Study objective: To assess the feasibility of initiating treatment for alcohol use disorder with extended-release naltrexone and case management services in the emergency department (ED) and measure the intervention's impact on daily alcohol consumption and quality of life. Methods: This is a 12-week prospective open-label single-arm study of a multimodal treatment for alcohol use disorder consisting of monthly extended-release naltrexone injections and case management services initiated at an urban academic ED. Participants were actively drinking adult patients in ED with known or suspected alcohol use disorder and an AUDIT-C score more than 4. The main feasibility outcomes included the rates of participant enrollment, retention in the study, and continuing treatment after study completion. Efficacy outcomes were the change in daily alcohol consumption (drinks per day; 14 g ethanol per drink), measured by a 14-day timeline followback, and the change in quality of life measured with a single-item Kemp quality of life scale. Results: One hundred seventy-nine patients were approached, and 32 were enrolled (18%). Of the 32 enrolled patients, 25 (78%) completed all visits, and 22 (69%) continued naltrexone after the trial. The mean baseline daily alcohol consumption was 7.6 drinks per day (interquartile range, 4.5, 13.4), and the mean quality of life was 3.6 (SD 1.7) on a 7-point scale. The median daily alcohol consumption change was-7.5 drinks per day (Hodges-Lehmann 95% confidence interval-8.6,-5.9). The mean quality of life change was 1.2 points (95% confidence interval 0.5, 1.9; P <.01). Conclusion: We found that initiation of treatment of alcohol use disorder with extended-release naltrexone and case management is feasible in an ED setting and observed significant reductions in drinking with improved quality of life in the short term. Multicenter randomized controlled trials are needed to further validate these findings. [Ann Emerg Med. 2023;81:440-449.]

Background: Emergency department (ED) workers have an increased seroprevalence of SARS-CoV-2 antibodies. However, breakthrough infections in ED workers have led to a reduced workforce within a strained healthcare system. By measuring levels of IgG antibodies to the SARS-CoV-2 nucleocapsid and spike antigens in ED workers, we determined the incidence of infection and described the course of antibody levels. We also measured the an-tibody response to vaccination and examined factors associated with immunogenicity.Methods: We conducted a prospective cohort study of ED workers conducted at a single ED from September 2020-April 2021. IgG antibodies to the SARS-CoV-2 nucleocapsid antigen were measured at baseline, 3, and 6 months, and IgG antibodies to the SARS-CoV-2 spike antigen were measured at 6 months.Results: At baseline, we found 5 out of 139 (3.6%) participants with prior infection. At 6 months, 4 of the 5 had antibody results below the test manufacturer's positivity threshold. We identified one incident case of SARS-COV-2 infection out of 130 seronegative participants (0.8%, 95% CI 0.02-4.2%). In 131 vaccinated participants (125 BNT162b2, 6 mRNA-1273), 131 tested positive for anti-spike antibodies. We identified predictors of anti-spike an-tibody levels: time since vaccination, prior COVID-19 infection, age, and vaccine type. Each additional week since vaccination was associated with an 11.1% decrease in anti-spike antibody levels. (95% CI 6.2-15.8%).Conclusion: ED workers experienced a low incidence of SARS-CoV-2 infection and developed antibodies in response to vaccines and prior infection. Antibody levels decreased markedly with time since infection or vaccination.(c) 2022 Elsevier Inc. All rights reserved.

