BACKGROUND:cute musculoskeletal pain in emergency department (ED) patients is challenging to treat with medications alone, but adding acupuncture may improve pain outcomes. METHODS:In this pragmatic randomized controlled trial, acupuncture was delivered by licensed acupuncturists in the ED and twice a week in follow-up clinic for 1 month. From February 10, 2020 to April 19, 2023, 2781 adult patients at an academic ED with acute (≤7 days) musculoskeletal pain in neck, back and/or extremities were screened, and 599 were enrolled and randomized to usual care only (n = 189, 31.6%) or acupuncture plus usual care (n = 410, 68.4%). RESULTS:Acupuncture and control arms had similar demographics (mean age 45.2, SD 15.8; 57.7% female) and baseline pain scores (control 7.1, SD 2.2; acupuncture 7.1, SD 2.3). At 1 month, pain scores were similar between arms (control 3.8, SD 3.2; acupuncture 3.2, SD 3.0). However, 178 (43.4%) participants in the acupuncture arm were unable to attend acupuncture clinic and reported time and financial constraints. Exploratory analysis of pain score by number of clinic sessions attended showed that patients attending 6 or more acupuncture sessions (n = 121, 20.2%) experienced significant pain improvements compared to those with fewer sessions (n = 478, 79.8%). CONCLUSION:Improving access and availability of acupuncture in outpatient settings may be needed for more effective pain management.

Older adults experience the highest burden of chronic pain and pain-related disability. Existing pathways-multimodal, stepped, and stratified prove useful pieces but do not fully account for the complexity of geriatric care. This article argues for principles to guide pathways: explaining and adopting the biopsychosocial framework, applying it with nuance, addressing expectations, structuring limited time, communicating effectively, coaching rather than commanding, focusing on movement and function, and using safe pain-modulatory interventions. Together, these principles anchor individualized, patient-centered, and function-focused pain care.

This cluster randomized clinical trial examines whether tailored messaging about updated COVID-19 vaccines and simple inquiry about vaccine acceptance during an emergency department visit increase patients' vaccine uptake within 30 days. QuestionDo tailored messaging interventions about updated COVID-19 vaccines and simple inquiry about vaccine acceptance increase vaccine uptake among emergency department (ED) patients within 30 days of the ED visit?FindingsIn this 3-arm, cluster randomized clinical trial of 852 participants across 6 EDs, neither a tailored messaging intervention nor inquiry about vaccine acceptance significantly increased 30-day vaccine uptake compared with usual care.MeaningThese findings suggest that tailored messaging and simple inquiry alone may be insufficient to increase updated COVID-19 vaccine uptake among ED patients. ImportancePatient uptake of updated COVID-19 vaccines is crucial for reducing severe outcomes, yet national uptake remains low.ObjectiveTo determine if tailored messaging or simple inquiry about vaccine acceptance increases 30-day uptake of updated COVID-19 vaccines among emergency department (ED) patients.Design, Setting, and ParticipantsThis 3-arm, cluster randomized clinical trial conducted from January 29 to June 18, 2024, enrolled adult ED patients who had not received a COVID-19 vaccine in the prior 6 months across 6 EDs in San Francisco, California; Philadelphia, Pennsylvania; Houston, Texas; and Durham, North Carolina.InterventionsIntervention M involved tailored messaging about updated COVID-19 vaccines and inquiry about vaccine acceptance. Intervention Q involved only inquiry about vaccine acceptance. Usual care (no messaging or vaccine acceptance questions) served as the control.Main Outcomes and MeasuresThe primary outcome was updated COVID-19 vaccine receipt within 30 days of the ED visit, assessed via electronic health record review and follow-up telephone calls. Secondary outcomes included vaccine acceptance and vaccination during the ED visit. Outcomes were also compared between study sites that had the updated COVID-19 vaccine available and those that did not.ResultsOf 852 participants (median age, 47 years [IQR, 33-63 years]; 464 [54.5%] women), 247 (29.0%) were in the intervention M group, 273 (32.0%) in the intervention Q group, and 332 (39.0%) in the control group. Vaccine uptake at 30 days was not significantly higher in either the intervention M group compared with control (14 participants [5.7%] vs 10 [3.0%]; absolute difference, 2.7 percentage points [pp] [95% CI, -0.8 to 6.3 pp]) or the intervention Q group compared with control (11 [4.0%] vs 10 [3.0%]; absolute difference, 1.0 pp [95% CI, -2.0 to 4.2 pp]). However, at sites where vaccines were available, the intervention M group had higher uptake compared with control (13 of 132 [9.8%] vs 5 of 150 [3.3%]; absolute difference, 6.5 pp [95% CI, 0.5-12.5 pp]).Conclusions and RelevanceIn this cluster randomized clinical trial of adult ED patients, tailored messaging and simple inquiry alone did not significantly increase 30-day updated COVID-19 vaccine uptake among patients. The slight increase in uptake among participants in the EDs that had access to the updated COVID-19 vaccines suggested that vaccine availability was an effect modifier, underscoring the importance of opportunity and convenience in vaccine delivery.Trial RegistrationClinicalTrials.gov Identifier: NCT06156215

