Mooneygood8438

In the last 2 decades, a growing body of evidence documented the efficacy and tolerability of repetitive transcranial magnetic stimulation (rTMS) in the treatment of psychiatric diseases, especially of major depressive disorder (a.k.a. unipolar depression). In our paper, we discuss briefly the historical aspects of TMS, its position among neurostimulatory methods and its mechanism of action. Then we review in details the practical aspects of the application of rTMS (e.g. stimulation parameters, contraindicatitions, side-effects) as well as the evidences of its efficacy in the treatment of depression. We also outline the possibilities of the use of rTMS in other psychiatric disorders than MDD. In our opinion, more than 10 years after receiving the FDA clearence, rTMS should be added to the Hungarian treatment guideline of MDD. Furthermore, the elaboration of the details of the insurance coverage of the rTMS treatment by the Hungarian National Health Insurance Fund would also be required.INTRODUCTION High levels of impulsivity represent a core feature of various psychiatric conditions, such as Attention Deficit Hyperactivity Disorder (ADHD), Borderline Personality Disorder (BPD), Impulse Control and Conduct Disorders, Bulimia Nervosa, Substance Use Disorders, and other maladaptive behaviors, like non-suicidal self-harm and suicidal behavior. The overall aim of our research is to carry out a trans-diagnostic study of impulsivity as a common behavioral risk factor, taking into consideration the different dimensions of impulsivity (motor, attentional, non-planning). The project investigates inhibitory neurocognitive deficits, electrophysiological correlates, childhood adversities and genetic vulnerability factors in the background of impulsivity. METHODS In this report, we describe the results of our pilot study which aims to compare impulsivity profiles, personality traits, and levels of aggression in patients with adult ADHD (aADHD) and BPD primary diagnoses, and healthy control subjects, baseN Impulsivity, as a diagnostic criterion of different psychiatric disorders is a heterogenous construct. Different characteristics of impulsivity are pronounced with respect to the condition it is part of. Studying impulsivity can improve our understanding of the etiology of different psychiatric conditions, which can result in more specific and effective therapeutic interventions.Although more and more data is now available on the background of suicidal behaviour, classical suicidal risk factors have only limited clinical predictive value because they provide little reliable information on the acute psychological processes leading to suicidal behaviour. As the lack of recognition of acute suicidal risk limits the ability to provide adequate care, intense research has begun to develop validated methods for risk analysis and risk assessment that provide more accurate predictions of suicidal behaviour. In recent years, two specific syndromes have been described that may assist in the more accurate assessment of presuicidal psychopathology and thus in the prediction of suicidal behaviour. Researchers from the United States suggest the introduction and the clinical use of two suicide-specific syndromes, the Acute Suicidal Affective Disorder (ASAD) and Suicidal Crisis Syndrome (SCS). In this paper, we present the most important features of these newly described suicide-specific syndromes, the experience with their clinical application, and the major research findings about them. Then these syndromes are compared with the classical psychological features of pre-suicidal crisis to find out whether these are really new transdiagnostic interpretations of the symptoms of suicidal behaviour or those are merely the well-known classical symptoms with new terminology.In the review I discuss the historical, social aspects of childhood and adolescent sexual abuse of males and the factors influencing trauma research and obstructing its exploration. In the light of the literature, I present the prevalence and the characteristics of the abuse, the risk factors, the short and long-term effects of sexual trauma and the consequential psychiatric disorders.Religious-spiritual crises include distress associated with the weakening or loss of faith, turbulent conversions, and affective states associated with negative spirituality. The differential diagnosis in regard to psychosis is often challenging. The purpose of the present study was to investigate the role of basic symptoms (changes in the subjective experience of perception, thinking, feeling, and self) in the differential diagnosis. We evaluated 106 help-seeking individuals with the Bonn Scale for the Assessment of Basic Symptoms (BSABS). The results indicated that religiousspiritual crises and psychotic states could be properly differentiated with the BSABS. Although the crisis and psychosis groups scored similarly on perplexity, self-disorder, depression, and anxiety, the disturbance of social contact and cognition was observed only in psychosis. These results indicate that the assessment of basic symptoms is useful in the differentiation of religious-spiritual crisis and psychosis, but it does not replace a multidisciplinary approach when, in addition to the routine psychiatric examination, the wider cultural context and the personal narratives are also considered.The short literature overview is organized around the idea that during our life course there is a classic competition between accumulated experience and the increased metacognitive reflection possibilities as the positive side, and the rusting of fast mental processes, mental slowdown with age as a negative side. This is non trivially crossed by the issue that in language, grammar corresponds to the early stabilizing procedural system, while vocabulary is a system that remains open during all our life regarding its acquisition, but shows signs of access problems due to the age sensitivity of the declarative memory system. Language and speech in this regard as well are subject to multiple determination different age parameters characterize its acquisition and usage. I show some summaries of age related changes in grammar, vocabulary, and articulation. The review specifically discusses the possible role of age related in memory and executive functions during physiological ageing. In this domain as well, the new IT system brought in new environmental and