was assessed with paired t-tests. Results were expressed as the mean and standard deviation (SD). RESULTS: Mean intravascular fluid loss was increased from simulated arterial wounds with the external soft-tissue hemostatic clamp as compared to the compression tourniquet at the lower leg (119.8mL versus 15.9mL; P <.001) and in the thigh (103.1mL versus 5.2mL; P <.001). CONCLUSION: In this hemorrhagic, coagulopathic, cadaveric-extremity experimental flow model, the use of the external soft-tissue hemostatic clamp as a hasty hemostatic adjunct was associated with statistically significant greater fluid loss than with the use of the compression tourniquet.Paquette R, Bierle R, Wampler D, Allen P, Cooley C, Ramos R, Michalek J, Gerhardt RT. External soft-tissue hemostatic clamp compared to a compression tourniquet as primary hemorrhage control device in pilot flow model study. Prehosp Disaster Med. 2019;34(2):175-181.

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BACKGROUND: A troponin assay is commonly sent for patients presenting to emergency departments (EDs) with supraventricular tachycardia (SVT). Multiple studies suggest that elevated troponin levels do not predict coronary artery disease in these patients. Patients with elevated troponins are more likely to have additional cardiac testing, which can lead to increased health care costs and unnecessary invasive procedures. OBJECTIVE: Our objective was to evaluate low- to intermediate-risk patients (HEART [history, electrocardiography, age, risk factors and troponin] Score 1-6) presenting to the ED with SVT. Our hypothesis was that an elevated troponin would not predict major adverse cardiac events (MACE), but would be associated with increased hospital admission rates and lengths of stay. METHODS: This was a retrospective cohort study of adult patients who presented with SVT to a large, urban, academic hospital ED over 4 years who had a troponin result. A total of 46 patients were included in the study. RESULTS: Patients with a positive troponin (>0.05 ng/mL) had a hospital admission rate of 86% versus 21% for patients with negative troponin (p = 0.006); rate of cardiology consult of 86% versus 21% (p < 0.001); and a mean total length of stay of 4157 min versus 1347 min (p = 0.04). At 3 months, none of the patients with a positive troponin had an MACE, death from any cause, or positive results of cardiac testing. CONCLUSIONS: Patients with a positive troponin result had significantly more admissions, cardiology consults, and longer hospital stays. These patients did not have an increased prevalence of MACE.

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Emergency department (ED) providers have limited time to evaluate patients at risk for opioid misuse. A validated tool to assess the risk for aberrant opioid behavior may mitigate adverse sequelae associated with prescription opioid misuse. We sought to determine if SOAPP-R, COMM, and provider gestalt were able to identify patients at risk for prescription opioid misuse as determined by pharmacy records at 12 months. We conducted a prospective observational study of adult patients in a high volume US ED. Patients completed the SOAPP-R and COMM, and treating EM providers evaluated patients' opioid misuse risk. We performed variable-centered, person-centered, and hierarchical cluster analyses to determine whether provider gestalt, SOAPP-R, or COMM, or a combination, predicted higher misuse risk. The primary outcome was the number of opioid prescriptions at 12 months according to pharmacy records. For 169 patients (mean age 43 years, 51% female, 73% white), correlation analysis showed a strong relationship between SOAPP-R and COMM with predicting the number of opioid prescriptions dispensed at 12 months. Provider scores estimating opioid misuse were not related to SOAPP-R and only weakly associated with COMM. In our adjusted regression models, provider gestalt and SOAPP-R uniquely predicted opioid prescriptions at 6 and 12 months. Using designated cutoff scores, only SOAPP-R detected a difference in the number of opioid prescriptions. Cluster analysis revealed that provider gestalt, SOAPP-R, and COMM scores jointly predicted opioid prescriptions. Provider gestalt and self-report instruments uniquely predicted the number of opioid prescriptions in ED patients. A combination of gestalt and self-assessment scores can be used to identify at-risk patients who otherwise miss the cutoff scores for SOAPP-R and COMM.