Background The COVID-19 pandemic is a dynamic public health issue that requires up-to-date surveillance data to guide healthcare and public policy interventions. Objectives We sought to address gaps in COVID-19 surveillance data of underserved populations by assessing self-reported COVID-19 positivity rates in a national sample of patients in emergency departments (EDs). Methods We used data from two cross-sectional survey studies of adult patients presenting to 19 US EDs during two periods: Period 1 (December 2020 - March 2021) and Period 2 (December 2022 - December 2023). Results In Period 1(n= 2101), 333 (15.8%) reported having had a positive COVID-19 test. Positivity rates were significantly higher in Hispanic vs White (non-Hispanic) participants (21.7% vs 14.3%; difference 7.4%, 95% CI [3.2 - 11.8%]) and non-English vs English speakers (21.5% vs 14.5%; difference 7.0%, 95% CI [2.9 -11.5%]). In Period 2 (n= 3658), 1674 (45.8%) reported having had a positive COVID-19 test. Positivity rates were significantly higher in women vs men (50.3% vs 40.6%, difference 9.6%, 95% CI [6.4 -12.8%]); White (non-Hispanic) vs African American (non-Hispanic) participants (47.9% vs 39.1%; difference 8.8%, 95% CI [4.8 - 12.8%]); Hispanic vs White (non-Hispanic) participants (52.8% vs 47.9%; difference 4.9%, 95% CI [0.5 - 9.3%]); and non-English vs English speakers (49.3% vs 45.0%; difference 4.2%, 95% CI [0.05 - 8.4%]). Conclusions We found that Hispanics had higher rates of prior positive COVID-19 tests that persisted throughout the pandemic. In the later pandemic period, women had significantly higher rates of prior positive COVID-19 tests than men.

OBJECTIVE:Acupuncture is an evidence-based pain treatment in clinic settings, but its optimal delivery has not been established in emergency departments (EDs). As part of an adaptive pragmatic randomized controlled trial of ED acupuncture for acute musculoskeletal pain (NCT04290741), we embedded a qualitative evaluation of acupuncture treatment acceptability and suggestions for improvement from study participants receiving acupuncture in the ED. METHODS:Semi-structured interviews conducted remotely evaluated factors impacting patients' perspectives, willingness to participate in, and experiences with ED acupuncture. The codebook was iteratively developed, and recruitment and analysis continued until information saturation was reached. RESULTS:Twenty-eight participants receiving ED acupuncture between February 2020-March 2021 were interviewed, with median age 44 years, 46.4% female, and 61% having never previously received acupuncture. Overall, ED patients with acute musculoskeletal pain expressed interest in acupuncture and reported an overall positive experience. Most reported acupuncture met their expectations for pain improvement, and many reported additional improvements in stress, anxiety, and sleep quality. Participants with a positive experience were more likely to recommend acupuncture to others. Key positive aspects included open communication with compassionate and knowledgeable acupuncturists. Participants found the ED setting acceptable and convenient for receiving acupuncture. Furthermore, participants provided actionable feedback like addressing fear of needles to improve the ED acupuncture experience. CONCLUSIONS:In conclusion, ED patients with acute musculoskeletal pain were interested in and had positive experiences with acupuncture treatment for pain and found the ED setting acceptable and convenient. Participant feedback can be used to improve acupuncture treatment in the ED.