research method challenges.BACKGROUND In the past decade, Lynn Etheredge presented a vision for the Learning Health System (LHS) as an opportunity for increasing the value of health care via rapid learning from data and immediate translation to practice and policy. An LHS is defined in the literature as a system that seeks to continuously generate and apply evidence, innovation, quality, and value in health care. OBJECTIVE This review aimed to examine themes in the literature and rhetoric on the LHS in the past decade to understand efforts to realize the LHS in practice and to identify gaps and opportunities to continue to take the LHS forward. METHODS We conducted a thematic analysis in 2018 to analyze progress and opportunities over time as compared with the initial Knowledge Gaps and Uncertainties proposed in 2007. RESULTS We found that the literature on the LHS has increased over the past decade, with most articles focused on theory and implementation; articles have been increasingly concerned with policy. CONCLUSIONS There is a need for attention to understanding the ethical and social implications of the LHS and for exploring opportunities to ensure that these implications are salient in implementation, practice, and policy efforts. ©Jodyn E Platt, Minakshi Raj, Matthias Wienroth. Originally published in the Journal of Medical Internet Research (http//www.jmir.org), 19.03.2020.BACKGROUND In recent years, mobile health (mHealth)-related apps have been developed to help manage chronic diseases. Apps may allow patients with a chronic disease characterized by exacerbations, such as chronic obstructive pulmonary disease (COPD), to track and even suspect disease exacerbations, thereby facilitating self-management and prompt intervention. Nevertheless, there is insufficient evidence regarding patient compliance in the daily use of mHealth apps for chronic disease monitoring. OBJECTIVE This study aimed to provide further evidence in support of prospectively recording daily symptoms as a useful strategy to detect COPD exacerbations through the smartphone app, Prevexair. It also aimed to analyze daily compliance and the frequency and characteristics of acute exacerbations of COPD recorded using Prevexair. METHODS This is a multicenter cohort study with prospective case recruitment including 116 patients with COPD who had a documented history of frequent exacerbations and were monitored over nio Amado Diago, Francisco Javier Callejas González, Rosa Malo De Molina Ruiz, Manuel E Fuentes Ferrer, Jose Luis Álvarez Sala-Walther, Myriam Calle Rubio. Originally published in JMIR mHealth and uHealth (http//mhealth.jmir.org), 19.03.2020.BACKGROUND Improving the quality of patient care through the use of mobile devices is one of the hot topics in the health care field. In unwanted situations like an accident, ambulances and rescuers often require a certain amount of time to arrive at the scene. Providing immediate cardiopulmonary resuscitation (CPR) to patients might improve survival. OBJECTIVE The primary objective of this study was to evaluate the feasibility of an emergency and mutual-aid app model in Taiwan and to provide a reference for government policy. METHODS A structured questionnaire was developed as a research tool. All questionnaires were designed according to the technology acceptance model, and a Likert scale was used to measure the degree of agreement or disagreement. Moreover, in-depth interviews were conducted with six experts from medical, legal, and mobile app departments. Each expert was interviewed once to discuss feasible countermeasures and suggestions. Statistical Package for the Social Sciences (SPSS version 19; IBM rceived usefulness had an intermediary influence on use willingness. Experts in law, medical, and technology fields consider that an emergency and mutual-aid model can be implemented in Taiwan. Along with the development of an emergency and mutual-aid app model, we recommend an increase in the number of automated external defibrillators per region and promotion of correct knowledge about CPR in order to decrease morbidity and mortality. ©Shuo-Chen Chien, Md Mohaimenul Islam, Chen-An Yeh, Po-Han Chien, Chun You Chen, Yen-Po Chin, Ming-Chin Lin. Originally published in JMIR Formative Research (http//formative.jmir.org), 19.03.2020.BACKGROUND Sedentary time (ST) has been associated with detrimental health outcomes in fibromyalgia. Previous evidence in the general population has shown that not only is the total amount of ST harmful but the pattern of accumulation of sedentary behaviors is also relevant to health, with prolonged unbroken periods (ie, bouts) being particularly harmful. OBJECTIVE To examine the association of the patterns of ST with health-related quality of life (HRQoL) in women with fibromyalgia and to test whether these associations are independent of moderate-to-vigorous physical activity (MVPA). METHODS A total of 407 women (mean 51.4 years of age [SD 7.6]) with fibromyalgia participated. ST and MVPA were measured with triaxial accelerometry. The percentage of ST accumulated in bouts and the frequency of sedentary bouts of different lengths (≥10 min, ≥20 min, ≥30 min, and ≥60 min) were obtained. Four groups combining total ST and sedentary bout duration (≥30 min) were created. We assessed HRQoL using the 36-item Short-06; not independent of MVPA) than those with low ST and low sedentary bout duration. CONCLUSIONS Greater ST in prolonged periods of any length and a higher frequency of ST bouts, especially in longer bout durations, are associated with worsened HRQoL in women with fibromyalgia. These associations were generally independent of MVPA. ©Blanca Gavilán-Carrera, Víctor Segura-Jiménez, Pedro Acosta-Manzano, Milkana Borges-Cosic, Inmaculada C Álvarez-Gallardo, Manuel Delgado-Fernández. Originally published in JMIR mHealth and uHealth (http//mhealth.jmir.org), 19.03.2020.BACKGROUND Mental health services aim to provide recovery-focused care and facilitate coproduced care planning. In practice, mental health providers can find supporting individualized coproduced care with service users difficult while balancing administrative and performance demands. To help meet this aim and using principles of coproduction, an innovative mobile digital care pathway tool (CPT) was developed to be used on a tablet computer and piloted in the West of England. OBJECTIVE The aim of this study was to examine mental health care