AIMS:The aims of this study were to (1) estimate the effect of extended-release naltrexone compared with placebo on alcohol consumption in patients with alcohol use disorder (AUD) and (2) conduct pre-planned subgroup analyses to test whether being abstinent when initiating treatment (lead-in abstinence) or the duration of treatment improves treatment efficacy. DESIGN:Systematic review and random-effects meta-analysis of blinded randomized placebo-controlled trials reporting the effect extended-release naltrexone on alcohol consumption. SETTING:Outpatient clinics. PARTICIPANTS:Seven trials evaluating a total of 1500 adults with AUD receiving monthly injections of either placebo or extended-release naltrexone at doses of 150-400 mg for 2-6 months and some form of behavioral therapy. MEASUREMENTS:Pooled weighted mean difference (WMD) in drinking days per month and heavy drinking days per month. FINDINGS:The WMD was -2.0 [95% confidence interval (CI) = -3.4, -0.6; P = 0.03] in favor of extended-release naltrexone for drinking days per month and -1.2 (95% CI = -0.2, -2.1; P = 0.02) for heavy drinking days per month, indicating that treatment resulted in two fewer drinking days per month and 1.2 fewer heavy drinking days per month compared with placebo. Trials not requiring lead-in abstinence and those lasting longer than 3 months reported larger reductions in heavy drinking days per month; WMD -2.0 (95% CI = -3.52, -0.48; P = 0.01) and -1.9 (95% CI = -3.2, -0.5; P = 0.01), respectively. In all cases, the I2 statistics (0-7.2%) did not suggest substantial heterogeneity. CONCLUSIONS:Extended-release naltrexone reduces drinking days and heavy drinking days per month compared with placebo. Reductions are larger with a longer duration of treatment.

Health care workers who frequently care for infected patients may be at higher risk of coronavirus disease 2019 (COVID-19) compared with the general population.1Xu X. Sun J. Nie S. et al.Seroprevalence of immunoglobulin M and G antibodies against SARS-CoV-2 in China.Nat Med. 2020; 26: 1193-1195Crossref PubMed Scopus (310) Google Scholar The emergency department (ED) represents a high-risk environment because the COVID-19 status of ED patients is frequently unknown, and ED providers must test for the disease and perform aerosol-generating procedures. A prior study of ED providers found severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibodies in 23 of 50 ED providers (46%) in New York City. We conducted this study to estimate the seroprevalence of SARS-CoV-2 antibodies in ED providers at an academic ED and review the clinical history of providers with evidence of prior infection. We conducted a prospective, cross-sectional study to estimate the seroprevalence of antibodies to SARS-CoV-2 among ED providers (attending physicians, nurses, midlevel practitioners, patient care technicians, and pharmacists) at an academic medical center from September 1 to October 15, 2020. Exclusion criteria were pregnancy or immunocompromise. Participants underwent venipuncture to measure SARS-CoV-2 immunoglobulin G (IgG) antibodies. Samples were tested with a chemiluminescent immunoassay for IgG antibodies to the nucleocapsid antigen (Abbott Architect SARS-CoV-2 IgG; Abbot Laboratories, Abbott Park, IL). Positive results were confirmed by testing with a different chemiluminescent immunoassay for IgG antibodies to the S1/S2 spike antigens (Diasorin Liaison SARS-CoV-2 S1/S2 IgG; Diasorin Inc., Cypress, CA). Both assays have excellent test characteristics. Of 360 ED patient care staff, 139 study participants were included: 90 women (64.7%) and 88 whites (63.3%), with a median age of 36 years (interquartile range 27 to 61). A total of 126 of 139 participants (90.6%) reported contact with COVID-19–positive patients, 10 of these (7.9%) without personal protective equipment. A total of 5 participants (3.6%) judged that they had a 76% to 100% likelihood for having antibodies. Four of the providers had antibodies to SARS-CoV-2, resulting in a seroprevalence of 4 of 139 (2.9%; exact 95% confidence interval 0.8% to 7.2%) (Table). Three of the 4 seropositive participants were emergency physicians who had a prior diagnosis of COVID-19 based on a prior positive polymerase chain reaction test result and judged that they had a 76% to 100% likelihood of seropositivity. One seropositive participant, an ED nurse, had not received a prior diagnosis of COVID-19. This individual traveled at the beginning of February and subsequently developed fever and cough for 14 days, before the widespread availability of polymerase chain reaction testing.TableCharacteristics of the study participants.CharacteristicNumberPercentageTotal N139Sex Women9064.7Race Asian3122.3 Black42.9 White8863.3 Other/multiple1611.5Ethnicity Latinx1510.8Age Mean (SD)38.29.5 Median (IQR)3627–61Site Adult hospital ED11280.6 Children's hospital ED2719.4Provider type ED nurse6446.0 Attending physician3122.3 Resident physician2316.5 Advanced practice provider75.0 Patient care technician96.5 Other53.6Prior diagnosis of COVID-19 based on PCR testing Yes42.9SARS-CoV-2 IgG test result Positive42.9IQR, Interquartile range; PCR, polymerase chain reaction. Open table in a new tab IQR, Interquartile range; PCR, polymerase chain reaction. A pediatric ED nurse reported traveling in February and subsequently experiencing symptoms of malaise, headache, loss of smell, and shortness of breath, leading to a positive polymerase chain reaction and positive antibody test result in May 2020; the nurse had a negative result in our study. Treating this individual as having had COVID-19 raises the prevalence of prior infection in our sample to 5 of 139=3.6% (exact 95% confidence interval 1.2% to 8.2%). It is likely that seroprevalence among frontline providers varies with the cumulative incidence of COVID-19 in the communities they serve. The prevalence of prior infection in our sample is lower than the seroprevalence in some studies of frontline and ED providers, such as Vanderbilt,2Stubblefield W.B. Talbot H.K. Feldstein L. et al.Seroprevalence of SARS-CoV-2 among frontline healthcare personnel during the first month of caring for COVID-19 patients: Nashville, Tennessee.Clin Infect Dis. 2020; (ciaa936)Crossref PubMed Scopus (65) Google Scholar Montefiore, and Coney Island Hospital,3Self W.H. Tenforde M.W. Stubblefield W.B. et al.Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network—13 academic medical centers, April–June 2020.MMWR Morb Mortal Wkly Rep. 2020; 69: 1221-1226Crossref PubMed Scopus (158) Google Scholar reporting respective seroprevalences of 8.2%, 31.2%, and 46%. San Francisco has had a low seroprevalence of antibodies, with an age- and sex-adjusted seroprevalence of 1.0%.4Havers F.P. Reed C. Lim T. et al.Seroprevalence of antibodies to SARS-CoV-2 in 10 sites in the United States, March 23–May 12, 2020.JAMA Intern Med. 2020; Crossref PubMed Scopus (447) Google Scholar We found a low SARS-CoV-2 seroprevalence among our ED providers, similar to other low community-seroprevalence EDs.