Importance:Patient uptake of updated COVID-19 vaccines is crucial for reducing severe outcomes, yet national uptake remains low. Objective:To determine if tailored messaging or simple inquiry about vaccine acceptance increases 30-day uptake of updated COVID-19 vaccines among emergency department (ED) patients. Design, Setting, and Participants:This 3-arm, cluster randomized clinical trial conducted from January 29 to June 18, 2024, enrolled adult ED patients who had not received a COVID-19 vaccine in the prior 6 months across 6 EDs in San Francisco, California; Philadelphia, Pennsylvania; Houston, Texas; and Durham, North Carolina. Interventions:Intervention M involved tailored messaging about updated COVID-19 vaccines and inquiry about vaccine acceptance. Intervention Q involved only inquiry about vaccine acceptance. Usual care (no messaging or vaccine acceptance questions) served as the control. Main Outcomes and Measures:The primary outcome was updated COVID-19 vaccine receipt within 30 days of the ED visit, assessed via electronic health record review and follow-up telephone calls. Secondary outcomes included vaccine acceptance and vaccination during the ED visit. Outcomes were also compared between study sites that had the updated COVID-19 vaccine available and those that did not. Results:Of 852 participants (median age, 47 years [IQR, 33-63 years]; 464 [54.5%] women), 247 (29.0%) were in the intervention M group, 273 (32.0%) in the intervention Q group, and 332 (39.0%) in the control group. Vaccine uptake at 30 days was not significantly higher in either the intervention M group compared with control (14 participants [5.7%] vs 10 [3.0%]; absolute difference, 2.7 percentage points [pp] [95% CI, -0.8 to 6.3 pp]) or the intervention Q group compared with control (11 [4.0%] vs 10 [3.0%]; absolute difference, 1.0 pp [95% CI, -2.0 to 4.2 pp]). However, at sites where vaccines were available, the intervention M group had higher uptake compared with control (13 of 132 [9.8%] vs 5 of 150 [3.3%]; absolute difference, 6.5 pp [95% CI, 0.5-12.5 pp]). Conclusions and Relevance:In this cluster randomized clinical trial of adult ED patients, tailored messaging and simple inquiry alone did not significantly increase 30-day updated COVID-19 vaccine uptake among patients. The slight increase in uptake among participants in the EDs that had access to the updated COVID-19 vaccines suggested that vaccine availability was an effect modifier, underscoring the importance of opportunity and convenience in vaccine delivery. Trial Registration:ClinicalTrials.gov Identifier: NCT06156215.

Background:Spine surgery is increasingly common in the United States, contributing substantially to spine-related health care costs. While many patients benefit, up to 25% experience chronic postsurgical pain, and the procedure is linked to high rates of opioid misuse. Key risk factors for persistent pain and opioid use include poorly controlled early postsurgical pain, high pain-sensitivity, and poor pain-coping. Clinical guidelines recommend multimodal treatment to address these risks, but such approaches are not well studied or widely implemented. Combining two safe and effective nonpharmacologic treatments, specifically mindfulness and acupuncture that target these factors, has the potential to improve postsurgical recovery and reduce the incidence of chronic pain and opioid use. Objective:This paper describes the study protocol for the Integrating Mindfulness and Acupuncture after Spine Surgery (I-MASS), which is a single-site, 2-arm randomized controlled trial that will assess the feasibility and acceptability of a novel multicomponent program integrating mindfulness delivered via a mobile app, acupuncture, and education for patients undergoing single-level spine surgery. Methods:A total of 50 participants will be randomized 1:1 to receive (1) mindfulness and acupuncture (ie, I-MASS program) plus enhanced education or (2) enhanced education alone. Mindfulness training will consist of a 4-week app-based program starting 1 week prior to surgery, and acupuncture will include up to 8 visits (1 visit prior to surgery and 7 after surgery) during the 13-week program. Enhanced education appropriate for each phase of recovery will be delivered through the mobile app. Primary outcomes are recruitment eligibility and enrollment rates, mindfulness module and acupuncture visit completion rates, questionnaire completion rates, and participant satisfaction. Secondary outcomes include physical function, fatigue, pain interference, depressive symptoms, anxiety, ability to participate in social roles and activities, sleep disturbance, fear avoidance beliefs, pain intensity, pain medication use, adverse events, hospital readmissions, and emergency department visits. Results:Trial enrollment began in August 2024. As of May 9, 2025, 35 participants have been enrolled. Data analysis has not yet been performed. Enrollment is expected to be completed in the fall of 2025. Conclusions:The I-MASS program addresses the need for mind and body treatments to improve recovery and reduce the risk of persistent pain and opioid use after spine surgery. This integrated model of care is designed to be user-friendly and scalable, enhancing its potential for implementation in real-world settings. A future pragmatic trial is planned to determine if the I-MASS program results in better outcomes compared to either treatment alone or usual care.

