bluuebunny/crossref_metadata_2025_split huggingface dataset:
“Rewarding and Challenging at the Same Time”: Emergency Medicine Residents' Experiences Caring for Patients Who Are Homeless
Authors: Doran Kelly M. , Curry Leslie A. , Vashi Anita A. , Platis Stephanie , Rowe Michael , Gang Maureen , Vaca Federico E. 
Published: July 2014

AbstractObjectivesThe objectives were to examine how emergency medicine (EM) residents learn to care for patients in the emergency department (ED) who are homeless and how providing care for patients who are homeless influences residents' education and professional development as emergency physicians.MethodsWe conducted in‐depth, one‐on‐one interviews with EM residents from two programs. A random sample of residents stratified by training year was selected from each site. Interviews were digitally recorded and professionally transcribed. A team of researchers with diverse content‐relevant expertise reviewed transcripts independently and applied codes to text segments using a grounded theory approach. The team met regularly to reconcile differences in code interpretations. Data collection and analysis occurred iteratively, and interviews continued until theoretical saturation was achieved.ResultsThree recurring themes emerged from 23 resident interviews. First, residents learn unique aspects of EM by caring for patients who are homeless. This learning encompasses both specific knowledge and skills (e.g., disease processes infrequently seen in other populations) and professional development as an emergency physician (e.g., the core value of service in EM). Second, residents learn how to care for patients who are homeless through experience and informal teaching rather than through a formal curriculum. Residents noted little formal curricular time dedicated to homelessness and instead learned during clinical shifts through personal experience and by observing more senior physicians. One unique method of learning was through stories of “misses,” in which patients who were homeless had bad outcomes. Third, caring for patients who are homeless affects residents emotionally in complex, multifaceted ways. Emotions were dominated by feelings of frustration. This frustration was often related to feelings of futility in truly helping homeless patients, particularly for patients who were frequent visitors to the ED and who had concomitant alcohol dependence.ConclusionsCaring for ED patients who are homeless is an important part of EM residency training. Our findings suggest the need for increased formal curricular time dedicated to the unique medical and social challenges inherent in treating patients who are homeless, as well as enhanced support and resources to improve the ability of residents to care for this vulnerable population. Future research is needed to determine if such interventions improve EM resident education and, ultimately, result in improved care for ED patients who are homeless.
Critical Drug Shortages: Implications for Emergency Medicine
Authors: Mazer‐Amirshahi Maryann , Pourmand Ali , Singer Steven , Pines Jesse M. , van den Anker John 
Published: July 2014

AbstractPrescription drug shortages have become increasingly common and more severe over the past decade. In addition, reported shortages are longer in duration and have had a greater effect on patient care. Some of the causes of current drug shortages are multifactorial, including the consolidation of drug manufacturers, quality problems at production plants that restrict the supply of drugs, and a lack of financial incentives for manufacturers to produce certain products, particularly generic medications. Generic injectable medications are most commonly affected by shortages because the production process is complex and costly for these drugs, and profit margins are often smaller than for branded medications. Many commonly used emergency department (ED) generic injectables have been affected by shortages, including multiple resuscitation and critical care drugs. Several reports have shown that shortages can potentially have major effects on the quality of medical care, including medication errors, treatment delays, adverse outcomes, and increased health care costs. Currently, no published data exist outside of case reports that directly link ED‐based drug shortages to overall patient safety events; however, there are several examples in the ED where first‐line therapies for life‐saving medications have been in short supply, and alternatives have higher rates of adverse events, narrower therapeutic indexes, or both. Aside from increasing notification about shortages, the U.S. Food and Drug Administration has little power to coerce manufacturers to produce medications during a shortage. Therefore, ED providers must learn to mitigate the effects of shortages locally, through active communication with pharmacy staff to identify safe and effective alternatives for commonly used medications when possible. Particularly given the effect on critical care medications, therapeutic alternatives should be clearly communicated to all staff so that providers have easy access to this information during resuscitations. This review focuses on the etiology of drug shortages, their effect on the ED, and potential solutions and mitigation strategies.
Assessment of Dyspnea Early in Acute Heart Failure: Patient Characteristics and Response Differences Between Likert and Visual Analog Scales
Authors: Pang Peter S. , Collins Sean P. , Sauser Kori , Andrei Adin‐Cristian , Storrow Alan B. , Hollander Judd E. , Tavares Miguel , Spinar Jindrich , Macarie Cezar , Raev Dimitar , Nowak Richard , Gheorghiade Mihai , Mebazaa Alexandre 
Published: July 2014