providers' views of and experiences with the CPT during the pilot implementation phase and identify factors influencing its implementation. METHODS A total of 20 in-depth telephone interviews were conducted with providers participating in the pilot and managers in the host organization. Interviews were audio recorded, transcribed, anonymized, and thematically analyzed guided by the Consolidated Framework for Implementation Research. RESULTS The tool was thought to facilitatthara, Michelle Farr, Sarah A Sullivan, Hannah B Edwards, William Hall, Caroline Gadd, Julian Walker, Nick Hebden, Jeremy Horwood. Originally published in the Journal of Medical Internet Research (http//www.jmir.org), 19.03.2020.BACKGROUND Extended criteria donors (ECD) are widely utilized due to organ shortage, but they may increase the risk of graft dysfunction and poorer outcomes. Hypothermic oxygenated perfusion (HOPE) is a recent organ preservation strategy for marginal kidney and liver grafts, allowing a redirect from anaerobic metabolism to aerobic metabolism under hypothermic conditions and protecting grafts from oxidative species-related damage. These mechanisms may improve graft function and survival. OBJECTIVE With this study, we will evaluate the benefit of end-ischemic HOPE on ECD grafts for livers and kidneys as compared to static cold storage (SCS). The aim of the study is to demonstrate the ability of HOPE to improve graft function and postoperative outcomes of ECD kidney and liver recipients. METHODS This is an open-label, single-center randomized clinical trial with the aim of comparing HOPE with SCS in ECD kidney and liver transplantation. In the study protocol, which has been approved by the ethics committee, 220 NS The proposed preservation method should improve ECD graft function and consequently the postoperative patient outcomes. TRIAL REGISTRATION ClinicalTrials.gov NCT03837197; https//clinicaltrials.gov/ct2/show/NCT03837197 ; Archived by WebCite® at http//www.webcitation.org/76fSutT3R. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/13922. ©Matteo Ravaioli, Lorenzo Maroni, Andrea Angeletti, Guido Fallani, Vanessa De Pace, Giuliana Germinario, Federica Odaldi, Valeria Corradetti, Paolo Caraceni, Maurizio Baldassarre, Francesco Vasuri, Antonia D'Errico, Gabriela Sangiorgi, Antonio Siniscalchi, Maria Cristina Morelli, Anna Rossetto, Vito Marco Ranieri, Matteo Cescon, Massimo Del Gaudio, Chiara Zanfi, Valentina Bertuzzo, Giorgia Comai, Gaetano La Manna. Originally published in JMIR Research Protocols (http//www.researchprotocols.org), 19.03.2020.BACKGROUND Having a reliable source for health information is vital to build a strong foundation of knowledge, especially with the current revolution of the internet and social media, which raises many concerns regarding harmful effects on the health of the public. However, there are no studies on how the Saudi Arabian population seeks health information. Details about the most used and trusted sources of health information among the public will help health authorities and public awareness accounts on social media to effectively disseminate health information. OBJECTIVE To investigate the types of sources accessed by the Saudi Arabian population while seeking health information, as well as their level of trust in the sources and to assess the impact of these sources on their perception of medical knowledge and health decision-making. METHODS A cross-sectional study was conducted to meet the objectives. The study population included both men and women who were aged 16 years or more and visited primary care clilf of the respondents (197/413, 47.7%) acknowledged that various sources of information can often help them understand their health problems. However, the majority disagreed on substituting a doctor's prescription with information obtained from the internet or a friend or relative. CONCLUSIONS Although physicians were preferred and highly trusted, internet sources appeared to impact the medical knowledge of the population. The population still preferred to use internet search to obtain health information prior to a doctor's visit. ©Shatha A Alduraywish, Lamees A Altamimi, Rawan A Aldhuwayhi, Lama R AlZamil, Luluh Y Alzeghayer, Futoon S Alsaleh, Fahad M Aldakheel, Shabana Tharkar. Originally published in the Journal of Medical Internet Research (http//www.jmir.org), 19.03.2020.Neocortex expansion is largely based on the proliferative capacity of basal progenitors (BPs), which is increased by extracellular matrix (ECM) components via integrin signaling. Here we show that the transcription factor Sox9 drives expression of ECM components and that laminin 211 increases BP proliferation in embryonic mouse neocortex. We show that Sox9 is expressed in human and ferret BPs and is required for BP proliferation in embryonic ferret neocortex. Conditional Sox9 expression in the mouse BP lineage, where it normally is not expressed, increases BP proliferation, reduces Tbr2 levels and induces Olig2 expression, indicative of premature gliogenesis. Conditional Sox9 expression also results in cell-non-autonomous stimulation of BP proliferation followed by increased upper-layer neuron production. Our findings demonstrate that Sox9 exerts concerted effects on transcription, BP proliferation, neuron production, and neurogenic vs. gliogenic BP cell fate, suggesting that Sox9 may have contributed to promote neocortical expansion. © 2020, Güven et al.The spindle generates force to segregate chromosomes at cell division. In mammalian cells, kinetochore-fibers connect chromosomes to the spindle. The dynamic spindle anchors kinetochore-fibers in space and time to move chromosomes. Yet, how it does so remains poorly understood as we lack tools to directly challenge this anchorage. Here, we adapt microneedle manipulation to exert local forces on the spindle with spatiotemporal control. Pulling on kinetochore-fibers reveals the preservation of local architecture in the spindle-center over seconds. Sister, but not neighbor, kinetochore-fibers remain tightly coupled, restricting chromosome stretching. Further, pulled kinetochore-fibers pivot around poles but not chromosomes, retaining their orientation within 3 μm of chromosomes. This local reinforcement has a 20 s lifetime, and requires the microtubule crosslinker PRC1. Together, these observations indicate short-lived, specialized reinforcement in the spindle center. This could help