Current models of vaccination coverage screening and surveillance might miss underserved populations whose only health care access occurs in emergency departments (EDs). During April-December 2024, a survey of non-critically ill adult patients evaluated in 10 EDs in eight U.S. cities across five states was conducted to ascertain patients' vaccination knowledge, self-reported vaccination coverage, and willingness to receive vaccines in an ED. Among 4,326 patients approached by the research team, 3,285 (75.9%) agreed to participate. Non-Hispanic Black or African American (Black), non-Hispanic White, and Hispanic or Latino (Hispanic) persons each accounted for approximately 30% of participants; 17.9% spoke Spanish as their primary language; 7.8% had unstable or marginal housing; and 21.0% lacked a source of primary health care. Approximately one half (49.4%) had not heard of one or more CDC-recommended vaccines for their age group, and 85.9% had not received one or more of the recommended vaccines. Factors associated with not being up to date with recommended vaccinations included non-Hispanic Black race and ethnicity (adjusted odds ratio [aOR] = 1.93; 95% CI = 1.32-2.85), lack of primary health care (aOR = 2.91; 95% CI = 1.74-5.13), and lack of health insurance (aOR = 3.01; 95% CI = 1.27-8.82). Among 2,821 participants who were not up to date with recommended vaccines, 46.4% said that they would accept one or more missing vaccines if they could be provided during their ED visit, and 86.7% of these persons said they would accept all missing vaccines. The primary reasons for missed vaccine doses were that the participant was unaware of or had not been offered the vaccines. EDs could be explored as additional sites to offer vaccination screening, recommendations, counseling, and referrals to increase vaccination coverage among underserved populations.

Integrating point-of-care ultrasound (POCUS) into patient care requires a multifaceted culture change using a multi-pronged approach. A standardized implementation method is lacking for POCUS program sustainability. We developed a standardized training curriculum and clinical POCUS documentation, archival, and image review process at a single Veterans Affairs Emergency Department (ED). We hypothesized that co-designed development and implementation of the multifaceted POCUS intervention would maximize ED provider uptake and sustainability. Using Participatory Action Research (PAR) and adapted Experience-Based Co-design (EBCD) methods, stakeholders collaboratively co-designed our POCUS intervention to optimize implementation. Using the PRODUCES framework, 12 stakeholder participants (co-creators including study researchers, ultrasound faculty, ED leadership, and ED providers (POCUS end-users)) met in four monthly co-design meetings from July to October 2021 to brainstorm, discuss, refine, and finalize the POCUS intervention and implementation plan. Throughout the co-design process, stakeholders reviewed findings from prior meetings, reflected on successes and failures, and held open discussions on refining and finalizing the proposed POCUS educational and clinical program. By involving stakeholders as co-creators throughout the co-design process, we maximized end-user POCUS enthusiasm, program uptake, and sustained use. This simple, streamlined, and generalizable user-centered co-design method serves as a framework for future POCUS implementation and dissemination plans.