AbstractBackgroundDyspnea is the most common symptom in acute heart failure (AHF), yet how to best measure it has not been well defined. Prior studies demonstrate differences in dyspnea improvement across various measurement scales, yet these studies typically enroll patients well after the emergency department (ED) phase of management.ObjectivesThe aim of this study was to determine predictors of early dyspnea improvement for three different, commonly used dyspnea scales (i.e., five‐point absolute Likert scale, 10‐cm visual analog scale [VAS], or seven‐point relative Likert scale).MethodsThis was a post hoc analysis of URGENT Dyspnea, an observational study of 776 patients in 17 countries enrolled within 1 hour of first physician encounter. Inclusion criteria were broad to reflect real‐world clinical practice. Prior literature informed the a priori definition of clinically significant dyspnea improvement. Resampling‐based multivariable models were created to determine patient characteristics significantly associated with dyspnea improvement.ResultsOf the 524 AHF patients, approximately 40% of patients did not report substantial dyspnea improvement within the first 6 hours. Baseline characteristics were similar between those who did or did not improve, although there were differences in history of heart failure, coronary artery disease, and initial systolic blood pressure. For those who did improve, patient characteristics differed across all three scales, with the exception of baseline dyspnea severity for the VAS and five‐point Likert scale (c‐index ranged from 0.708 to 0.831 for each scale).ConclusionsPredictors of early dyspnea improvement differ from scale to scale, with the exception of baseline dyspnea. Attempts to use one scale to capture the entirety of the dyspnea symptom may be insufficient.
Delaying the American Board of Emergency Medicine Qualifying Examination Is Associated With Poorer Performance
Authors: Marco Catherine A. , Counselman Francis L. , Korte Robert C. , Purosky Robert G. , Whitley Cameron Thomas , Reisdorff Earl J. 
Published: July 2014

AbstractObjectivesThe initial step in certification by the American Board of Emergency Medicine (ABEM) requires passing a multiple‐choice‐question qualifying examination. The qualifying examination is typically taken in the first year after residency training. This study was undertaken to determine if a delay in taking the qualifying examination is associated with poorer performance. The authors also examined the relationship between in‐training examination scores and qualifying examination scores.MethodsThis was a pooled time‐series cross‐section study. Primary measurements were initial qualifying examination scores, the timing of the qualifying examination, and in‐training examination scores. The three groups, based on qualifying examination timing, were immediate, 1‐year delay, and ≥2‐year delay. In‐training examination scores were analyzed to determine the relationship between intrinsic ability, examination timing, and qualifying examination scores. For analysis, a generic pooled ordinary least‐squares dummy variable model with robust standard errors was used. A pre hoc level of significance was determined to be α < 0.01.ResultsThere were 16,353 qualifying examination test administrations between 2000 and 2012. In‐training examination scores were positively correlated with qualifying examination scores (p < 0.001). The group pass rates were 98.9% immediate, 95.6% 1‐year delay, and 86.6% ≥2‐year delay. After controlling for in‐training examination scores, delay taking the qualifying examination of 1 year was associated with a decrease in score of –0.6 (p = 0.003). A delay in taking the qualifying examination ≥2 years was associated with a decrease in score of –2.5 points (p < 0.001).ConclusionsAfter accounting for innate ability using in‐training examination scores, delay taking the qualifying examination was associated with poorer performance. This effect was more pronounced if the delay was ≥2 years.
Programmatic Assessment of Level 1 Milestones in Incoming Interns
Authors: Hauff Samantha R. , Hopson Laura R. , Losman Eve , Perry Marcia A. , Lypson Monica L. , Fischer Jonathan , Santen Sally A. 
Published: July 2014