protect chromosome attachments from transient forces while allowing spindle remodeling, and chromosome movements, over longer timescales. © 2020, Suresh et al.INTRODUCTION Prehospital and emergency medical services (EMS) providers are usually the first to respond to an individual's urgent health needs, sometimes in emotionally charged circumstances. Because violence toward EMS providers in the Czech Republic is often overlooked and under-reported, we do not have a complete understanding of the extent of such violence, nor do we have recommendations from EMS professional organizations on how to resolve this problem in prehospital emergency medicine. METHODS We conducted this study to explore the process of violence against EMS providers, using the Strauss/Corbin systematic approach of grounded theory to create a paradigm model. The participants in this research included personnel who had at least two years experience in the EMS systems of the city of Prague and the Central Bohemian Region, and who had been victims of violence. Our sample included 10 registered paramedics and 10 emergency medical technicians ages 23-33 (mean ± standard deviation 27.7). The impact of jobs) who found themselves in a very stressful situation. Thanks to grounded theory we learned that for all 20 participants there was a potential opportunity to prevent the conflict.INTRODUCTION Increased out-of-hospital time is associated with worse outcomes in trauma. Sparse literature exists comparing prehospital scene and transport time management intervals between adult and pediatric trauma patients. National Emergency Medical Services guidelines recommend that trauma scene time be less than 10 minutes. The objective of this study was to examine prehospital time intervals in adult and pediatric trauma patients. METHODS We performed a retrospective cohort study of blunt and penetrating trauma patients in a five-county region in North Carolina using prehospital records. We included patients who were transported emergency traffic directly from the scene by ground ambulance to a Level I or Level II trauma center between 2013-2018. We defined pediatric patients as those less than 16 years old. Urbanicity was controlled for using the Centers for Medicare and Medicaid's Ambulance Fee Schedule. We performed descriptive statistics and linear mixed-effects regression modeling. RESULTS A totalorter scene time. Males, non-White patients, and patients in urban environments tended to have shorter transport times. Future studies with outcomes data are needed to identify factors that prolong out-of-hospital time and to assess the impact of out-of-hospital time on patient outcomes.INTRODUCTION Emergency medical services (EMS) systems exist to provide prehospital care in diverse environments throughout the world. Advanced Life Support (ALS) services can provide advanced care including 12-lead electrocardiogram (ECG), endotracheal intubation and parenteral medication administration. Basic Life Support (BLS) can provide basic care such as splinting, wound care and cardiopulmonary resuscitation. ALS can release patients to BLS for transport to the hospital, and this is an area of high risk. Our study examines patients who were triaged and admitted to a critical care location, including an intensive care unit (ICU), cardiac catheterization laboratory, or operating room (OR). METHODS The analysis included data from 2007-2015 of all patients who were triaged. We evaluated demographics, admission diagnoses, and dispositions using descriptive statistics. Diagnoses were grouped into categories based on the system. RESULTS We found that 372/17,639 (2%) of patients were mistriaged to BLS and admitted to a critical care location. The average age was 64. The most common diagnosis categories were neurological (24%), gastrointestinal (GI)/abdominal pain (15%), respiratory (12%), and cardiac (12%). CONCLUSION It is uncommon for patients triaged from ALS to BLS to be admitted to an ICU, catheterization lab or OR, with a rate of 2%. Neurological, GI, respiratory, and cardiac diagnoses were the most frequent categories of patient complaints that were mistriaged. This study should lead to further studies to examine this patient population.INTRODUCTION There is considerable interest in triaging victims of large vessel occlusion (LVO) strokes to comprehensive stroke centers. Timely access to interventional therapy has been linked to improved stroke outcomes. Accurate triage depends upon the use of a validated screening tool in addition to several emergency medical system (EMS)-specific factors. This study examines the integration of a modified Rapid Arterial oCcclusion Evaluation (mRACE) score into an existing stroke treatment protocol. METHODS We performed a retrospective review of EMS and hospital charts of patients transported to a single comprehensive stroke center. Adult patients with an EMS provider impression of "stroke/TIA," "CVA," or "neurological problem" were included for analysis. EMS protocols mandated the use of the Cincinnati Prehospital Stroke Score (CPSS). The novel protocol authorized the use of the mRACE score to identify candidates for triage directly to the comprehensive stroke center. We calculated specificity and sensitivis of LVO triage protocols.INTRODUCTION In-service exam scores are used by residency programs as a marker for progress and success on board exams. Conference curriculum helps residents prepare for these exams. At our institution, due to resident feedback a change in curriculum was initiated. Our objective was to determine whether assigned Evidence-Based Medicine (EBM) articles and Rosh Review questions were non-inferior to Tintinalli textbook readings. We further hypothesized that the non-textbook assigned curriculum would lead to higher resident satisfaction, greater utilization, and a preference over the old curriculum. METHODS We collected scores from both the allopathic In-training Examination (ITE) and osteopathic Emergency Medicine Residency In-service Exam (RISE) scores taken by our program's residents from both the 2015-2016 and 2016-2017 residency years. We compared scores pre-curriculum change (pre-CC) to scores post-curriculum change (post-CC). A five-question survey was sent to the residents regarding their satisfaction, preference, and utilization of the two curricula. RESULTS Resident scores post-CC were shown to be non-inferior to their scores pre-CC for both exams. There