Introduction/Purpose:Point-of-care ultrasound (POCUS) is an important diagnostic bedside tool, yet a gap remains between Emergency Department (ED) POCUS programme implementation and achieving sustained POCUS use and retention. We performed an impact evaluation of a co-designed POCUS programme implementation intervention and assessed programme acceptability, effectiveness and feasibility. Methods:Our mixed-methods cohort study implemented a co-designed, multifaceted intervention using the consolidated framework for implementation research at a single Veterans Affairs ED (November 2021-October 2022) to enhance POCUS usability and sustainability, including provider education, image review and archival. Primary ED providers (20/25) participated in hands-on POCUS training sessions between February and May 2022. We assessed POCUS program acceptability, appropriateness, and feasibility via provider pre/post-course surveys, interviews, and health record data using a validated tool (AIM-IAM-FIM; assessing ED POCUS, radiology ultrasound orders, and ED metrics). Results:ED POCUS significantly increased (from 72 to 267 scans, p < 0.001) 6 months post-intervention, with no significant change in radiology ultrasounds ordered (from 355 to 361, p = 0.417) or ED length-of-stay (from 6.7 to 7.5 h, p = 0.0849). Cardiac, deep vein thrombosis (DVT), soft tissue, musculoskeletal, and biliary ED POCUS were most common; and radiology studies were DVT, biliary and scrotal ultrasound. The pre/post-intervention surveys showed provider comfort with performing and teaching diagnostic and procedural POCUS changed minimally. All respondents approved of POCUS use and education (acceptability), endorsed clinical tool applicability (appropriateness) and stated the course/training was doable (feasibility). Discussion/Conclusions:POCUS use increased post-program implementation. Future studies should evaluate program sustainability, incorporate methods to reduce radiology ultrasound and improve patient-centered outcomes.

BackgroundInfluenza vaccine uptake is low among underserved populations whose primary health care access occurs in emergency departments. We sought to determine whether implementation of two interventions would increase 30-day influenza vaccine uptake in unvaccinated patients in the emergency department.MethodsThis three-group, prospective, cluster-randomized controlled trial compared two interventions with a control group in noncritically ill, adult patients in the emergency department who were not vaccinated for influenza in the current vaccine season. The unit of randomization was individual calendar days. Participants received either Intervention M (an influenza vaccine messaging platform consisting of a video, one-page flyer, and scripted message, followed by a vaccine acceptance question and provider notification if participants indicated vaccine acceptance), Intervention Q (no messaging but the vaccine acceptance question and provider notification), or control (usual care/no intervention). The primary outcome was receipt of an influenza vaccine at 30 days ascertained by electronic health record review and telephone follow-up, comparing the Intervention M group with the control group. Secondary outcomes included comparisons of 30-day vaccine uptake in Intervention Q versus control and Intervention M versus Intervention Q.ResultsBetween October 2022 and February 2023, a total of 767 trial participants were enrolled at six emergency departments in five U.S. cities. Median age was 46 years; 353 (46%) participants were female, 274 (36%) were African American, and 158 (21%) were Latinx; 126 (16%) lacked health insurance, and 244 (32%) lacked primary care. The Intervention M, Intervention Q, and control groups had 30-day vaccine uptakes of 41%, 32%, and 15%, respectively (P<0.0001 for Intervention M vs. control). Comparing Intervention M versus Intervention Q, the adjusted difference in 30-day vaccine uptake was 8.7 percentage points (95% confidence interval, -0.1 to 17.6 percentage points).ConclusionsImplementation of influenza vaccine messaging platforms (video clips, printed materials, and verbal scripts) improved 30-day vaccine uptake among unvaccinated patients in the emergency department. (Funded by the National Institute of Allergy and Infectious Diseases; ClinicalTrials.gov number, NCT05836818.)

Consistent point-of-care ultrasound (POCUS) use and retention is difficult to achieve, with prior studies citing a lack of provider training, credentialed ultrasound users, and image review as contributing factors. We aimed to assess user feedback on a POCUS implementation intervention by identifying and characterizing the perceived barriers and facilitators at a single Veterans Affairs (VA) hospital using the consolidated framework for implementation research (CFIR). We implemented a co-designed multifaceted training intervention at a VA emergency department (ED) to enhance POCUS usability and sustainability from November 2021-October 2022. We performed semi-structured interviews with 13 attending physicians and 1 Advanced Practice Provider (average of 15 years of clinical practice) in August-October 2022. Interviews were audio-recorded, transcribed, and double-coded using inductive content analysis and mapped to the CFIR, using deductive coding strategies. Through inductive analysis, five major themes emerged: 1) POCUS workflow convenience and efficiency, 2) ED environment and resources, 3) perceptions of high clinical utility of POCUS, 4) perceptions of high educational utility of POCUS, and 5) peer influences, feedback, and teaching. Within these major themes, POCUS facilitator subthemes include: machine availability, use in resident teaching, use in ED procedures, hands-on group training, colleagues’ contagiousness and enthusiasm, and support from ultrasound faculty, ED, and hospital leadership. POCUS barrier subthemes were: time constraints, alternative radiology imaging availability, cumbersome steps for image acquisition and documentation/storage, and limited POCUS knowledge and skills comfort. Additional needs identified through CFIR mapping (archiving software, image review process, and faculty credentialing), require development locally to strengthen provider skills and reduce duplicated radiology studies. Our model is a reproducible clinical tool to evaluate barriers and facilitators to POCUS program implementation at any site. Future work should tailor POCUS education to individuals, use momentum from positive peer feedback including “ED clinical champions”, and integrate ED/hospital leadership support for program sustainability.