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BACKGROUND: Dietary supplement use (protein/amino acids, weight-loss supplements, performance enhancers) is common among U.S. military members. Reported dietary supplement use in deployed troops is limited and is of concern in settings where troops are exposed to high ambient temperatures, increased physical demands, and dehydration. Our objective was to describe dietary supplement use and adverse events (AEs) among deployed U.S. service members compared with their pre-deployment use. METHODS: We conducted an institutional review board (IRB) approved, descriptive study in Afghanistan using a written questionnaire and collected demographic information, dietary supplement use before and during deployment, AEs associated with supplement use, and physical workout routines. Participants were U.S. military personnel of all branches of service deployed to Afghanistan. They were recruited in high-traffic areas in the combat theater. We analyzed the data with descriptive statistics. Paired t-test/Wilcoxon signed-rank test was conducted to examine the before/during deployment changes for continuous data, and McNemar's chi-square test was conducted for categorical data. We constructed separate logistic regression models to determine the best predictors of increases or decreases in dietary supplement use, with demographic information, reasons for using supplements, and education requested/received as covariates in each model. All statistical tests were two-sided at a significance level of 5% (P < 0.05). RESULTS: Data were collected on 1685 participants. Ninety-seven of the participants were in the Army or Air Force. The participants were more likely to work out daily or more than once a day during deployment. Thirty-five percent of the participants reported no supplement use before or during deployment. The remaining 65% of participants reported increased use and increased frequency of use of supplements (e.g., daily) during deployment compared with pre-deployment. Additionally, more people followed label instructions strictly during deployment vs. pre-deployment. Overall, the frequency of self-reported AEs among supplement users remained consistent before and during deployment. The only significant difference noted was in problems falling or staying asleep, which increased during deployment. In the adjusted logistic regression models, the level of formal education, military branch, occupational specialty, education about dietary supplements, and certain reasons for using supplements (to boost energy, lose weight, gain muscle strength and mass, and as a meal replacement) were significant predictors of changes in supplement use. CONCLUSION: Deployed U.S. service members were more likely to use dietary supplements, use more than one supplement and use supplements more frequently during deployment than pre-deployment. No serious AEs were reported, but problems falling or staying asleep increased during deployment.

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BACKGROUND: Emergency medicine providers (EMPs) prescribe about 25% of opioids, but the effect of EMP risk perception on decisions to prescribe opioids is unknown. This study was undertaken to identify factors that influence EMP risk and opioid prescribing practices. METHODS: We distributed an anonymous questionnaire to EMPs at a military trauma and referral center. Response frequencies and distributions were assessed for independence using the Chi-square test. RESULTS: Eighty-nine EMPs completed the questionnaire (100% response). Respondents were primarily younger male physicians (80%) in practice under five years (55%). Male EMPs were more likely to prescribe more opioid tablets than female ones both when and when not concerned for opioid misuse (P<0.001, P<0.007, respectively). Of the providers, 70% stated that patient age would influence their prescribing decisions. Hydrocodone and oxycodone were the opioids prescribed most frequently. About 60% of the providers reported changing their prescribing behavior would not prevent opioid misuse. Additionally, 40% of the providers believed at least 10% of patients seen at this military ED misused opioids. CONCLUSION: Female EM providers reported prescribing fewer opioid tablets. Patient age influenced prescribing behavior, but the effect is unknown. Finally, EM providers reported that altering their prescribing behavior would not prevent prescription opioid misuse.

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OBJECTIVE: This study aimed to elucidate the overall risk and demographic/occupational predictors of neck pain among professional aviators. METHODS: There were 413 surveys characterizing the severity and character of neck pain symptoms that were administered to a multinational cohort of pilots representing 3 separate airframe types. All results were compared to a nonaviator control group. Univariate and multivariate regression analyses were performed to elucidate independent predictors of occupationally related neck pain. RESULTS: Of the surveys, 92% were completed and returned. Multivariate analysis reveals that the pilot profession is independently predictive of increased occupational neck pain symptoms (OR 1.94, 95% CI 3.72, 1.01). High performance airframes, cargo/passenger airframes, and increasing age were also independent predictors of increased neck pain scores (OR = 3.91, 95% CI 7.10, 2.15; OR = 3.22, 95% CI 5.83, 1.77; OR = 4.00, 95% CI 7.43, 2.15, respectively). CONCLUSIONS: Our broad, multinational/multi-airframe analysis reveals that the pilot profession, most notably high performance and long-haul cargo/passenger airframes, display an increased risk of neck pain symptoms.

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Opioid analgesics misuse is a significant military health concern recognized as a priority issue by military leadership. Opioids are among those most commonly prescribed medications in the military for pain management. The military has implemented opioid risk mitigation strategies, including the Sole Provider Program and the Controlled Drug Management Analysis and Reporting Tool, which are used to identify and monitor for risk and misuse. However, there are substantial opportunities to build on these existing systems to better ensure safer opioid prescribing and monitor for misuse. Opioid risk mitigation strategies implemented by the civilian sector include establishing clinical guidelines for opioid prescribing and prescription monitoring programs. These strategies may help to inform opioid risk mitigation in the military health system. Reducing the risk of opioid misuse and improving quality of care for our Warfighters is necessary. This must be done through evidence-based approaches with an investment in research to improve patient care and prevent opioid misuse as well as its sequelae.

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Stress fractures are a common overuse problem among military trainees resulting in preventable morbidity, prolonged training, and long-term disability following military service. Femoral neck stress fractures (FNSFs) account for 2% of all stress fractures but result in disproportionate burden in terms of cost and convalescence. The purpose of this study was to describe and investigate FNSF in U.S. Air Force basic trainees and to present new data on risks factors for developing FNSF. We examined 47 cases of FNSF occurring in Air Force basic trainees between 2008 and 2011 and 94 controls using a matched case-control model. Analysis with t tests and conditional logistic regression found the risk of FNSF was not associated with body mass index or abdominal circumference. Female gender (p < 0.001) and slower run time significantly increased risk of FNSF (1.49 OR, p < 0.001; 95% CI 1.19-1.86). A greater number of push-up and sit-up repetitions significantly reduced risk of FNSF (0.55 OR, p = 0.03; 95% CI 0.32-0.93; 0.62 OR, p = 0.04; 95% CI 0.4-0.98) for females. In this study body mass index was not correlated with FNSF risk; however, physical fitness level on arrival to training and female gender were significantly associated with risk of FNSF.

