Evaluation of a Pharmacist-Led COVID-19 Vaccination Program in a Hospital Setting.

PURPOSE: A pharmacist-led COVID-19 vaccination screening and administration tool was implemented at a tertiary care hospital in the Upper Midwest, allowing pharmacists to determine if an inpatient is a candidate for the COVID-19 vaccination. The purpose of this observational study was to examine the feasibility of a pharmacist-led, COVID-19 vaccination administration workflow to the inpatient population in a tertiary care hospital. METHODS: This observational study was conducted at an Upper-Midwest facility and includes a study population of adult patients admitted to the hospital between 10/1/2021 - 1/1/2022. The primary outcome of this study was the number of COVID-19 vaccinations administered. Secondary outcomes included the number of attending physician approvals, pharmacist time dedicated to the vaccination program, patient demographics, and patient acceptance of vaccination. Group differences were evaluated using odds ratios, 95% confidence intervals, Pearson's chi-square test, the Mann-Whitney U test, and multivariate logistic regression. RESULTS: There were 715 patients eligible to receive COVID-19 vaccination. Of those, 23 (3.2%) patients received a COVID-19 vaccine while inpatient. After adjusting for sex at birth, age at admission, and length of hospital stay, compared to previously unvaccinated patients, those with their second dose due were 7.3 times more likely to have been given a vaccination (95% CI 1.3-42.1, P = 0.026), while patients with their booster due were 4 times more likely to have been given a vaccination (95% CI 1.3-12.3, P = 0.014). CONCLUSIONS: Although unvaccinated patients were successfully identified, only 23 were able to be vaccinated. Additional barriers need to be addressed to make this program successful.

Impact of Pharmacist-Led Education on Proper Prophylactic Enoxaparin Dosing in Obese Patients.

Background/Purpose: Venous thromboembolism (VTE) is a common cardiovascular complication in middle-aged adults. There is a likelihood a patient may experience VTE when admitted to a hospital. Prophylactic medications such as low-dose unfractionated heparin and enoxaparin are started to prevent VTE. A pharmacist-led health system-wide Grand Rounds promoted prophylactic enoxaparin 40 mg twice daily instead of once daily in patients with a body mass index (BMI) 40 kg/m2 or greater. Methodology: This case-control study was conducted at a Essentia Health - Fargo, in the Upper Midwest. Data of acute care patients were extracted from electronic health records 2 years before and after the pharmacist-led education. Patients in the study were 18 years old or older, hospitalized with a need for prophylactic anticoagulation receiving enoxaparin, and had a BMI 40 kg/m2 or greater. Patients with a diagnosis of COVID-19 and recent bleeding were excluded. Groups were compared to determine the effect of pharmacist-led education. The outcome was the number of patients who received enoxaparin 40 mg twice daily compared to once daily. Results: In the control group, 9 out of 15 hospitalizations received enoxaparin 40 mg subcutaneous twice daily and in the case group 34 out of 70 hospitalizations received the twice daily dosing. The odds ratio of receiving enoxaparin 40 mg twice daily after the pharmacist-led education compared to before the education was OR = .99, 95% CI = .96, 1.02. Conclusions: There was no difference in enoxaparin 40 mg once daily and twice daily dosing after the pharmacist-led education.

Outcomes of same-day discharge following percutaneous coronary intervention in a rural population.

BACKGROUND: Same-day discharge (SDD) following percutaneous coronary intervention (PCI) is safe, yet the nationwide rate of SDD remains low. The impact that residing in a rural area has on the safety of SDD is unknown. OBJECTIVE: To investigate the safety of SDD compared to next-day discharge (NDD) among PCI patients living in a largely rural area. METHODS: There were 3502 outpatient elective PCIs at a tertiary care center between January 1, 2011 and December 31, 2017. Data from the National Cardiovascular Data Registry CathPCI Registry® and the electronic medical records were obtained for patient demographics, procedural characteristics, and procedural outcomes. Data from the initial PCI in each 365-day period were included in the analysis for each patient. Rural-Urban Commuting Area codes 4-10 were used to define rural status. RESULTS: A total of 2099 (59.9%) PCIs met the inclusion criteria (63% rural). The overall rate of SDD increased over time (4.7% in 2011 to 39.6% in 2017) as radial access increased (14.2% in 2011 to 59.9% in 2017). In this population, a total of 329 PCIs had SDD (15.7%; median (interquartile range) age 66.0 (14.0) years, 20.1% female, 52.3% rural status). Compared to NDD, SDD patients had less hyperlipidemia, atrial fibrillation, congestive heart failure, history of coronary artery bypass graft, and more radial access. SDD was noninferior to NDD for 30-day readmission but had a decreased 1-year (adjusted odds ratio [aOR]: 0.20, 95% confidence interval [CI]: 0.05-0.81, p = 0.024) and 5-year (aOR: 0.43, 95% CI: 0.28-0.66, p < 0.001) all-cause mortality compared to NDD. Rural status did not predict outcomes. CONCLUSIONS: SDD in patients in rural areas does not have a significantly higher rate of 30-day readmission. SDD patients had lower odds of 1- and 5-year mortality when compared to NDD. Future studies prospectively evaluating the safety of SDD in this population are warranted.

