Comparing the Safety and Efficacy of a Rapid High-Sensitivity Cardiac Troponin I Protocol Between Hospital-Based and Free-Standing Emergency Departments

Study Objectives: Current high sensitivity cardiac troponin I (hs-cTnI) research has been conducted almost exclusively in hospital-based emergency department (HBED) settings and the translation of these protocols into free-standing emergency departments (FSED) has yet to be explored. This study compared the safety and efficacy of applying a rapid-rule out protocol using hs-cTnI for exclusion of acute myocardial infarction (AMI) in HBEDs and FSEDs. Methods: This was a secondary analysis of a randomized trial of patients evaluated for possible AMI in 9 emergency departments (ED) from July 2020 through March 2021. The trial arms included a new 0/1-hour rapid protocol using hs-cTnI versus standard care, which used a 0/3-hour protocol without reporting hs-cTnI values below the 99th percentile. The primary outcome was safe ED discharge, defined as discharge with no death or AMI within 30-days. Analysis included a mixed-effect model adjusting for demographic variables. Results: There was a statistically significant difference in safe discharges from FSEDs when comparing the standard care arm (86.2%) to the rapid rule-out protocol (95.1%). There was a statistically significant reduction in FSED length of stay with application of a rapid rule-out protocol at 3.43 hours vs. 3.97 hours using standard care. The percentage of patients who ruled-out with their initial hs-cTnI (\u3c4 ng/L) at FSEDs (74%) was also significantly larger when compared to HBEDs (54%). Conclusion: Implementation of a hs-cTnI rapid 0/1-hour protocol to evaluate for AMI in FSEDs is feasible and had greater impact on safe ED discharge and length of stay compared to HBEDs

Prehospital Tibial Intraosseous Drug Administration is Associated with Reduced Survival Following Out of Hospital Cardiac Arrest: A study for the CARES Surveillance Group

BACKGROUND: Recent reports have questioned the efficacy of intraosseous (IO) drug administration for out-of-hospital cardiac arrest (OHCA) resuscitation. Our aim was to determine whether prehospital administration of resuscitative medications via the IO route was associated with lower rates of return of spontaneous circulation (ROSC) and survival to hospital discharge than peripheral intravenous (IV) infusion in the setting of OHCA. METHODS: We obtained data on all OHCA patients receiving prehospital IV or IO drug administration from the three most populous counties in Michigan over three years. Data was from the Michigan Cardiac Arrest Registry to Enhance Survival (CARES) database. The association between route of drug administration and outcomes was tested using a matched propensity score analysis. RESULTS: From a total of 10,626 OHCA patients, 6869 received parenteral drugs during their prehospital resuscitation (37.8% by IO) and were included in analysis. Unadjusted outcomes were lower in patients with IO vs. IV access: 18.3% vs. 23.8% for ROSC (p \u3c 0.001), 3.2% vs. 7.6% for survival to hospital discharge (p \u3c 0.001), and 2.0% vs. 5.8% for favorable neurological function (p \u3c 0.001). After adjustment, IO route remained associated with lower odds of sustained ROSC (OR 0.72, 95% CI 0.63-0.81, p \u3c 0.001), hospital survival (OR 0.48, 95% CI 0.37-0.62, p \u3c 0.001), and favorable neurological outcomes (OR 0.42, 95% CI 0.30-0.57, p \u3c 0.001). CONCLUSION: In this cohort of OHCA patients, the use of prehospital IO drug administration was associated with unfavorable clinical outcomes

Molecular Diagnosis of Primary Mediastinal B Cell Lymphoma Identifies a Clinically Favorable Subgroup of Diffuse Large B Cell Lymphoma Related to Hodgkin Lymphoma