Introduction Phenobarbital has been successfully used in the emergency department (ED) to manage symptoms of alcohol withdrawal, but few studies have reported outcomes for ED patients who receive phenobarbital and are discharged. We compared return encounter rates in discharged ED patients with alcohol withdrawal who were treated with benzodiazepines and phenobarbital. Methods This is a retrospective cohort study conducted at a single academic medical center utilizing chart review of discharged ED patients with alcohol withdrawal from July 1, 2016, to June 30, 2019. Patients were stratified according to ED management with benzodiazepines, phenobarbital, or a combination of both agents. The primary outcome was return ED encounter within three days of the index ED encounter. Multivariate logistic regression identified significant covariates of an ED return encounter. Results Of 470 patients who were discharged with the diagnosis of alcohol withdrawal, 235 were treated with benzodiazepines, 133 with phenobarbital, and 102 with a combination of both. Baseline characteristics were similar among the groups. However, patients who received phenobarbital were provided significantly more lorazepam equivalents compared to patients who received benzodiazepines alone. Treatment with phenobarbital, alone or in combination with benzodiazepines, was associated with significantly lower odds of a return ED visit within three days compared with benzodiazepines alone [AOR 0.45 (95% CI 0.23, 0.88) p = 0.02 and AOR 0.33 (95% CI 0.15, 0.74) p = 0.007]. Conclusions Patients who received phenobarbital for alcohol withdrawal were less likely to return to the ED within three days of the index encounter. Despite similar baseline characteristics, patients who received phenobarbital, with or without benzodiazepines, were provided greater lorazepam equivalents the ED.