Bridging Community Mental Health and Primary Care to Improve Medication Monitoring and Outcomes for Patients With Mental Illness Taking Second-Generation Antipsychotics-Phase 2: Quality Improvement Initiative Over 15 Months.

Objective: To evaluate the effectiveness of a quality improvement (QI) initiative to improve family medicine residents' metabolic monitoring of second-generation antipsychotics (SGAs) for patients comanaged across nonintegrated community mental health and family medicine clinics.Methods: Patients were aged ≥ 18 years seen by family medicine residents and prescribed at least 1 SGA (N = 175). Preparative and scheduled QI interventions were nonblinded and included collaboration across organizations, education, and monthly interprofessional care conferences. The QI outcome included evaluation of pre-post metabolic monitoring laboratory data over the 15-month study period. A subset of patients (n = 26) was reviewed at least once at monthly interprofessional care conferences. Patients were stratified by diagnosis of diabetes (n = 45) and no diabetes (n = 130) at baseline. Analyses of the QI intervention outcomes were framed by the time period of monthly care conferences (January 31, 2019-April 30, 2020) and compared to baseline (the historical time period) (October 31, 2017-January 29, 2019).Results: Improved adherence in glycated hemoglobin (HbA1c) (P = .042) and lipid (P < .001) monitoring per guidelines from baseline to follow-up was seen in the total patient population (N = 175). Patients without diabetes (n = 130) had significant improvement (P = .001) in HbA1c monitoring from baseline to follow-up. The subgroup of patient cases that were discussed at a care conference showed no significant improvement in HbA1c or lipid monitoring.Conclusion: Preparative and scheduled QI interventions provided family medicine residents powerful reminders of the SGA monitoring guidelines that improved the metabolic monitoring behaviors for all patients on SGAs.Prim Care Companion CNS Disord. 2023;25(3)22m03432. Author affiliations are listed at the end of this article.

Epidemiology of traumatic brain injuries at a rural-serving Level II trauma center, 2004 - 2016.

OBJECTIVE: To describe the epidemiology of traumatic brain injury (TBI) and quantify rural and urban differences. METHODS: Patient characteristics, injury characteristics, imaging, and outcomes were extracted from the trauma registry of the level II trauma center at Essentia Health-St. Mary's Medical Center, Duluth, MN, for patients admitted for a TBI from January 1, 2004, through December 31, 2016. Estimated relative risk (RR) per year, Wald 95% confidence intervals, and p-values were calculated. RESULTS: Of the 5,079 TBI admissions during the study period, just under half (2,510, 49.4%) resided in rural areas at the time of admission. Overall, there was a 3.8% unadjusted annual increase in TBI risk rom 2004-2016, with 2.9% and 4.7% annual increases among rural and urban U.S. residents, respectively. Rural residents had significant annual increases in risk of TBI admission resulting in 30-day post-discharge emergency department readmission and 30-day post-discharge combined inpatient/emergency department readmission of 35.2% and 22.4%, respectively. CONCLUSIONS: We found that risk of rural resident TBI admission due to MVC was significantly greater than that for urban residents. Public health and medical interventions to decrease the rural/urban disparity are warranted, including public health campaigns to increase seat belt use, and supportive care post-discharge into rural communities.

Epidemiology, Management, and Outcomes of Accidental Hypothermia: A Multicenter Study of Regional Care.