Using current diagnostic criteria, primary mediastinal B cell lymphoma (PMBL) cannot be distinguished from other types of diffuse large B cell lymphoma (DLBCL) reliably. We used gene expression profiling to develop a more precise molecular diagnosis of PMBL. PMBL patients were considerably younger than other DLBCL patients, and their lymphomas frequently involved other thoracic structures but not extrathoracic sites typical of other DLBCLs. PMBL patients had a relatively favorable clinical outcome, with a 5-yr survival rate of 64% compared with 46% for other DLBCL patients. Gene expression profiling strongly supported a relationship between PMBL and Hodgkin lymphoma: over one third of the genes that were more highly expressed in PMBL than in other DLBCLs were also characteristically expressed in Hodgkin lymphoma cells. PDL2, which encodes a regulator of T cell activation, was the gene that best discriminated PMBL from other DLBCLs and was also highly expressed in Hodgkin lymphoma cells. The genomic loci for PDL2 and several neighboring genes were amplified in over half of the PMBLs and in Hodgkin lymphoma cell lines. The molecular diagnosis of PMBL should significantly aid in the development of therapies tailored to this clinically and pathogenetically distinctive subgroup of DLBCL

ALCOHOL USE AMONG TRAUMA VICTIMS ADMITTED TO A LEVEL I TRAUMA CENTER IN ISRAEL.

מטרה: לקבוע את שיעור מקרי הטראומה שנגרמו כתוצאה משימוש באלכוהול ולבחון את מאפייניהם. שיטה: ניתוח נתונים על 854 מטופלים מתוך 5,529 מטופלים שהופיעו ברישום הטראומה הישראלי בשנים 2001-.2003 מן הממצאים: אצל 170 מהפונים נמצאה רמה גבוהה של אלכוהול בדם. בקרב אלה היה שיעור תאונות הדרכים גבוה מזה שבקרב הנפגעים ללא האלכוהול (35% לעומת 24%) וכך גם לגבי דקירות (29% לעומת 7%). חומרת הפגיעות בקרב קבוצת ה"אלכוהול" הייתה רבה יותר ושיעורי הלא-יהודים, הצעירים, והגברים בקבוצה זו היו גבוהים מהשיעורים אצל שאר הנבדקים. רוב הפגיעות המיוחסות לאלכוהול התרחשו בסופי שבוע ובשעות הערב-לילה

Evaluating electronic medical record based screening protocol on hepatitis c screening and linkage to care

Background and Objectives: The Emergency Department (ED) is potentially a high-yield site in health care to reach patients at risk for the hepatitis C virus (HCV) infection, the most common chronic bloodborne pathogen in the United States. Of the 71 million HCV-infected individuals globally in 2017, only an estimated 19% were aware of their positive HCV status. If EDs can identify the infected patients, this is a step toward reducing new hepatitis infections and death due to HCV, goals set by the World Health Organization to be reached by 2030. The primary aim of this project is to determine the effectiveness of upgrading the laboratory infrastructure to enable routine HCV ribonucleic acid (RNA) reflex testing and determine its effect on linking patients to care. Methods: An automated HCV screening protocol was implemented into the EPIC electronic medical record (EMR). The system screens patients born from 1945 through 1965 and/or those with a history of intravenous drug use, two identified risk factors for HCV set by the Center for Disease Control and Prevention. A best practice advisory (BPA) notifies providers to order an HCV antibody (Ab) test for patients with an ordered complete blood count with at least one risk factor. Positive HCV Ab test triggers a second BPA, prompting a HCV RNA test. In January 2019, HCV RNA reflex testing began where the RNA test would be automatically ordered after a positive Ab result. Linkage to care team followed up with patients until they attended their first visit with a qualified provider. The data analysis is inclusive of data obtained between August 2018 and November 2019. Results: HCV Ab tests were performed on 9,704 patients. Prior to RNA reflex implementation, out of the 445 patients who tested positive for HCV Ab, 220 had HCV RNA test performed (49.4%). After the revised protocol, out of 671 patients who tested positive for HCV Ab, 601 had RNA test performed (90%). Before RNA reflex testing was initiated, 66 patients were linked to care versus 126 patients were linked to care after the implementation, an increase of 66%. Conclusion: A significantly higher percentage of patients with positive HCV Ab testing had HCV RNA tests completed after the implementation of routine HCV RNA reflex testing. Connection to care rates also increased. Overall, the utilization of BPA capability of an EMR system may be an invaluable tool in efforts to reduce the prevalence of HCV

