Staying InformED: Top emergency Medicine pharmacotherapy articles of 2020

This article is made available for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.The year 2020 was not easy for Emergency Medicine (EM) clinicians with the burden of tackling a pandemic. A large focus, rightfully so, was placed on the evolving diagnosis and management of patients with COVID-19 and, as such, the ability of clinicians to remain up to date on key EM pharmacotherapy literature may have been compromised. This article reviews the most important EM pharmacotherapy publications indexed in 2020. A modified Delphi approach was utilized for selected journals to identify the most impactful EM pharmacotherapy studies. A total of fifteen articles, eleven trials and four meta-analyses, were identified. This review provides a summary of each study, along with a commentary on the impact to the EM literature and EM clinician

The James Webb Space Telescope Mission

Twenty-six years ago a small committee report, building on earlier studies, expounded a compelling and poetic vision for the future of astronomy, calling for an infrared-optimized space telescope with an aperture of at least $4m$. With the support of their governments in the US, Europe, and Canada, 20,000 people realized that vision as the $6.5m$ James Webb Space Telescope. A generation of astronomers will celebrate their accomplishments for the life of the mission, potentially as long as 20 years, and beyond. This report and the scientific discoveries that follow are extended thank-you notes to the 20,000 team members. The telescope is working perfectly, with much better image quality than expected. In this and accompanying papers, we give a brief history, describe the observatory, outline its objectives and current observing program, and discuss the inventions and people who made it possible. We cite detailed reports on the design and the measured performance on orbit.Comment: Accepted by PASP for the special issue on The James Webb Space Telescope Overview, 29 pages, 4 figure

A Human-Operant Investigation of Preceding- and Following-Schedule Behavioral Contrast

Behavioral contrast occurs when a change in the rate of reinforcement in one context results in a change in behavior in the opposite direction in another context. Research findings with nonhumans regarding the symmetry of positive and negative contrast have been mixed, especially regarding the relative influence of preceding and following schedules of reinforcement. Research has also been mixed regarding the extent to which systematic within-session contrast is demonstrated. Despite applied implications of contrast, the vast majority of research has been conducted with nonhumans. The purpose of the current study was to investigate the differential influence of preceding- and following-schedules of reinforcement on positive and negative behavioral contrast, as well as within-session contrast, with adult humans with intellectual and/or developmental disabilities in a 3-component human-operant arrangement. Positive contrast was found in 5 of 6 cases, whereas negative contrast was found in only 2 of 6. The effect of the following schedule was larger with positive contrast, but the effect of the preceding schedule was larger with negative contrast. There were no systematic within-session effects characteristic of behavioral contrast

Piloting a screening tool in a breast cancer survivorship clinic

66 Background: Breast cancer survivors experience physical, psychosocial, and practical concerns. Our Adult Survivorship Clinic provides patients a comprehensive survivorship visit following curative intent therapy to identify and address these needs. This study assessed patient and staff feasibility, usefulness, and burden of a screening tool. Methods: Patients seen in the Robert H. Lurie Breast Cancer Survivorship Clinic were randomly assigned to receive a screener (Coleman Supportive Oncology Tool including a concerns checklist & the 4-item Patient Health Questionnaire [PHQ-4]) versus no screener prior to their survivorship clinic appointment. All patients were asked to complete the FACIT-TS-PS to assess treatment satisfaction following the appointment. The screener group also completed an additional set of screener acceptability questions. The survivorship clinician completed a questionnaire after each patient visit. Results: Patients with breast cancer (n = 100) were randomized. Twenty-six (52%) of the participants not given a screener and 26 (52%) of the participants given a screener completed the FACIT TS-PS. 48% of participants were age 55 years or older and 54% received chemotherapy. While there were no statistically significant differences between the groups, both groups scored high on the FACIT TS-PS. Screener patients provided high ratings for the satisfaction survey with 100% of the respondents reporting the screener was “probably” or “definitely” clear and relevant. 85% reported that the questions provided little or no distress. The median time to complete the tool was 4 to 5 minutes. The survivorship provider reported that in 47% of patients (23/49) the screener uncovered an additional significant concern. In 35% of screened patients (17/49), the provider felt the screener prompted an additional referral to supportive oncology services or a medical specialist. Conclusions: A comprehensive and brief screener for patient concerns was feasible and acceptable for both patients and provider. Even in the context of a comprehensive survivorship visit, a screening tool uncovered additional concerns that led to supportive care referrals

Piloting a supportive oncology screener with adult survivors of childhood cancers