was also no significant difference when we compared scores from each class post-CC to their respective class year pre-CC for both exams. Our survey showed significantly more satisfaction, utilization, and preference for this new curriculum among residents. CONCLUSION We found question-based learning and Evidence-Based Medicine articles non-inferior to textbook readings. This study provides evidence to support a move away from textbook readings without sacrificing scores on examinations.INTRODUCTION Since the development of an Accreditation Council of Graduate Medical Education (ACGME)-accredited emergency medical services (EMS) fellowship, there has been little published literature on effective methods of content delivery or training modalities. Here we explore a variety of innovative approaches to the development and revision of the EMS fellowship curriculum. METHODS Three academic, university-based ACGME-accredited EMS fellowship programs each implemented an innovative change to their existing training curricula. These changes included the following a novel didactic curriculum delivery modality and evaluation; implementation of a distance education program to improve EMS fellows' rural EMS experiences; and modification of an existing EMS fellowship curriculum to train a non-emergency medicine physician. RESULTS Changes made to each of the above EMS fellowship programs addressed unique challenges, demonstrating areas of success and promise for more generalized implementation of these curricula. Obstacles remain in tailoring the described curricula to the needs of each unique institution and system. CONCLUSION Three separate curricula and program changes were implemented to overcome specific challenges and achieve educational goals. It is our hope that our shared experiences will enable others in addressing common barriers to teaching the EMS fellowship core content and share similar innovative approaches to educational challenges.Initiatives for addressing resident wellness are a recent requirement of the Accreditation Council for Graduate Medical Education in response to high rates of resident burnout nationally. We review the literature on wellness and burnout in residency education with a focus on assessment, individual-level interventions, and systemic or organizational interventions.INTRODUCTION Shortening emergency department (ED) visit time can reduce ED crowding, morbidity and mortality, and improve patient satisfaction. Point-of-care testing (POCT) has the potential to decrease laboratory turnaround time, possibly leading to shorter time to decision-making and ED length of stay (LOS). We aimed to determine whether the implementation of POCT could reduce time to decision-making and ED LOS. METHODS We conducted a randomized control trial at the Urgency Room of Siriraj Hospital in Bangkok, Thailand. Patients triaged as level 3 or 4 were randomized to either the POCT or central laboratory testing (CLT) group. Primary outcomes were time to decision-making and ED LOS, which we compared using Mann-Whitney-Wilcoxon test. RESULTS We enrolled a total of 248 patients 124 in the POCT and 124 in the CLT group. The median time from arrival to decision was significantly shorter in the POCT group (106.5 minutes (interquartile [IQR] 78.3-140) vs 204.5 minutes (IQR 165-244), p less then 0.001). The median ED LOS of the POCT group was also shorter (240 minutes (IQR 161.3-410) vs 395.5 minutes (IQR 278.5-641.3), p less then 0.001). CONCLUSION Using a point-of-care testing system could decrease time to decision-making and ED LOS, which could in turn reduce ED crowding.INTRODUCTION Emergency departments (ED) are on the front line for treating victims of multi-casualty incidents. The primary objective of this study was to gather and detail the common experiences from those hospital-based health professionals directly involved in the response to the San Bernardino terrorism attack on December 2, 2015. Secondary objectives included gathering information on experiences participants found were best practices. METHODS We undertook a qualitative study using Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines by performing semi-structured interviews with physicians, nurses, and incident management staff from multiple institutions responding to the San Bernardino terrorist attack. We coded transcripts using qualitative analysis techniques and we delineated and agreed upon a refined list with code definitions using a negotiated group process. Final themes were developed and analyzed. RESULTS A total of 26 interviews were completed; 1172 excerpts were coded and categorized into 66 initial themes. Six final categories of communication, training, unexpected help, process bypassed, personal impact/emotions, and practical advice resulted. CONCLUSION Our study provides context regarding the response of healthcare personnel from multiple institutions to a singular terrorist attack in the United States. It elucidates several themes to help other institutions prepare for similar events. Understanding these common experiences provides opportunity to prepare for future incidents and develop questions to study in future events.On Saturday, October 27, 2018, a man with anti-Semitic motivations entered Tree of Life synagogue in the Squirrel Hill section of Pittsburgh, Pennsylvania; he had an AR-15 semi-automatic rifle and three handguns, opening fire upon worshippers. Eventually 11 civilians died at the scene and eight people sustained non-fatal injuries, including five police officers. Each person injured but alive at the scene received care at one of three local level-one trauma centers. The injured had wounds often seen in war-settings, with the signature of high velocity weaponry. We describe the scene response, specific elements of our hospital plans, the overall out-of-hospital preparedness in Pittsburgh, and the lessons learned.INTRODUCTION Since 2013, the First Care Provider (FCP) model has successfully educated the non-medical population on how to recognize life-threatening injuries and perform interventions recommended by the Committee for Tactical Emergency Casualty Care (C-TECC) and the Hartford Consensus in the disaster setting. Recent programs, such as the federal "Stop The Bleed" campaign, have placed the emphasis of public training on hemorrhage control. However, recent attacks demonstrate that access to wounded, recognition of injury, and rapid evacuation are