Study objective Most long coronavirus disease (long COVID) studies rely on traditional surveillance methods that miss underserved populations who use emergency departments (EDs) as their primary health care source. In medically underserved ED populations, we sought to determine (1) whether there are gaps in awareness and self-declared understanding about long COVID illness, and (2) the prevalence, impact on school/work attendance, and receipt of care for long COVID symptoms. Methods This study was a cross-sectional, convenience sample survey study of adult patients at 11 geographically representative US EDs from December 2022 to October 2023. Awareness and self-declared understanding about long COVID illness were measured. Prevalence, impact on school/work attendance, and receipt of care for long COVID symptoms were also assessed. Results Of 1,618 eligible patients, 1455 (89.9%) agreed to participate, including 33.4% African Americans and 30.9% Latino/a. Of the patients, 17.1% lacked primary care. In total, 33.2% had persistent COVID-19 symptoms lasting >1 month, and 20.3% had symptoms >3 months. Moreover, 49.8% with long COVID symptoms missed work/school because of symptoms; 30.3% of all participants and 33.5% of participants who had long COVID symptoms had prior awareness and self-declared understanding of long COVID. Characteristics associated with poor understanding of long COVID were African American race (adjusted odds ratio [aOR] 3.68, 95% confidence interval [CI] 2.66 to 5.09) and Latino/a ethnicity (aOR 3.16, 95% CI 2.15 to 4.64). Participants lacking primary care were less likely to have received long COVID care (24.6% versus 51.2%; difference 26.6%; 95% CI 13.7% to 36.9%). Conclusions Despite high prevalence and impact on school/work attendance of long COVID symptoms, most of this ED population had limited awareness and self-declared understanding of long COVID, and many had not received care. EDs should consider the development of protocols for diagnosis, education, and treatment of long COVID illness.

Author(s): Theophanous, Rebecca G.; Tupetz, Anna; Ragsdale, Luna; Krishnan, Padmaja; Vigue, Raelynn; Herman, Carson E.; White, Jaran; Peethumnongsin, Erica; Staton, Catherine A.; Gordee, Alexander; Kuchibhatla, Maragatha; Eucker, Stephanie

Musculoskeletal pain is one of the most common reasons for Emergency Department (ED) visits, yet pain reporting is limited to the 0-10 numeric rating scale, and its impact tends to be underestimated by healthcare providers. The Optimal Screening for Prediction of Referral and Outcome (OSPRO) Review of Symptoms (ROS) and Yellow Flag (YF) Assessment Tools identify somatic symptoms and psychological factors affecting pain-related outcomes previously validated in outpatient physical therapy populations. The purpose of this study was to assess the construct validity of the OSPRO instruments for measuring pain psychological factors in ED patients with musculoskeletal pain. Of 215 adult ED patients presenting with musculoskeletal neck, back, or extremity pain, 165 completed the OSPRO-ROS, OSPRO-YF, Functional Comorbidity Index (FCI) and Patient-Reported Outcomes Measurement Information System (PROMIS-29) and were included in this analysis. Spearman correlation coefficients were calculated between OSPRO-ROS or OSPRO-YF scores and each of the seven PROMIS-29 domains. Moderate associations were found between total OSPRO-ROS or total OSPRO-YF and several PROMIS-29 domains. Moreover, moderate subdomain-specific associations were identified, such as YF-negative coping with PROMIS fatigue (r = 0.43 [95% CI: 0.29, 0.55]) and impaired physical function (r = -0.40 [95% CI: -0.52, -0.25]), as well as YF-negative mood with PROMIS depression (r = 0.50 [95% CI: 0.37, 0.61]). These findings suggest the OSPRO assessments may improve physician understanding of ED patients’ pain experience and the biopsychosocial factors that may inform their treatment.