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OBJECTIVES/HYPOTHESIS: To evaluate voice disorder differences between deployed and nondeployed US army soldiers. STUDY DESIGN: Cross-sectional study. METHODS: More than 1.3 million health records of active duty US army soldiers with no history of dysphonia were queried for voice disorder diagnoses over a 3.5-year period. A sample of 292 soldiers was further evaluated for known factors linked to dysphonia. RESULTS: US army soldiers were 1.13 times more likely to have a diagnosis of dysphonia if they were deployed. Risk factors and exposures common to patients with dysphonia were not statistically different between deployed and nondeployed soldiers. Additionally, the type of dysphonia diagnosis was not significantly different between deployed and nondeployed soldiers. CONCLUSIONS: US army soldiers deployed to war zones are more likely to be diagnosed with dysphonia. None of the reviewed parameters accounted for the difference in dysphonia rate between deployed and nondeployed soldiers, suggesting that occupational exposures of deployed soldiers account for the increase in the diagnoses of dysphonia.

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OBJECTIVES: We sought to determine whether the prevalence of metabolic syndrome among US women of childbearing age (18-44 years) has increased since 1988 and to estimate its current prevalence by race/ethnicity and risk that a maternal history of select metabolic syndrome characteristics imposes on offspring. METHODS: We used survey-specific data analysis methods to examine data from the National Health and Nutrition Examination Surveys conducted from 1988 to 2004. RESULTS: The prevalence of the metabolic syndrome phenotype and 2 of its clinical correlates significantly increased between 1988 and 2004 (increase for metabolic syndrome phenotype=7.6%, for obesity=13.3%, and for elevated C-reactive protein=10.6%; P < .001 for all 3). Hispanic women were more likely than were White women to possess the phenotype (P = .004). Women who reported that their mothers had been diagnosed with diabetes were more likely to possess the phenotype than those whose mothers had not been so diagnosed (odds ratio=1.9; 95% confidence interval=1.3, 2.8). CONCLUSIONS: The current trends of metabolic syndrome among women of childbearing age demonstrate the need for additional rigorous investigations regarding its long-term effects in these women and their offspring.

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The lack of knowledge about the earliest events in disease development is due to the multi-factorial nature of disease risk. This information gap is the consequence of the lack of appreciation for the fact that most diseases arise from the complex interactions between genes and the environment as a function of the age or stage of development of the individual. Whether an environmental exposure causes illness or not is dependent on the efficiency of the so-called "environmental response machinery" (i.e., the complex of metabolic pathways that can modulate response to environmental perturbations) that one has inherited. Thus, elucidating the causes of most chronic diseases will require an understanding of both the genetic and environmental contribution to their etiology. Unfortunately, the exploration of the relationship between genes and the environment has been hampered in the past by the limited knowledge of the human genome, and by the inclination of scientists to study disease development using experimental models that consider exposure to a single environmental agent. Rarely in the past were interactions between multiple genes or between genes and environmental agents considered in studies of human disease etiology. The most critical issue is how to relate exposure-disease association studies to pathways and mechanisms. To understand how genes and environmental factors interact to perturb biological pathways to cause injury or disease, scientists will need tools with the capacity to monitor the global expression of thousands of genes, proteins and metabolites simultaneously. The generation of such data in multiple species can be used to identify conserved and functionally significant genes and pathways involved in gene-environment interactions. Ultimately, it is this knowledge that will be used to guide agencies such as the U.S. Department of Health and Human Services in decisions regarding biomedical research funding and policy.

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Asthma research has traditionally focused on children and the elderly, the two populations considered most susceptible to complications. The prevalence of asthma in the adult population (19-64 years of age) is, however, gaining recognition as a formidable clinical and public health problem. Few studies have compared the incidence of adult asthma hospitalizations in urban and nonurban areas. The study reported here, using population size, population density, and traffic-related factors to define urban versus nonurban environments, selected six Pennsylvania counties to test the hypothesis that the degree of urbanization influences the asthma hospitalization rate for adults. The study group comprised adults 19-64 years of age who were hospitalized for asthma (as the primary diagnosis) from 1999 to 2001. To define urbanization in relation to traffic, the study used daily vehicular traffic count and miles of roads/highways for each of the six counties. The authors found a decrease in the adult asthma hospitalization rate as urbanization decreased in some of the counties. For other counties, however, the rate increased as urbanization decreased. The counties in which the latter was observed had depressed measures of socioeconomic status. These findings suggest that depressed socioeconomic conditions may supersede exposure to traffic-related pollution as a factor associated with asthma hospitalizations.

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