9 Background: Adult survivors of childhood cancers experience a host of late effects. Our Survivors Taking Action and Responsibility (STAR) clinic treats those needs. Methods: We piloted the Coleman Supportive Oncology Tool (CSOT, which includes a concerns checklist & the 4-item Patient Health Questionnaire [PHQ-4]) that patients completed before STAR visits. We used chi-square, T-tests, and logistic regression to identify differences in CSOT scores associated with patient characteristics. Results: Patients (n = 115) completed the CSOT: 54% women; 81% White; 34% leukemias, 30% lymphomas, 10% brain tumors, 8% sarcomas, and 18% other cancers. Mean years: current age = 33.48 (SD = 7.71) and age at diagnosis = 9.8 (SD = 5.84). The majority had chemotherapy (95%) and radiation (74%). A minority underwent surgery (38%) and transplant (22%); experienced a cancer recurrence or second malignancy (each 20%). We assessed 21 potential late effects; the mean number per patient was 1.92 (range = 0-9); most frequent were cardiologic (23%), endocrine (17%), musculoskeletal (17%) and infertility (16%). Controlling for current age, each 13 years (a) since diagnosis was associated with roughly 1 more long term effect (β = 1.02, p = 300 mg anthracycline was associated with a nearly 8-fold increase in cardiologic late effects (OR = 7.94, p < .01). Recurrence, second malignancy, and age < 10 years at diagnosis were associated with significantly more late effects (p = < .001, 01, < .01, and .02 respectively); those variables were not associated with greater CSOT concerns. We assessed 32 CSOT supportive care concerns; the mean number per patient was 3.23 (range = 0-18); the most frequent were difficulties with body weight (34%), sleep (19%), work / school (18%), concentration and health insurance (each 17%). On an item assessing fear of recurrence (FoR) frequency, most (74%) endorsed “not at all” but any FoR was associated with endorsing a greater number of CSOT concerns (p < .0001). Conclusions: Using a brief screener was feasible in a clinic providing follow-up care to adult survivors of childhood cancers to identify patients’ current medical and supportive care needs

Use of a best-practice advisory to increase survivorship clinic referrals

53 Background: The American College of Surgeons Commission on Cancer require accredited institutions to give patients a survivorship care plan (SCPs) within six months of completing curative intent therapy. However, only a minority are receiving SCP’s. Some institutions have survivorship clinics to deliver comprehensive care, including SCP’s. Insufficient referrals to such clinics are a common barrier due to survivorship not being integrated into oncology workflows. To address this, we developed and implemented a best practice advisory (BPA) alert within our EMR to identify eligible patients and facilitate referrals to the survivorship clinic. Methods: Our pilot included breast cancer patients within medical oncology. The BPA electronic alert criteria included: stage 0-III, new patient encounter within 12 months, no SCP completed or previous referral. Upon triggering, the BPA asks “Does your patient require a SCP?” followed by 3 options: 1) SCP needed- an automatic order is generated, if signed, the BPA will not fire again, if unsigned, it will fire at the next encounter (no sooner than 30 days) and will continue until an order is placed or the response “ SCP not needed” is selected. 2) SCP not needed- the BPA will never trigger again for that patient. 3) Don’t know/still on treatment-the BPA will re-fire in 30 days. Data on frequency of BPA firing and number of referrals was compared 90 days prior and post implementation. Chi-square analysis was used. Results: Between 4/1/2015-3/31/2016, 902 patients were seen with stage 0-III breast cancer at Northwestern. Ninety days prior to implementation of the BPA, 30 patients (3.3%) were referred by 8 oncology providers. In the 90 days following implementation, the BPA fired 845 times (48.5% option 1, 24.8% option 2, 26.6% option 3) and 198 patients (22%) were referred. The difference was statistically significant ( χ2 = 141.7, p < 0.0001). Conclusions: The implementation of BPAs within an EMR is an effective way to increase referrals to a survivorship clinic, thus increasing the number of patients given SCPs. Challenges identified were having enough staff availible to deal with a rapid increase in referrals, need for refinement of BPA criteria to more precisely identify eligible patients, and provider burden

Patient screening tool as input to the survivorship summary of care plan appointment