Intraosseous drug administration is associated with lower survival in out-of-hospital cardiac arrest

Background: Recent data has questioned the efficacy of intraosseous (IO) route of drug administration in out-of-hospital cardiac arrest (OHCA) resuscitation. Our primary aim was to test if pre-hospital IO versus intravenous (IV) drug administration was associated with lower rates of return of spontaneous circulation (ROSC) and survival to hospital discharge in OHCA. Methods: Using data from the Michigan Cardiac Arrest Registry to Enhance Survival (CARES) database, we analyzed all OHCA in the 3 most populous counties of Michigan over 2 years (population 3.8 million). We excluded patients that did not receive any IV/IO access or parenteral drugs in their resuscitation. Pre-hospital protocols designated tibial IO placement. We tested the association between route of drug administration and rates of ROSC and survival using a multivariate logistic regression model adjusting for age, gender, initial rhythm, bystander CPR, witnessed status, endotracheal intubation, time to EMS response, and location of arrest. We also performed sensitivity analyses limiting the cohort to non-nursing home OHCA. Results: Of 10,626 OHCA patients, we analyzed 6,869 that received parenteral drugs during resuscitation (37.8% by IO and 62.2% by IV route). Patients with IO drug administration were more often female, had bystander CPR, had a non-shockable rhythm, had an unwitnessed arrest, and were in a nursing home. There was no difference in time to EMS response between patients with IO vs. IV drug administration. Unadjusted outcomes were lower in patients with IO vs. IV access: 18.3% vs. 23.8% for ROSC (p\u3c0.001), 3.2% vs. 7.6% for survival to hospital discharge (p\u3c0.001), and 2.0% vs. 5.8% for favorable neurological function (p\u3c0.001). After adjustment, IO route remained associated with lower rates of sustained ROSC (OR 0.72, 95% CI 0.63 - 0.81, p\u3c0.001), hospital survival (OR 0.48, 95% CI 0.37 - 0.62, p\u3c0.001), and favorable neurological function (OR 0.42, 95% CI 0.30 - 0.57, p\u3c0.001). Sensitivity analyses had identical findings. Conclusion: In this cohort of OHCA with a large proportion of IO placement, the IO route of drug administration was associated with half the odds of survival after adjusting for major pre-hospital covariates

49 Comparing the Safety and Efficacy of a Rapid High-Sensitivity Cardiac Troponin I Protocol Between Hospital-Based and Free-Standing Emergency Department