Methamphetamine intoxication is an increasing cause of emergency department (ED) visits in the United States, particularly in the west. In San Francisco, California, 47% of patients visiting psychiatric emergency services are intoxicated with methamphetamine. Such patients often visit the ED due to acute psychiatric symptoms, yet ED‐based research investigating the outcomes and resource utilization of these visits is limited.

STUDY OBJECTIVE:With increased use of chest computed tomography (CT) in trauma evaluation, traditional teachings in regard to rib fracture morbidity and mortality may no longer be accurate. We seek to determine rates of rib fracture observed on chest CT only; admission and mortality of patients with isolated rib fractures, rib fractures observed on CT only, and first or second rib fractures; and first or second rib fracture-associated great vessel injury.METHODS:We conducted a planned secondary analysis of 2 prospectively enrolled cohorts of the National Emergency X-Radiography Utilization Study chest studies, which evaluated patients with blunt trauma who were older than 14 years and received chest imaging in the emergency department. We defined rib fractures and other thoracic injuries according to CT reports and followed patients through their hospital course to determine outcomes.RESULTS:Of 8,661 patients who had both chest radiograph and chest CT, 2,071 (23.9%) had rib fractures, and rib fractures were observed on chest CT only in 1,368 cases (66.1%). Rib fracture patients had higher admission rates (88.7% versus 45.8%; mean difference 42.9%; 95% confidence interval [CI] 41.4% to 44.4%) and mortality (5.6% versus 2.7%; mean difference 2.9%; 95% CI 1.8% to 4.0%) than patients without rib fracture. The mortality of patients with rib fracture observed on chest CT only was not statistically significantly different from that of patients with fractures also observed on chest radiograph (4.8% versus 5.7%; mean difference -0.9%; 95% CI -3.1% to 1.1%). Patients with first or second rib fractures had significantly higher mortality (7.4% versus 4.1%; mean difference 3.3%; 95% CI 0.2% to 7.1%) and prevalence of concomitant great vessel injury (2.8% versus 0.6%; mean difference 2.2%; 95% CI 0.6% to 4.9%) than patients with fractures of ribs 3 to 12, and the odds ratio of great vessel injury with first or second rib fracture was 4.4 (95% CI 1.8 to 10.4).CONCLUSION:Under trauma imaging protocols that commonly incorporate chest CT, two thirds of rib fractures were observed on chest CT only. Patients with rib fractures had higher admission rates and mortality than those without rib fractures. First or second rib fractures were associated with significantly higher mortality and great vessel injury.

Dear Editor, The ProCESS study1 brings to mind the observation by Sir William Osler that (to paraphrase) one should use a new therapy as often as possible while it still works. I have used Swan Ganz catheters, aminophylline, bretyllium, MAST trousers, nasal intubation, ipecac and neonatal suction bulbs while they worked and abandoned them when they no longer …

Urban Tree Canopy (UTC) Prioritizations can be both a set of geographic analysis tools and a planning process for collaborative decision-making. In this paper, we describe how UTC Prioritizations can be used as a planning process to provide decision support to multiple government agencies, civic groups and private businesses to aid in reaching a canopy target. Linkages to broader City-scale sustainability plans are explored. This article represents an extension and update to the UTC Canopy Goal Setting Guide by Raciti et al (2006). We conclude with recommendations for a market-like analysis of neighborhoods to better match planting initiatives to particular neighborhoods’ motivations, capacities and interests in order to improve the adoption of improved urban forestry practices.