AbstractObjectivesWith the Accreditation Council for Graduate Medical Education (ACGME) Next Accreditation System, emergency medicine (EM) residency programs will be required to report residents' progress through the EM milestones. The milestones include five progressively advancing skill levels, with Level 1 defining the skill set of a medical school graduate and Level 5, that of an attending physician. The ACGME stresses that multiple forms of assessment should be used to ensure capture of the multifaceted competencies. The objective of this study was to determine the feasibility and results of programmatic assessment of Level 1 milestones using multisource assessments for incoming EM interns in July.MethodsThe study population was interns starting in 2012 and 2013. Interns' Level 1 milestone assessment was done with four distinct methods: 1) the postgraduate orientation assessment (POA) by the Graduate Medical Education Office for all incoming interns (this multistation examination covers nine of the EM milestones and includes standardized patient cases, task completion, and computer‐based stations); 2) direct observation of patient encounters by core faculty using a milestones‐based clinical skills competency checklist; 3) the global monthly assessment at the end of the intern orientation month that was updated to reflect the EM milestones; and 4) faculty assessment during procedural labs. These occurred during the July orientation month that included the POA, clinical shifts, didactic sessions, and procedure labs.ResultsIn the POA, interns were competent in 48% to 93% of the milestones assessed. Overall, competency was 70% to 80%, with low scores noted in aseptic technique (patient care Milestone 13 [PC13]) and written and verbal hand‐off (interpersonal communications skills [ICS]2). In overall communication, 70% of interns demonstrated competency. In excess of 80% demonstrated competency in critical values interpretation (PC3), informed consent (PC9), pain assessment (PC11), and geriatric functional assessment (PC3). On direct observation, almost all Level 1 milestones were achieved (93% to 100%); however, only 78% of interns achieved competency in pharmacotherapy (PC5). On global monthly evaluations, all interns met Level 1 milestones.ConclusionsA multisource assessment of EM milestones is feasible and useful to determine Level 1 milestones achievement for incoming interns. A structured assessment program, used in conjunction with more traditional forms of evaluation such as global monthly evaluations and direct observation, is useful for identifying deficits in new trainees and may be able inform the creation of early intervention programs.
Prevalence of Nonmedical Problems Among Older Adults Presenting to the Emergency Department
Authors: Stevens Tarshona B. , Richmond Natalie L. , Pereira Gregory F. , Shenvi Christina L. , Platts‐Mills Timothy F. 
Published: July 2014

AbstractObjectivesHealth outcomes among older emergency department (ED) patients may be influenced by physical, economic, and psychological problems not routinely identified during the ED visit. The objective of this study was to characterize such problems among older adults presenting to the ED.MethodsThis was a prevalence study with enrollment during 4‐hour periods randomly selected between 9 a.m. and 9 p.m. on random days of the week over a period of 8 weeks at an academic ED in the southeast United States. Participants were noninstitutionalized, cognitively intact adults aged 65 years or older without life‐threatening illness or injury. Consenting patients were asked about the frequency of 10 prespecified problems during the past year.ResultsPatients (N = 138) were non‐Hispanic white (69%) and female (57%) and almost all had primary providers (95%) and health insurance (98%). Forty percent reported their overall health as fair (21%) or poor (19%). Hazardous drinking habits were reported by 10% of patients. The prevalence of problems occurring either “sometimes” or “often” in the past year were pain (60%), difficulty walking (47%), lack of money (32%), isolation and loneliness (14%), lack of transportation (12%), difficulty scheduling a doctor's appointment (4%), difficulty getting prescriptions filled (4%), and lack of dental care (6%). Nine patients (7%) reported experiencing physical or psychological abuse at some point in the past year. Females, minorities, and individuals living in urban areas reported higher rates of most problems.ConclusionsNonmedical problems are common among cognitively intact, independent living, non–critically ill older patients presenting to an ED in the southeast United States.
Diagnostic Yields, Charges, and Radiation Dose of Chest Imaging in Blunt Trauma Evaluations
Authors: Rodriguez Robert M. , Baumann Brigitte M. , Raja Ali S. , Langdorf Mark I. , Anglin Deirdre , Bradley Richard N. , Medak Anthony J. , Mower William R. , Hendey Gregory W. 
Published: July 2014