140 Background: A review of the literature failed to identify a screening tool specific to the unique needs of cancer survivors. The Coleman Supportive Oncology Collaborative (CSOC) developed a tool to evaluate psychosocial, physical and practical concerns, and emotional distress for concurrent use during the cancer survivorship visit. Based on pilot results of the tool, minor modifications were made and tested. Methods: The CSOC (v.3) survivorship tool was used in patients (n = 49) who had completed their adjuvant therapy at one of two safety net hospitals in Chicago, IL. The CSOC v.3 screening tool items (n = 44) include: PHQ4, fear of another cancer or recurrence, financial, social and religious concerns, nutritional concerns, physical concerns, lifestyle risk factors, and treatment/care concerns. Results: The most common patient concerns included: fear of another cancer 53% (26/49), tingling in my hands/feet 53% (26/49), concerns about diet 51% (25/49), pain 51% (25/49), sleep 51% (25/49), dry skin 47% (23/49); endorsement of these concerns were not significantly associated. Of the 44 items, 16 were reported by at least 30% of patients, and 3 items were reported by less than 10% of patients. There was an average of 15 items/concerns noted by patients with a maximum of 27 items and a minimum of 5 items. Clinicians (n = 7) reported the use of the screening tool results aided the survivorship appointment discussion, directing the focus to reported patient’s concerns. Conclusions: Survivors continue to experience multiple concerns and distress, thus they may benefit from a comprehensive tool that is tailored to capture their unique survivorship needs. Administration of the tool at the beginning of the survivorship appointment provided the framework for the patient’s appointment narrative. An additional study is planned to compare use of the tool versus current practice at a large academic center

Utilization of a web-based survivorship and supportive oncology training curriculum for clinicians

19 Background: A challenge in supportive oncology, integral to patient care, is training the health professional workforce. A collaborative funded by The Coleman Foundation of 30+ clinicians (faculty) from 25 institutions (academic, community & safety net) developed a unique fundamental survivorship care (Weldon JCO 2017) and supportive oncology training curriculum (Trosman JNCCN 2017). Methods: Using data from The National Comprehensive Cancer Network Continuing Education team, we analyzed utilization of survivorship and supportive oncology education courses using simple frequencies. Results: Over 3200 courses were completed (pretest, course, post-test, evaluation) and 4850 accessed. Nurses completed 56%, physicians 15%, social workers/psychologists/support staff 14%, advance practice clinicians 8%, and various roles for the rest. Courses in table. Conclusions: NCCN’s education portal achieved strong utilization from a variety of healthcare professionals in these courses. The Coleman Supportive Oncology Collaborative supports improvement in supportive care with tools, processes and training and will continue to update/offer courses through this portal.[Table: see text

High prevalence of fluoroquinolone-resistant UTI among US emergency department patients diagnosed with urinary tract infection, 2018–2020

Background: Uropathogen resistance, fluoroquinolone-resistance (FQR), and extended spectrum beta-lactamase (ESBL), has been observed to be emerging worldwide with prevalences above recommended thresholds for routine empirical treatment. The primary aim of our study was to determine the prevalence of FQR from a geographically diverse sample of United States emergency departments (EDs). Methods: We conducted a multi-center, observational cohort study using a network of 15 geographically diverse US EDs. All patients ≥18 years of age with the primary or secondary diagnosis of urinary tract infection (UTI) in the ED identified using International Classification of Diseases (ICD-10) diagnosis code of cystitis, pyelonephritis, or UTI from 2018 to 2020 were included. We calculated descriptive statistics for uropathogens and susceptibilities. Logistic regression analysis was used to identify antimicrobial resistance risk factors associated with FQR Escherichia coli. Results: Among 3779 patients who met inclusion criteria, median age was 62.9 years (interquartile range [IQR]: 41–77.6) and 76.3% were female. The most common diagnoses were complicated (41.2%) and uncomplicated cystitis (40.3%). E. coli was the most common pathogen (63.2%), followed by Klebsiella pneumoniae (13.2%) and Enterococcus species (5.8%). Across all sites, overall E. coli FQ-resistance prevalence was 22.1%, ranging from 10.5 to 29.7% by site. The prevalence of ESBL-producing uropathogen was 7.4%, ranging from 3.6% to 11.6% by site. Previous IV or oral antimicrobial use in the past 90-days and history of a multi-drug resistant pathogen were associated with FQ-resistant E. coli (odds ratio [OR] 2.68, 95% confidence interval [CI]: 2.04–3.51, and OR 6.93, 95% CI: 4.95–9.70, respectively). Of the patients who had FQ-resistant E. coli or an ESBL-producing uropathogen isolated, 116 (37.1%) and 61 (36.7%) did not have any documented risk factors for resistance. Conclusion: FQ-resistant E. coli is widely prevalent across US sites highlighting the need for ongoing monitoring of antimicrobial resistance and, at some locations, modification of empirical treatments

Geographies of food: 'Afters'

This third and final ‘Geographies of food’ review is based on an online blog conversation provoked by the first and second reviews in the series (Cook et al., 2006; 2008a). Authors of the work featured in these reviews – plus others whose work was not but should have been featured – were invited to respond to them, to talk about their own and other people’s work, and to enter into conversations about – and in the process review – other/new work within and beyond what could be called ‘food geographies’. These conversations were coded, edited, arranged, discussed and rearranged to produce a fragmentary, multi-authored text aiming to convey the rich and multi-stranded content, breadth and character of ongoing food studies research within and beyond geography. <br/