Study Objectives: Significant variability exists in patient population and diagnostic capabilities of large academic tertiary, community-based hospital, and free-standing emergency departments (ED). Current high sensitivity cardiac troponin I (hs-cTnI) research has been conducted almost exclusively in hospital-based ED (HBED) settings and the translation of these protocols into the free-standing EDs (FSED) has yet to be explored. This study compared the safety, efficacy, and ED throughput of applying a 0/1-hour, rapid-rule out protocol using hs-cTnI for exclusion of acute myocardial infarction (AMI) in HBEDs and FSEDs. Methods: This was a pre-planned, secondary analysis of a stepped wedge cluster randomized trial of patients evaluated for possible AMI in 9 EDs in an integrated health system from July 2020 through March of 2021. Five of the EDs were HBEDs and four were FSEDs. The trial arms included a new 0/1-hour rapid protocol using hs-cTnI versus standard care, which used a 0/3-hour protocol without reporting hs-cTnI values below the 99th percentile. All adult ED patients were eligible if the treating clinician ordered an ECG and cardiac troponin. We excluded patients with STEMI, a hs-cTnI \u3e18 ng/L in the ED, or a traumatic cause of symptoms. The primary outcome was safe ED discharge, defined as discharge with no death or AMI within 30-days. Analysis included a mixed effect model adjusting for ED site, time, sex, age, and race. We report adjusted odds ratios (aOR). Results: The trial included 32,609 patients, of whom 26,957 were seen in HBEDs and 5,652 were seen in FSEDs. Safe discharge from HBED occurred 53% (5947/11,062) of the time in the standard care arm and 50.4% (8,005/15894) under the rapid rule-out protocol (aOR 1.04, 95% CI 0.94 – 1.15, p = 0.5). Safe discharge from a FSED occurred 86.2% (2106/2443) of the time in the standard care arm and increased to 95.1% (3052/3209) under the rapid protocol (aOr 1.48, 95% CI 1.03 – 2.13, p=.033). Initiation of a rapid rule-out protocol had no significant impact on overall ED length of stay (aOR 1.00, 95% CI 0.98-1.03, p = 0.8). There was a statistically significant reduction in FSED length of stay with application of a rapid rule-out protocol (3.43 hours (2.55, 4.58) vs. 3.97 hours (2.88, 4.77) using standard care, aOR 0.91, 95% CI 0.87- 0.95, p \u3c0.001). The percentage of patients who rule-out with their initial hs-cTnI (\u3c4 ng/L) at FSEDs (74%) was significantly larger when compared to hospital based EDs (54%), p\u3c.001. Safe discharge data for all 9 ED sites is detailed in table 1. Conclusion: Implementation of a hs-cTnI rapid 0/1-hour protocol to evaluate for AMI in FSEDs is feasible and had greater impact on safe ED discharge and length of stay compared to HBEDs