AbstractBackgroundChest radiography (CXR) is the most common imaging in adult blunt trauma patient evaluation. Knowledge of the yields, attendant costs, and radiation doses delivered may guide effective chest imaging utilization.ObjectivesThe objectives were to determine the diagnostic yields of blunt trauma chest imaging (CXR and chest computed tomography [CT]), to estimate charges and radiation exposure per injury identified, and to delineate assessment points in blunt trauma evaluation at which decision instruments for selective chest imaging would have the greatest effect.MethodsFrom December 2009 to January 2012, we enrolled patients older than 14 years who received CXR during blunt trauma evaluations at nine U.S. Level I trauma centers in this prospective, observational study. Thoracic injury seen on chest imaging and clinical significance of the injury were defined by a trauma expert panel. Yields of imaging were calculated, as well as mean charges and effective radiation dose (ERD) per injury.ResultsOf 9,905 enrolled patients, 55.4% had CXR alone, 42.0% had both CXR and CT, and 2.6% had CT alone. The yields for detecting thoracic injury were CXR 8.4% (95% confidence intervals [CIs]) = 7.8% to 8.9%), chest CT 28.8% (95% CI = 27.5% to 30.2%), and chest CT after normal CXR 15.0% (95% CI = 13.9% to 16.2%). The mean charges and ERD (millisievert [mSv]) per injury diagnosis of CXR, chest CT, and chest CT after normal CXR were $3,845 (0.24 mSv), $10,597 (30.9 mSv), and $20,347 (59.3 mSv), respectively. The mean charges and ERD per clinically major thoracic injury diagnosis on chest CT after normal CXR were $203,467 and 593 mSv.ConclusionsDespite greater diagnostic yield, chest CT entails substantially higher charges and radiation dose per injury diagnosed, especially when performed after a normal CXR. Selective chest imaging decision instruments should identify patients who require no chest imaging and patients who may benefit from chest CT after a normal CXR.
A systematic review and meta‐analysis of the i‐gel® vs laryngeal mask airway in adults
Authors: de Montblanc J. , Ruscio L. , Mazoit J. X. , Benhamou D. 
Published: July 2014

SummaryWe systematically reviewed 31 adult randomised clinical trials of the i‐gel® vs laryngeal mask airway. The mean (95% CI) leak pressure difference and relative risk (95% CI) of insertion on the first attempt were similar: 0.40 (−1.23 to 2.02) cmH2O and 0.98 (0.95–1.01), respectively. The mean (95% CI) insertion time and the relative risk (95% CI) of sore throat were less with the i‐gel: by 1.46 (0.33–2.60) s, p = 0.01, and 0.59 (0.38–0.90), p = 0.02, respectively. The relative risk of poor fibreoptic view through the i‐gel was 0.29 (0.16–0.54), p < 0.0001. All outcomes displayed substantial heterogeneity, I2 ≥ 75%. Subgroup analyses did not decrease heterogeneity, but suggested that insertion of the i‐gel was faster than for first‐generation laryngeal mask airways and that the i‐gel leak pressure was higher than first generation, but lower than second‐generation, laryngeal mask airways. A less frequent sore throat was the main clinical advantage of the i‐gel.
Risk factors of symptomatic NSAID‐induced small intestinal injury and diaphragm disease
Authors: Ishihara M. , Ohmiya N. , Nakamura M. , Funasaka K. , Miyahara R. , Ohno E. , Kawashima H. , Itoh A. , Hirooka Y. , Watanabe O. , Ando T. , Goto H. 
Published: July 2014