BACKGROUND: Hypothermia is an uncommon, potentially life-threatening condition. We hypothesized (1) advanced rewarming techniques were more frequent with increased hypothermia severity, (2) active rewarming is increasingly performed with smaller intravascular catheters and decreased cardiopulmonary bypass, and (3) mortality was associated with age, hypothermia severity, and type. METHODS: Trauma patients with temperatures <35°C at 4 ACS-verified trauma centers in Wisconsin and Minnesota from 2006 to 2016 were reviewed. Statistical analysis included chi-square and Fisher's exact tests. A P value < .05 was considered significant. RESULTS: 337 patients met inclusion criteria; primary hypothermia was identified in 127 (38%), secondary in 113 (34%), and mixed primary/secondary in 96 (28%) patients. Hypothermia was mild in 69%, moderate in 26%, and severe in 5% of patients. Intravascular rewarming catheter was the most frequent advanced modality (2%), used increasingly since 2014. Advanced techniques were used for primary (12%) vs. secondary (0%) and mixed (5%) (P = .0002); overall use increased with hypothermia severity but varied by institution. Dysrhythmia, acute kidney injury, and frostbite risk worsened with hypothermia severity (P < .0001, P = .031, and P < .0001, respectively). Mortality was greatest in patients with mixed hypothermia (39%, P = .0002) and age >65 years (33%, P = .03). Thirty-day mortality rates were similar among severe, moderate, and mild hypothermia (P = .44). CONCLUSION: Advanced rewarming techniques were used more frequently in severe and primary hypothermia but varied among institutions. Advanced rewarming was less common in mixed hypothermia; mortality was highest in this subgroup. Reliance on smaller intravascular catheters for advanced rewarming increased over time. Given inconsistencies in management, implementation of guidelines for hypothermia management appears necessary.

Feasibility of preemptive pharmacogenetic testing in colorectal cancer patients within a community oncology setting.

INTRODUCTION: Pharmacogenetics, in hand with precision medicine in oncology, represents an opportunity to holistically tailor a patient's treatment regimen using both somatic and germline variants to improve efficacy and decrease toxicity. Colorectal cancer patients represent a population with frequent use of fluoropyrimidine and irinotecan and are an ideal opportunity for implementation of preemptive pharmacogenetics as evidence supports pharmacogenetic testing for DPYD and UGT1A1 to reduce fluoropyrimidine and irinotecan toxicities. METHODS: This was a single arm proof-of-concept study at a large community-based health system. Participants provided samples for pharmacogenetic testing via an external vendor prior to chemotherapy initiation and an oncology pharmacist was responsible for pharmacogenetic interpretation and pharmacogenetic-guided therapeutic recommendation to the treating provider. RESULTS: A total of 24 (60%) participants had a UGT1A1 variant. All participants (100%) were DPYD*1/*1. Results were available and interpreted for 29/40 (72.5%) participants prior to scheduled chemotherapy initiation (p value <0.014). Of the participants whose results were available in 5 weekdays or less (n = 23), 20 (87%) were communicated with the treating provider prior to scheduled chemotherapy administration. A total turnaround time of 5 days or less was significantly associated with PGx feasibility in a community-based oncology clinic (p = 0.03). CONCLUSIONS: In conclusion, we were able to show that implementation of preemptive pharmacogenetic testing into a community oncology clinic with results interpretation available prior to scheduled initiation of chemotherapy was feasible. As pharmacogenetic testing in oncology expands, pharmacists should be prepared to optimize supportive medication regimens as well as chemotherapy with pharmacogenetic results.

Development, Implementation, and Evaluation of an Early Mobility Protocol in a Regional Level II Trauma Center.

The purpose of this project was to develop and evaluate a collaborative nursing/therapist protocol for early mobility in a medical-surgical intensive care unit (MICU) in a regional level II trauma center. Data for patients in the MICU were compared for the periods August 3, 2015-August 2, 2016, and August 3, 2014-August 2, 2015. Semistructured interviews were conducted with 10 nurses and 1 therapist. Average MICU length of stay decreased from 3.81 to 3.50 days (P = .057). Mean time in mobility chairs did not change (0.12 days vs 0.11 days, P = .389). Mean number of days to first documented level 2-5 activity decreased significantly, from 1.81 to 1.51 days (P = .036). The percentage of hospitalizations with any documented level 3 or 4 activity increased significantly (from 3.8% to 7.4% and from 61.5% to 66.7%, P = .003 and P = .031, respectively). Barriers/challenges to implementation included having enough people to assist, space, documentation, having to coax the physician to place order for upright mobility, availability of therapists for later stages of protocol, patient variability, fear of patient falls, availability of therapy chairs, staff changes, time, and patient refusal. A multidisciplinary approach to protocol development for early mobility in an intensive care unit was successfully implemented at a regional level II trauma center.