equally as important as hemorrhage control in minimizing mortality. To date, no training programs have produced a validated study with regard to training a community population in these necessary principles of disaster response. METHODS In our study, we created a reproducible community training model for implementation into prehospital systems. Two matched demographic groups were chosen and divided into "trained" and "untrained" groups. The trained group was taught thuntrained groups, respectively, were 20.5 seconds and 43 seconds (p-value = .1064), while the TtS were 32.6 seconds in the trained group and 7 minutes and 3 seconds in the untrained group (p-value = .0087). Simulation values for recently graduated nursing students and a local fire department engine company (emergency medical services [EMS]) were also given for reference. The trained group's results mirrored times of EMS. CONCLUSION This study demonstrates an effective training model to civilian trauma response, while adhering to established recommendations. We offer our model as a potential solution for accomplishing the Stop The Bleed mission while advancing the potential of public disaster response.INTRODUCTION It is commonly assumed that orally-administered radiocontrast material (ORC) preceding abdominal ultrasound (US) performance can obscure image quality and potentially impair diagnostic accuracy when assessing patients with abdominal pain. Due to this concern, ORC administration per protocol for computed tomography (CT) is often delayed until after US performance, potentially contributing to prolonged length of stay in the emergency department (ED) in patients with concern for abdominal pathology. The objective of this study was to evaluate whether early administration of ORC in children with abdominal pain receiving abdominal CT for possible appendicitis obscures subsequent abdominal US image quality. METHODS We designed a prospective observational study of children less then 18 years of age presenting to a pediatric ED with abdominal pain who were set to receive ORC prior to obtaining an abdominal CT. These patients received a point-of-care ultrasound (POCUS) of the abdomen to assess the abdomirly administration of ORC prior to US performance to help minimize ED length of stay without impairing US diagnostic accuracy.INTRODUCTION We sought to determine whether ultrasound-guided arterial cannulation (USGAC) is more successful than traditional radial artery cannulation (AC) as performed by emergency medicine (EM) residents with standard ultrasound training. METHODS We identified 60 patients age 18 years or older at a tertiary care, urban academic emergency department who required radial AC for either continuous blood pressure monitoring or frequent blood draws. Patients were randomized to receive radial AC via either USGAC or traditional AC. If there were three unsuccessful attempts, patients were crossed over to the alternative technique. All EM residents underwent standardized, general ultrasound training. RESULTS The USGAC group required fewer attempts as compared to the traditional AC group (mean 1.3 and 2.0, respectively; p less then 0.001); 29 out of 30 (96%) successful radial arterial lines were placed using USGAC, whereas 14 out of 30 (47%) successful lines were placed using traditional AC (p less then 0.001). There was no significant difference in length of procedure or complication rate between the two groups. There was no difference in provider experience with respect to USGAC vs traditional AC. CONCLUSION EM residents were more successful and had fewer cannulation attempts with USGAC when compared to traditional AC after standard, intern-level ultrasound training.INTRODUCTION There are currently no robust tools available for risk stratification of emergency department (ED) patients with lower gastrointestinal bleed (LGIB). Our aim was to identify risk factors and develop a preliminary model to predict 30-day serious adverse events among ED LGIB patients. METHODS We conducted a health records review including adult ED patients with acute LGIB. We used a composite outcome of 30-day all-cause death, recurrent LGIB, need for intervention to control the bleeding, and severe adverse events resulting in intensive care unit admission. One researcher collected data for variables and a second researcher independently collected 10% of the variables for inter-observer reliability. We used backward multivariable logistic regression analysis and SELECTION=SCORE option to create a preliminary risk-stratification tool. We assessed the diagnostic accuracy of the final model. RESULTS Of 372 patients, 48 experienced an adverse outcome. We found that age ≥75 years, hemoglobin ≤100 g/L, international normalized ratio ≥2.0, ongoing bleed in the ED, and a medical history of colorectal polyps were statistically significant predictors in the multivariable regression analysis. The area under the curve (AUC) for the model was 0.83 (95% confidence interval, 0.77-0.89). We developed a scoring system based on the logistic regression model and found a sensitivity 0.96 (0.90-1.00) and specificity 0.53 (0.48-0.59) for a cut-off score of 1. CONCLUSION This model showed good ability to differentiate patients with and without serious outcomes as evidenced by the high AUC and sensitivity. The results of this study could be used in the prospective derivation of a clinical decision tool.INTRODUCTION Skin and soft tissue infections (SSTI) occur along a continuum from cellulitis to abscess. Point-of-care ultrasound (POCUS) is effective in differentiating between these two diagnoses and guiding acute management decisions. Smaller and more superficial abscesses may not require a drainage procedure for cure. The goal of this study was to evaluate the optimal abscess size and depth cut-off for determining when a drainage procedure is necessary. METHODS We conducted a retrospective study of adult patients with a SSTI who had POCUS performed. Patients were identified through an ultrasound database. We reviewed examinations for the presence, size, and depth of abscess. Medical records were reviewed to determine acute ED management and assess outcomes. The primary outcome evaluated the optimal abscess size and depth when a patient could be safely discharged without a drainage procedure. We defined a treatment failure as a return visit within seven days requiring admission, change in antibiotics, or drainage