OBJECTIVE We sought to determine the incidence of acute myocardial infarction (AMI) in emergency department (ED) patients with syncope, the characteristics of these AMIs and how helpful the initial electrocardiogram (ECG) was in identifying these cases. METHODS In a prospective cohort of consecutive patients with syncope, the initial ECG was found to be abnormal using a prespecified definition (any nonsinus rhythm or any new or age- indeterminate abnormalities). Patients were then followed up to identify an AMI diagnosed within 30 days of presentation. RESULTS There were 1474 consecutive patient visits for syncope or near-syncope over a 45-month period spanning from Jul. 1, 2000, to Feb. 28, 2002, and Jul. 15, 2002, to Aug. 31, 2004, of which 46 (3.1%) were diagnosed with AMI. The majority of the AMI patients (42) had no ST segment elevation. The initial ECG was abnormal in 37 out of 46 cases. The diagnostic performance of the initial ECG was sensitivity 80% (95% confidence interval [CI] 67%-89%), specificity 64% (95% CI 61%-67%), negative predictive value 99% (95% CI 98%-100%), positive predictive value 7% (95% CI 6%-8%), positive likelihood ratio 2.2 (95% CI 1.6-2.5) and negative likelihood ratio 0.3 (95% CI 0.2-0.5). CONCLUSION The incidence of AMI in patients presenting with syncope is low. A normal ECG has a high negative predictive value, although its sensitivity is limited.

Hypertensive emergencies are uncommon and physiologically diverse. Consequently, it is difficult for most physicians to develop a familiarity with all the different hypertensive crises and with all drugs available for treating them (Table 4). Clinicians should not agonize over which is the perfect therapeutic agent for a particular emergency, but instead, they should focus on scrupulous monitoring and familiarize themselves with a few agents that will serve in most situations. Generally, these agents will be sodium nitroprusside and nitroglycerin. Vigilant neurologic monitoring is mandatory in all hypertensive emergencies. The early symptoms and signs of cerebral hypoperfusion can be vague and subtle, but if recognized, serious complications of therapy can be avoided. Remember, the patient may still be hypertensive. Avoid acute (during the first hour) reductions in MAP of more than 20% whenever possible; subsequent reductions should be gradual. In patients known to have markedly elevated ICP and who need acute reductions in their BP, serious consideration should be given to direct monitoring of the ICP so that CPP can be maintained within safe limits. In general, oral agents should not be used for the treatment of hypertensive emergencies. Intravenous Labetalol and intravenous nicardipine are not suitable for general use in hypertensive emergencies. In special situations (e.g., perioperative hypertension and subarachnoid hemorrhage), however, they may be employed. Their role may expand with further study. Trimethaphan may be superior to nitroprusside for hypertension complicated by elevated ICP or cerebral dysfunction. Realistically, most physicians will continue to use nitroprusside. Intense neurologic monitoring is more important than the specific agent used. Nitroglycerin is the agent of choice for acute ischemic heart disease complicated by severe hypertension; if it fails, use nitroprusside. For aortic dissection, the combination of nitroprusside and IV propranolol is the therapy of choice; beta-blockade must be achieved rapidly or the dissection may worsen. Trimethaphan is also an agent for first-line therapy. Esmolol is an alternative to IV propranolol for the treatment of aortic dissection, if prolonged beta-blockade might seriously jeopardize the patient. For eclampsia, unless an expert in hypertension during pregnancy has established an alternative, the therapy of choice is hydralazine and magnesium. The treatment of subarachnoid hemorrhage is in flux; calcium channel blockers are used to prevent spasm, not to lower BP. If the BP must be lowered immediately, use nitroprusside.

Routine releases of tritium to the atmosphere from the Savannah River Plant (SRP) have averaged 5.12 x 10/sup 5/ curies per year during the period 1974 to 1977. Patterns of tritium dispersion in the environment surrounding SRP indicate a power law relationship between air concentration and distance from the source. The relationship between the concentration of tritiated water in vegetation and distance is more complex. A model of the tritium dispersion and cycling in the environment explains the dispersion patterns in terms of the ratio of tritiated hydrogen to tritiated water, climate, and vegetation characteristics. The annual variation in the environmental patterns around the SRP is almost completely determined by the fraction of tritiated hydrogen in the release.