Predictive utility of the Activity Measure for Post-Acute Care '6-Clicks' short forms on discharge disposition and effect on readmissions: a retrospective observational cohort study.

OBJECTIVES: To evaluate the predictive utility of the Activity Measure for Post-Acute Care '6-Clicks' daily activity and basic mobility functional assessment short forms on inpatient discharge to home compared with skilled nursing facilities, including by diagnostic group (trauma injury, major lower joint replacement/reattachment, spinal fusion excluding cervical), as well as assess the effect of the short forms on 30-day inpatient readmissions. DESIGN: Retrospective, observational cohort study of electronic health record data. SETTING: Five hospitals in a multistate, integrated healthcare system serving a large, rural US population. PARTICIPANTS: The population-based adult (age ≥18) sample of acute care hospitalised patients receiving rehabilitation services included 10 316 patients with 12 314 hospital admissions from the year prior to 6-Clicks implementation (1 June 2015-31 May 2016) (pre-6-Clicks cohort) and 10 931 patients with 13 241 admissions from the year after 6-Clicks implementation (1 January 2017-31 December 2017) (post-6-Clicks cohort). Patients were admitted for major lower joint replacement/reattachment, spinal fusion excluding cervical, trauma injury or another reason. INTERVENTION: Occupational and physical therapist use of 6-Clicks daily activity and basic mobility short forms in the post-6-Clicks cohort. PRIMARY AND SECONDARY OUTCOMES: Discharge disposition (home, including to assisted living, or skilled nursing facility, including swing beds) and 30-day inpatient readmissions. RESULTS: Areas under the receiver operating characteristic curve were 0.82-0.92 (daily activity) and 0.87-0.94 (basic mobility) for discharge to home or skilled nursing facilities, with trauma and spinal fusion patients having the highest values. Daily activity and basic mobility standardised positive and negative predictive values were highest for the three diagnostic groups compared with the full study sample. Few significant differences in 30-day readmissions were seen between pre- and post-6-Clicks cohorts. CONCLUSIONS: 6-Clicks performed well when distinguishing between discharge home or skilled nursing facilities, especially by diagnostic group, supporting use by occupational and physical therapists in discharge planning. Future research could assess where additional intervention or training may reduce 30-day readmissions.

Prevalence, Clinical Factors, and Outcomes Associated With Myocardial Infarction With Nonobstructive Coronary Artery.

BACKGROUND: Myocardial infarction with nonobstructive coronary arteries (MINOCA) is an underrecognized clinical problem in patients presenting with acute coronary syndrome. Various clinical disorders lead to MINOCA thus making treatment and diagnosis a challenge. We aimed to compare the clinical factors and outcomes of patients with MINOCA versus obstructive disease [myocardial infarction due to coronary artery disease (MI-CAD)] in a largely rural health system. METHODS: Between May 1, 2009 and June 24, 2019, all consecutive ST-segment elevation myocardial infarction patients at Essentia Health were prospectively examined. We categorized patients into MI-CAD (obstructive plaque ≥ 50% with revascularization) or MINOCA (obstructive plaque < 50% with exclusion of other alternative cause). Outcomes included 30-day and 1-year all-cause mortality, 30-day all-cause readmission and 30-day cardiac readmission. RESULTS: There were 2170 patients included in the study; 2097 (96.6 %) had MI-CAD and 73 (3.4%) met the definition of MINOCA. Within the MINOCA group, the 3 most common presentations were supply-demand mismatch (28.8%), spontaneous coronary artery dissection (9.6%), and other etiology (60.3%). Only 10 (13 %) MINOCA patients had cardiac magnetic resonance imaging studies obtained within 6 months. MINOCA patients were younger 61.6 versus 63.4 years with higher left ventricular function 51.6% versus 50.4% with less likelihood of prior myocardial infarction 4.1% versus 15.5% or congestive heart failure 2.7% versus 6.3% (P < 0.05). Compared with MI-CAD patients, MINOCA patients had similar 30-day mortality (7.1% vs. 8.2%; P = 0.70), 1-year mortality (10.4% vs. 8.2 %; P = 0.55), and 30-day cardiac readmission (8.7% vs. 9.6%; P = 0.29). MINOCA patients were less likely to be discharged on aspirin, betablockers, angiotensin-converting enzyme inhibitor/angiotensin receptor blockers, or statins (P < 0.05). CONCLUSION: Though there was no difference in readmission and mortality between MINOCA and MI-CAD; use of secondary prevention medications and cardiac rehabilitation referral was low in MINOCA patients. Prospective studies will be relevant to assess effective medical therapy to improve outcomes in MINOCA patients.