procedure. RESULTS A total of 162 patients had an abscess confirmed on POCUS and were discharged from the ED without a drainage procedure. The optimal cut-off to predict treatment failure by receiver operating curve analysis was 1.3 centimeters (cm) in longest dimension with a sensitivity of 85% and specificity of 37% (area under the curve [AUC] 0.60, 95% confidence interval [CI], 0.44-0.76), and 0.4cm in depth with a sensitivity of 85% and specificity of 68% (AUC 0.83, 95% CI, 0.74-93). CONCLUSION This retrospective data suggests that abscesses greater than 0.4 cm in depth from the skin surface may require a drainage procedure. Those less than 0.4 cm in depth may not require a drainage procedure and may be safely treated with antibiotics alone. Further prospective data is needed to validate these findings and to assess for an optimal size cut-off when a patient with a skin abscess may be discharged without a drainage procedure.INTRODUCTION We conducted a cross-sectional study at the Icahn School of Medicine at Mount Sinai to elicit emergency physician (EP) perceptions regarding intensive care unit (ICU) triage decisions and ongoing management for boarding of ICU patients in the emergency department (ED). We assessed factors influencing the disposition decision for critically ill patients in the ED to characterize EPs' perceptions about ongoing critical care delivery in the ED while awaiting ICU admission. METHODS Through content expert review and pilot testing, we iteratively developed a 25-item written survey targeted to EPs, eliciting current ICU triage structure, opinions on factors influencing ICU admission decisions, and views on caring for critically ill patients "boarding" in the ED for >4-6 hours. RESULTS We approached 732 EPs at a large, national emergency medicine conference, achieving 93.6% response and completion rate, with 54% academic and 46% community participants. One-fifth reported having formal ICU admission criteria, although only 36.6% reported adherence. Common factors influencing EPs' ICU triage decisions were illness severity (91.1%), ICU interventions needed (87.6%), and diagnosis (68.2%), while ICU bed availability (13.5%) and presence of other critically ill patients in ED (10.2%) were less or not important. While 72.1% reported frequently caring for ICU boarders, respondents identified high patient volume (61.3%) and inadequate support staffing (48.6%) as the most common challenges in caring for boarding ICU patients. CONCLUSION Patient factors (eg, diagnosis, illness severity) were seen as more important than system factors (eg, bed availability) in triaging ED patients to the ICU. Boarding ICU patients is a common challenge for more than two-thirds of EPs, exacerbated by ED volume and staffing constraints.INTRODUCTION Pediatric emergency department (PED) volume is often constrained by the number of available treatment rooms. In many PEDs patients occupy treatment rooms while awaiting test results or imaging, thereby delaying care for patients who arrive after them. METHODS We opened a PED where selected patients were moved to a playroom when they did not actively require a treatment room. The treatment room was then available for the next patient. We measured the effect of using the playroom on time from arrival to rooming and length of stay (LOS) using proportional hazards regression and the odds of being roomed within 30 minutes of arrival using logistic regression. We adjusted for the number of the previous eight patients who were "playroom eligible"; age; triage category; provider; the number of patients who arrived within the preceding hour; prior census; and testing ordered in the preceding eight patients. RESULTS We analyzed 43,634 patient encounters, of which 10,134 (23%) were playroom eligible. The adjusted hazards ratio for the next patient being roomed was 1.14 (95% confidence interval [CI], 1.10-1.18) per prior playroom eligible patient. The adjusted odds ratio of the next patient being roomed within 30 minutes was 1.46 (95% CI, 1.33-1.56) per prior playroom eligible patient. The playroom typically decreased median rooming time by four to 42 minutes and LOS by two to 40 minutes depending on patient volumes and acuity. The benefit of the playroom was maximal at busier times. CONCLUSION Implementing a playroom in the PED for selected patients generally decreased time to rooming of the next patient and LOS.INTRODUCTION Our goal was to critically examine emergency physician's (EP) beliefs about taking breaks for self-care on shift. Our operational definition of a break for self-care included time not engaging in direct patient care, eating, drinking, using the bathroom, or leaving a clinical area for a mental break. Using focus groups, the study aimed to accomplish the following 1) identify barriers to why residents and faculty at our academic center may not take breaks in the emergency department; 2) generate hypotheses for empirical testing; and 3) generate solutions to include in a departmental breaks initiative. METHODS We convened eight focus groups comprised separately of resident and faculty physicians. Group discussion was guided by eight questions representing a priori themes. The groups were recorded for transcription and subjected to a "cut-and-sort" process. Six themes were identified by consensus after independent review by three of the co-authors, which were confirmed by participant validation. RESULTS We identified six themes that represented the pooled outcomes of both resident and faculty focus groups 1) Physiological needs affect clinical performance, 2) EPs share beliefs around taking breaks that center on productivity, patient safety and the dichotomy of strength/weakness, 3) when taking breaks EPs fear worst-case scenarios, 4) breaking is a learned skill, 5) culture change is needed to allow EPs to engage in self-care; and 6) a flexible, individualized approach to breaking is necessary. Our central finding was that productivity and patient safety are of key importance to EPs when considering whether to take a break for self-care. We identified a dichotomy with the concept of strength related to productivity/patient safety, and the concept of weakness related to self-care. CONCLUSION The current practice culture of emergency medicine and the organization of our unique work environment may present barriers to physicians attempting to engage in self-care.INTRODUCTION Emergency physicians face multiple