Introduction: Pain is a major driver of visits to the emergency department (ED). Clinicians must consider not only the efficacy of treatment options but also subsequent healthcare utilization and patient-centered outcomes such as side effects from prescribed medications. Our goal in this study was to determine whether there was an association between acute pain treatment regimen (opioids, intranasal non-steroidal anti-inflammatory drugs [NSAIDs], or both) and unscheduled healthcare visits following ED discharge. Methods: This study was a secondary analysis of the Acute Management of Pain from the Emergency Department (AMPED) prospective, observational cohort study. We used Cox proportional hazards analysis to assess the relationship between treatment regimen and time to first unscheduled healthcare visit. Repeated measures logistic regression analyses were used to determine the relationship between treatment regimen and any unscheduled visits, and to evaluate whether this relationship was mediated by pain severity and/or medication side effects. Results: Of 831 total enrolled participants, 141 (16.9%) experienced an unplanned healthcare visit within five days of ED discharge. A majority of these visits happened one day after the ED visit. Those who were treated with intranasal NSAIDs only were less likely to have an unscheduled healthcare visit compared to those who received opioids only, with an adjusted odds ratio (AOR) of 0.63. The higher odds of unscheduled healthcare visits with opioids were mediated by both the presence of side effects and higher pain levels, with AORs of 2.24 and 1.33, respectively. Conclusion: Opioid treatment for acute pain is associated with increased unscheduled healthcare visits compared to those treated with intranasal ketorolac. This difference can be explained by higher levels of ongoing pain and greater medication side effects.

STUDY OBJECTIVE:Acute musculoskeletal pain in emergency department (ED) patients is frequently severe and challenging to treat with medications alone. The purpose of this study was to determine the feasibility, acceptability, and effectiveness of adding ED acupuncture to treat acute episodes of musculoskeletal pain in the neck, back, and extremities. METHODS:In this pragmatic 2-stage adaptive open-label randomized clinical trial, Stage 1 identified whether auricular acupuncture (AA; based on the battlefield acupuncture protocol) or peripheral acupuncture (PA; needles in head, neck, and extremities only), when added to usual care was more feasible, acceptable, and efficacious in the ED. Stage 2 assessed effectiveness of the selected acupuncture intervention(s) on pain reduction compared to usual care only (UC). Licensed acupuncturists delivered AA and PA. They saw and evaluated but did not deliver acupuncture to the UC group as an attention control. All participants received UC from blinded ED providers. Primary outcome was 1-hour change in 11-point pain numeric rating scale. RESULTS:Stage 1 interim analysis found both acupuncture styles similar, so Stage 2 continued all 3 treatment arms. Among 236 participants randomized, demographics and baseline pain were comparable across groups. When compared to UC alone, reduction in pain was 1.6 (95% confidence interval [CI]: 0.7 to 2.6) points greater for AA+UC and 1.2 (95% CI: 0.3 to 2.1) points greater for PA+UC patients. Participants in both treatment arms reported high satisfaction with acupuncture. CONCLUSION:ED acupuncture is feasible and acceptable and can reduce acute musculoskeletal pain better than UC alone.

Background: Bivalent mRNA vaccines were recommended since September 2022. However, coverage with a recent vaccine dose has been limited, and there are few robust estimates of bivalent VE against symptomatic SARS-CoV-2 infection (COVID-19). We estimated VE of a bivalent mRNA vaccine dose against COVID-19 among eligible U.S. healthcare personnel who had previously received monovalent mRNA vaccine doses. Methods: We conducted a case-control study in 22 U.S. states, and enrolled healthcare personnel with COVID-19 (case-participants) or without COVID-19 (control-participants) during September 2022-May 2023. Participants were considered eligible for a bivalent mRNA dose if they had received 2-4 monovalent (ancestral-strain) mRNA vaccine doses, and were >= 67 days after the most recent vaccine dose. We estimated VE of a bivalent mRNA dose using conditional logistic regression, accounting for matching by region and four-week calendar period. We adjusted estimates for age group, sex, race and ethnicity, educational level, underlying health conditions,