Chest Pain Severity Rating Is a Poor Predictive Tool in the Diagnosis of ST-Segment Elevation Myocardial Infarction.

Current ST-segment elevation myocardial infarction (STEMI) guidelines require persistent electrocardiogram ST-segment elevation, cardiac enzyme changes, and symptoms of myocardial ischemia. Chest pain is the determinant symptom, often measured using an 11-point scale (0-10). Greater severity of chest pain is presumed to be associated with a stronger likelihood of a true positive STEMI diagnosis. This retrospective observational cohort study considered consecutive STEMI patients from May 02, 2009 to December 31, 2018. Analysis of standard STEMI metrics included positive electrocardiogram-to-device and first medical contact-to-device times, presence of comorbidities, false-positive diagnosis, 30-day and 1-year mortality, and 30-day readmission. Chest pain severity was assessed upon admission to the primary percutaneous coronary intervention hospital. We analyzed 1409 STEMI activations (69% male, 66.3 years old ± 13.7 years). Of these, 251 (17.8%) had no obstructive lesion, consistent with false-positive STEMI. Four hundred sixty-six (33.1%) reported chest pain rating of 0 on admission, 378 (26.8%) reported mild pain (1-3), 300 (21.3%) moderate (4-6), and 265 (18.8%) severe (7-10). Patients presenting without chest pain had a significantly higher rate of false-positive STEMI diagnosis. Increasing chest pain severity was associated with decreased time from first medical contact to device, and decreased in-hospital, 30-day and 1-year mortality. Severity of chest pain on admission did not correlate to the likelihood of a true-positive STEMI diagnosis, although it was associated with improved patient prognosis, in the form of improved outcomes, and shorter times to reperfusion.

Blunt traumatic brachial plexus injuries in a northern rural US setting: increased likelihood in unshielded motor-powered crashes.

BACKGROUND: Blunt traumatic brachial plexus injuries (BTBPI) are severe peripheral nerve injuries which present in a small portion of trauma patients but can result in long-term neurological disability and severe chronic pain. OBJECTIVE: The goal of this study was to describe the epidemiology of BTBPI in a northern rural setting caused by motor-powered collisions, and to determine the relative risk of these injuries in shielded (cars, trucks, vans, and so on) and unshielded vehicles (snowmobiles, all-terrain vehicles and motorcycles). METHODS: This retrospective study describes the epidemiology of BTBPI caused by motor-powered collisions and treated at two level II trauma centers in northeast Minnesota and determines the relative risk of these injuries in shielded (cars, trucks, vans, and so on) and unshielded vehicles (snowmobiles, all-terrain vehicles and motorcycles). We hypothesized unshielded motor vehicle crashes in rural areas are at an increased risk of incurring BTBPI. RESULTS: Out of all injuries resulting from motor-powered collisions in a 20-year period (9951), BTBPIs were found in 63 trauma patients, a prevalence of 0.6%. The rate of BTBPI involving unshielded vehicles (1.0%) was significantly higher than those involving a shielded vehicle (0.4%) and primarily occurred in rural areas (70%). CONCLUSIONS: Unshielded vehicle crashes, particularly snowmobiles, have the highest risk for BTBPI in our rural region. The overall incidence of these injuries appears to be declining. LEVEL OF EVIDENCE: Level III.

Preventing Exercise-Associated Collapse Using Online Runner Education: A Randomized, Controlled Trial.