SummaryBackgroundThe aetiology for nonsteroidal anti‐inflammatory drug (NSAID)‐induced small intestinal injuries has not been well characterised.AimTo determine the risk factors of symptomatic NSAID‐induced small intestinal injuries, including diaphragm disease.MethodsOf the 1262 symptomatic patients who underwent videocapsule endoscopy and/or double‐balloon enteroscopy, 156 consecutive patients were verified as having taken NSAIDs. Their CYP2C9*2, *3 and *13 single nucleotide polymorphisms (SNPs) were determined by allelic discrimination with Taqman 5’‐nuclease assays.ResultsOf the 156 NSAIDs users, 31 patients (20%) were diagnosed with NSAID‐induced small intestinal injury. Multivariate analysis indicated that the presence of comorbidities and the use of oxicams (meloxicam, ampiroxicam and lornoxicam) or diclofenac were associated with an increased risk of NSAID‐induced small intestinal injury (adjusted OR: 2.97, 95% CI: 1.05–8.41, P = 0.041 and adjusted OR: 7.05, 95% CI: 2.04–24.40, P = 0.002, respectively). The combination of aspirin and non‐aspirin NSAID was more damaging than aspirin alone. Age, sex, concomitant use of proton pump inhibitors, indications for NSAIDs use, duration of NSAIDs use and CYP2C9*2, *3 and *13SNPs were unrelated. The use of meloxicam and CYP2C9*3SNPs were significantly associated with an increased risk for diaphragm disease (adjusted OR: 183.75, 95% CI: 21.34–1582.38; P < 0.0001 and adjusted OR: 12.94, 95% CI: 1.55–108.36, P = 0.018, respectively).ConclusionThe use of specific NSAIDs and the factors interfering with NSAIDs metabolism might associate with small intestinal injury, especially with diaphragm disease.
Systematic review: the association between eosinophilic oesophagitis and coeliac disease
Authors: Lucendo A. J. , Arias Á. , Tenias J. M. 
Published: July 2014

SummaryBackgroundThe relationship between eosinophilic oesophagitis (EoE) and coeliac disease (CD) remains controversial, with studies yielding varied results.AimTo systematically review the evidence of a possible association between both diseases.MethodsElectronic searches were performed with keywords relating to EoE and CD in the MEDLINE, EMBASE and SCOPUS databases. Summary estimates were calculated. A random‐effects model was used depending on heterogeneity (I2). Publication bias was assessed with the aid of funnel plot analysis, along with the Begg–Mazumdar, Harbord and Egger tests.ResultsThe search yielded 197 references; 30 were included in the quantitative summary, with most of these presenting methodological inconsistencies. Significant publication bias in favour of short studies reporting positive associations between both diseases was documented. The prevalence of EoE in CD ranged from 0% to 10.7% (I2 = 78.9%). Prevalence of CD in EoE varied between 0.16% and 57.1% (I2 = 89%). One high‐quality, prospective, randomly selected, population‐based study documented a 1.1% prevalence of CD, with no patients presenting EoE. Clinical and methodological heterogeneity hindered the performance of quantitative summaries for prevalence data. A gluten‐free diet was effective in achieving histological remission of EoE in 32.1% of coeliac patients (95% confidence interval, 14.9–52.2%; I2 = 52.2%), which was similar to that expected for wheat elimination in EoE patients.ConclusionsWhile a lack of valid studies prevents us from completely ruling out a true association between EoE and CD, currently available evidence does not support this hypothesis. Indeed, the only epidemiological study with sufficient validity points to the independence of both diseases.
Emotion regulation strategies in preschool children
Authors: Sala Maria Nives , Pons Francisco , Molina Paola 
Published: July 2014

This study investigated the development of emotion regulation strategies as reflected in the narratives of children between the ages of 3 and 6 years. An experimental procedure based on story completion tasks was devised to elicit the emotion‐related narratives of 69 preschool children. Coding of the narratives led to the observation of different emotion regulation strategies: Behavioural strategies, social support, and cognitive reappraisal. Several significant gender and age differences were identified in the use of these strategies. In addition, verbal skills, non‐verbal intelligence, and emotion comprehension were found to be associated with use of the observed emotion regulation strategies, although only at specific ages.