Operative dentistry - historical

Pape, Bud, "Class III Composite Restoration": The procedure for a composite restoration including cavity prep.,final caries removal, refinement and retention, pulpal protection,manip. and placement of composite mat. (31:53) Orig. air date: AUG 7 73Charbeneau, Gerald T., "Zinc Oxide Eugenol Base (B & T)": Mixing of B & T"" zinc oxide-eugenol cement for a cement"" based control during Complete Denture impressions. (5:40) Orig. air date: JAN 12 72Chasteen, Joseph, "Preparation of Cavity Liners": This presentation discusses the liners Copalite and Dycal, also shows the necessary techniques for each of their uses. (4:23) Orig. air date: DEC 17 75Comstock, Frank, "Introduction to Hand and Rotary Cutting Instruments": (16:39) Orig. air date: JAN 1 74Comstock, Frank, "Instrument Sharpening (Hand Cutting)": Demonstrates the technique for sharpening hand cutting instruments in Operative Dentistry. (14:26) Orig. air date: SEP 6 73Pape, Bud; Kahler, William, "Pulp Protection": Demonstrates pulpal protection of class II depth amalgam cavity. For proper pulpal protection a zinc oxide base and zinc phosphate base will be placed. (7:23) Orig. air date: AUG 4 72Pape, Bud, "Syringe Preparation and Handling": Demonstrates the correct method of loading a glass syringe, and the proper steps in giving the patient a painlessinjection. (9:49) Orig. air date: AUG 29 74Kahler, Frederick W., "Class II Slice Technique": Demonstrates the lightning disc on a class II slice preparation. (23:26) Orig. air date: OCT 26 73Dennison, Joseph; Kahler, Lloyd, "Class IV Composite - Acid Etch": A complete class IV composite restoration with demonstra- tion of acid etching. (26:13) Orig. air date: NOV 27 74Charbeneau, Gerald T., "Class I Buccal Pit Cohesive Gold Foil": Demonstration of the preparation and filling of a Class I buccal pit in a mandibular molar. Fibrous gold foil is used to restore this cavity. (23:32) Orig. air date: SEP 12 75Charbeneau, Gerald T., "Class III Cohesive Alloyed Gold Filling": Demonstrates the preparation and filling of a Class III cavity on a maxillary anterior tooth. Preparation is from the lingual and alloyed gold is the restorative material. (26:55) Orig. air date: SEP 15 75Charbeneau, Gerald T., "Intermediary Base - Calcium Hydroxide and Zinc Oxide Eugenol": The technique for mixing Dycal and Cavitec and discussion of their use are demonstrated. (4:08) Orig. air date: JAN 9 74Carter, Loretta, "Isolation Methods Used in Operative Dentistry": Use of the Erickson Vac-Ejector, suedapter and cotton roll holders. These methods used duringprocedureswith difficult access and when the operator is working alone. (21:44) Orig. air date: MAR 4 74Schield, Harvey, "Class V Amalgam:Cavity liner and cement base": Second part of the procedure, applying the cavity liner and cement base. (4:05) Orig. air date: MAR 8 74Cartwright, [], "Dental Anatomy and Restorative Dentistry": This tape focuses primarily on the Operative Department's view of Dental Anatomy. Cavity classification, aspects of crown and bridge and pulpal relationships discussed. (15:00) Orig. air date: MAY 15 74Olsen, Steven, "Fabricating Long Shaft Latch Burs": Shows one method of changing a straight hand piece bur into a long shaft latch bur. (9:17) Orig. air date: AUG 26 76Coopersmith, Joanne, "Amalgam Polishing": Presented in conjunction with a dental materials course to second year dental hygiene students. Shows proper armementarium and procedure for amalgam polishing. (36:00) Orig. air date: MAY 5 72Yaman, Peter, "Amalgam Preparation": Demonstrates the dispensing and mixing of amalgam in disposable and reusable capsules. (5:02) Orig. air date: JAN 9 76Kahler, Frederick W.; Urquiola, Nancy; Klausner, Leopold, "Application of Basic Instrumentation in Cavity Preparation": This tape shows how to effectively use the different rotary burrs on a cavity preparation. (8:28) Orig. air date: DEC 4 87Schield, Harvey, "Class V Amalgam Restoration: Cervical Matrix Application": A special case of the class V amalgam restoration using matrix material to aid in the condensation of the amalgam material due to cavity prep that extends to the cervical. (15:40) Orig. air date: MAR 8 74Pape, Bud, "Class I Amalgam Restoration": A demonstration of a complete Class I amalgam restoration from cavity preparation through finishing and polishing. (25:26) Orig. air date: AUG 30 73Schield, Harvey, "Class V Amalgam: Introduction, Cavity Prep and Retention": Shows the armamentarium and procedure to prepare the cavity and cut retention in the preparation. Done on visidont with rubber dam in place. (22:33) Orig. air date: MAR 8 74Schield, Harvey, "Class V Amalgam: Introduction, Cavity Prep and Retention": Shows the armamentarium and procedure to prepare the cavity and cut retention in the preparation. Done on visidont with rubber dam in place. (22:33) Orig. air date: MAR 8 74Schield, Harvey, "Class V Amalgam Restoration: Condensation and Carving": Third part of the procedure, amalgam condensation and carving. (8:39) Orig. air date: MAR 8 74Silvey, Ralph, "Trimming Dies, Duraly Cop., Occ.Reg.,Mounting the Case": FOUR PARTS, TRIMMING THE DIES, DURALAY COPINGS, OCCLUSAL REGISTRATION, MOUNTING ON ARTICULATOR Orig. air date: AUG 26 87http://deepblue.lib.umich.edu/bitstream/2027.42/64973/2/105-2.movhttp://deepblue.lib.umich.edu/bitstream/2027.42/64973/3/105-3.movhttp://deepblue.lib.umich.edu/bitstream/2027.42/64973/4/118-3CavityLinersPrep.movhttp://deepblue.lib.umich.edu/bitstream/2027.42/64973/5/134-2CuttingInstruments.movhttp://deepblue.lib.umich.edu/bitstream/2027.42/64973/6/136-2InstrumentSharpening.movhttp://deepblue.lib.umich.edu/bitstream/2027.42/64973/7/138-3PulpProtection.movhttp://deepblue.lib.umich.edu/bitstream/2027.42/64973/8/163-2SyringePrep.movhttp://deepblue.lib.umich.edu/bitstream/2027.42/64973/9/180-1SliceTechnique.movhttp://deepblue.lib.umich.edu/bitstream/2027.42/64973/10/220-1AcidEtch.movhttp://deepblue.lib.umich.edu/bitstream/2027.42/64973/11/224-1GoldFoil.movhttp://deepblue.lib.umich.edu/bitstream/2027.42/64973/12/224-2AlloyedFillingGold.movhttp://deepblue.lib.umich.edu/bitstream/2027.42/64973/13/236-2IntermediaryBase.movhttp://deepblue.lib.umich.edu/bitstream/2027.42/64973/14/334-1IsolationMethods.movhttp://deepblue.lib.umich.edu/bitstream/2027.42/64973/15/357-2ClassVamalgam.movhttp://deepblue.lib.umich.edu/bitstream/2027.42/64973/16/369-1Restorative.movhttp://deepblue.lib.umich.edu/bitstream/2027.42/64973/17/415-1Burs.movhttp://deepblue.lib.umich.edu/bitstream/2027.42/64973/18/AmalgamPolish195-1.movhttp://deepblue.lib.umich.edu/bitstream/2027.42/64973/19/AmalgamPrep419-2.movhttp://deepblue.lib.umich.edu/bitstream/2027.42/64973/20/CavityPrep757-1.movhttp://deepblue.lib.umich.edu/bitstream/2027.42/64973/21/CervicalMatrixApplic357-5.movhttp://deepblue.lib.umich.edu/bitstream/2027.42/64973/22/ClassIamalgamRestor228-3.movhttp://deepblue.lib.umich.edu/bitstream/2027.42/64973/23/ClassVamalgam_357-1.movhttp://deepblue.lib.umich.edu/bitstream/2027.42/64973/24/ClassVamalgam_357-1.movhttp://deepblue.lib.umich.edu/bitstream/2027.42/64973/25/ClassVamalgamRestor357-3.movhttp://deepblue.lib.umich.edu/bitstream/2027.42/64973/26/PreclSophArtic624-1.mo