challenges to obtaining federal funding. The objective of this investigation was to describe the demographics of federally-funded emergency physicians and identify key challenges in obtaining funding. METHODS We conducted a retrospective database search of the National Institutes of Health (NIH) Research Portfolio Online Reporting Tool (NIH RePORTER) to collect data regarding the distribution and characteristics of federally-funded grants awarded to emergency medicine (EM) principal investigators between 2010-2017. An electronic survey was then administered to the identified investigators to obtain additional demographic data, and information regarding their career paths, research environment, and perceived barriers to obtaining federal funding. RESULTS We identified 219, corresponding to 51 unique, mentored career development awardees and 105 independent investigators. Sixty-two percent of investigators responded to the electronic survey. Awardees were predominantly White males, although a larger portion of the mentored awardee group was female. Greater than half of respondents reported their mentor to be outside of the field of EM. The most common awarding institution was the National Heart Lung and Blood Institute. Respondents identified barriers in finding adequate mentorship, time to gather preliminary data, and the quality of administrative support. CONCLUSION The last five years have showed a trend toward increasing grants awarded to EM investigators; however, we identified several barriers to funding. Initiatives geared toward support and mentorship of junior faculty, particularly to females, minorities, and those in less heavily funded areas of the country are warranted.INTRODUCTION Promoting emergency medicine (EM) clinical trials research remains a priority. To characterize the status of clinical EM research, this study assessed trial quality, funding source, and publication of EM clinical trials and compared EM and non-EM trials on these key metrics. We also examined the volume of EM trials and their subspecialty areas. METHODS We abstracted data from ClinicalTrials.gov (February 2000 - September 2013) and used individual study National Clinical Trial numbers to identify published trials (January 2007 - September 2016). We used descriptive statistics and chi-square tests to examine study characteristics by EM and non-EM status, and Kaplan-Meier curves and log-rank tests to compare time to publication of completed EM and non-EM studies. RESULTS We found 638 interventional EM trials and 59,512 non-EM interventional trials conducted in the United States between February 2000 and September 2013, registered on ClinicalTrials.gov. EM studies were significantly less likely than valuable longitudinal view of progress in clinical EM research.INTRODUCTION Urban emergency departments (ED) provide care to populations with multiple health-related and overlapping risk factors, many of which are associated with intimate partner violence (IPV). We examine the 12-month rate of physical IPV and its association with multiple joint risk factors in an urban ED. METHODS Research assistants surveyed patients regarding IPV exposure, associated risk factors, and other sociodemographic features. The joint occurrence of seven risk factors was measured by a variable scored 0-7 with the following risk factors depression; adverse childhood experiences; drug use; impulsivity; post-traumatic stress disorder; at-risk drinking; and partner's score on the Alcohol Use Disorders Identification Test. The survey (N = 1037) achieved an 87.5% participation rate. RESULTS About 23% of the sample reported an IPV event in the prior 12 months. Logistic regression showed that IPV risk increased in a stepwise fashion with the number of present risk factors, as follows one risk factor (adjusted odds ratio [AOR] [3.09]; 95% confidence interval [CI], 1.47-6.50; p less then .01); two risk factors (AOR [6.26]; 95% CI, 3.04-12.87; p less then .01); three risk factors (AOR = 9.44; 95% CI, 4.44-20.08; p less then .001); four to seven risk factors (AOR [18.62]; 95% CI, 9.00-38.52; p less then 001). Ordered logistic regression showed that IPV severity increased in a similar way, as follows one risk factor (AOR [3.17]; 95% CI, 1.39-7.20; p less then .01); two risk factors (AOR [6.73]; 95% CI, 3.04-14.90; p less then .001); three risk factors (AOR [10.36]; 95%CI, 4.52-23.76; p less then .001); four to seven risk factors (AOR [20.61]; 95% CI, 9.11-46.64; p less then 001). CONCLUSION Among patients in an urban ED, IPV likelihood and IPV severity increase with the number of reported risk factors. The best approach to identify IPV and avoid false negatives is, therefore, multi-risk assessment.INTRODUCTION Emergency department (ED) visits related to opioid use disorder (OUD) have increased nearly twofold over the last decade. Treatment with buprenorphine has been demonstrated to decrease opioid-related overdose deaths. In this study, we aimed to better understand ED clinicians' attitudes toward the initiation of buprenorphine treatment in the ED. METHODS We performed a mixed-methods study consisting of a survey of 174 ED clinicians (attending physicians, residents, and physician assistants) and semi-structured interviews with 17 attending emergency physicians at a tertiary-care academic hospital. RESULTS A total of 93 ED clinicians (53% of those contacted) completed the survey. While 80% of respondents agreed that buprenorphine should be administered in the ED for patients requesting treatment, only 44% felt that they were prepared to discuss medication for addiction treatment. Compared to clinicians with fewer than five years of practice, those with greater experience were less likely to approve of ED-initiated buprenorphine. In our qualitative analysis, physicians had differing perspectives on the role that the ED should play in treating OUD. Most physicians felt that a buprenorphine-based intervention in the ED would be feasible with institutional support, including training opportunities, protocol support within the electronic health record, counseling and support staff, and a robust referral system for outpatient follow-up. CONCLUSION ED clinicians' perception of buprenorphine varied by years of practice and training level. Most ED clinicians did not feel prepared to initiate buprenorphine in the ED. Qualitative interviews identified several addressable barriers to ED-initiated buprenorphine.