Hepatitis C Virus Reflex Testing Protocol in an Emergency Department

Introduction: Our aim was to measure hepatitis C virus (HCV) screening and linkage-to-care rates in an urban emergency department (ED) before and after implementing an HCV viral RNA (vRNA) reflex testing protocol within a HCV screening program for at-risk patients. Our hypothesis was that using a reflex testing protocol would increase HCV testing rates of at-risk patients in the ED, which would increase the linkage-to-care rate. Methods: In August 2018, our institution implemented an automated, electronic health record-based HCV screening protocol in the ED for at-risk patients. In January 2019, we implemented an HCV vRNA reflex testing protocol (reflex testing) for all positive HCV antibody (Ab) tests that were initiated through the screening protocol. We compared completion rates of HCV vRNA testing and the rate of linkage to care for patients with positive HCV Ab test results before and after implementation of reflex testing (five months per study period). Results: Prior to reflex testing implementation, 233/425 (55%) patients with a positive HCV Ab test had an HCV vRNA test performed, whereas 270/323 (84%) patients with a positive HCV Ab test result had vRNA testing after reflex testing implementation (odds ratio [OR], 4.2; 95% confidence interval (CI): 3.0-6.0; P < 0.001). Of the eligible patients with positive HCV Ab test results who could be linked to care, 45 (10.6%) were linked to care before HCV reflex implementation and 46 (14.2%) were linked to care with reflex testing (OR, 1.4; 95% CI: 0.9-2.2; P = 0.13). Conclusion: Implementing a reflex testing initiative into an HCV screening program in the ED can result in an increase of the percentage of patients who receive an HCV vRNA test after having had a positive HCV Ab. Hepatitis C virus vRNA reflex testing was not associated with a statistically significant increase in linkage-to-care rates for HCV Ab-positive patients; however, further studies are required