OBJECTIVE: To determine whether online exercise-associated collapse (EAC) prevention education decreases medical tent EAC visits among first-time marathoners. DESIGN: A prospective controlled study, with age- and sex-stratified randomization, evaluated rates of medical tent diagnosed EAC among runners randomized to the intervention group and intervention participants, compared with a control group. SETTING: Grandma's Marathon Medical Tent in Duluth, MN, June 2016. PARTICIPANTS: Runners in the 2016 Grandma's Marathon who never previously ran a marathon (n = 2943), randomized into control (n = 1482) and intervention (n = 1461) groups. Intervention participants opened the EAC prevention video (n = 590). INTERVENTIONS: Online EAC education included an introductory webpage and 5-minute professional video describing EAC and prevention. MAIN OUTCOME MEASURES: Medical tent visit with EAC diagnosis. RESULTS: Intervention participants had no decreased likelihood of EAC, compared with controls [odds ratio (OR), 0.88, 95% confidence interval (CI), 0.46-1.69]. Exercise-associated collapse occurred less frequently in those with longer race times (OR, 0.58, 95% CI, 0.43-0.79). Intervention participation was associated with longer race times (OR, 1.12, 95% CI, 1.10-1.23). CONCLUSIONS: Those opening the EAC prevention video and controls had similar EAC rates. Slower running speed was associated with lower EAC rates. Video viewing was a predictor of slower running pace.

Mathematical Analysis of Melanocyte Patterns on Danio rerio.

The study of zebrafish skin pattern development could lead to a better understanding of how these patterns are generated and how they evolved. To compare and contrast wild-type (WT) striped and leopardt1 mutant spotted patterns, photographs were taken of the developing fish. Initial observations led to the hypothesis that the black melanocyte spots in leopardt1 mutants were not randomly distributed, but rather were located in "dashed" stripes. To test this, melanocyte-spot-sized transparent grids were overlaid onto photographs and the location of melanocyte clusters was recorded. The grid maps were used to identify whether a black, melanocyte positive, grid area was present adjacent to each melanocyte cluster in each cardinal and intercardinal direction. In addition, Python-based computer programs were used to analyze the photographs at the pixel level. When analyzed using analysis of variance and logistic regression models, the striped and spotted patterns expressed more similarities than expected. In the leopardt1 zebrafish, the spots were organized into dashed stripes that had similar locations to the WT stripes. This research suggests that spotted and striped patterns are related. Further, the leopardt1 spots were farther apart along the dorsal-ventral axis than in the anterior-posterior direction, suggesting that different mechanisms control spacing along these two axes.

Bridging Community Mental Health and Primary Care to Improve Medication Monitoring and Outcomes for Patients With Mental Illness Taking Second-Generation Antipsychotics-HDC/DFMC Bridge Project, Phase 1: Group Concept Mapping.

OBJECTIVE: Patients with severe mental illness often lack care coordination between primary care and mental health providers. Siloed patient care across separate health care systems can negatively impact quality and safety of patient care. The purpose of the project discussed in this article is to effectively engage stakeholders from separate primary care and mental health organizations to develop an ideal cross-organization communication system to improve metabolic monitoring for their comanaged patients prescribed second-generation antipsychotics (SGAs). METHODS: The mixed method approach of group concept mapping was used to engage stakeholders across a nonaffiliated primary care clinic and a community mental health organization over the time period of March 2018 through May 2018. RESULTS: Three important domains in communication were identified: (1) process/workflow, (2) advocacy, and (3) a patient-centered focus. Seven high priority/easier to implement brainstormed items were identified and resulted in practice changes across both organizations, including developing a standard release of information, identifying a point person from each clinic focused on cross-organization care coordination, endorsing an SGA monitoring protocol across organizations, agreeing that metabolic monitoring of SGAs will be the responsibility of the primary care clinicians, beginning monthly medication reconciliation and cross-organization care conferences, developing standard electronic health record documentation, and providing education. CONCLUSIONS: Care coordination across all health systems is critical to optimize patient care for chronic medical and psychiatric conditions. Group concept mapping provides a strategic process to allow shared decision-making among stakeholders to take steps toward solving more complex systematic problems such as poor electronic health record interoperability across health systems.

Online pre-race education improves test scores for volunteers at a marathon.

OBJECTIVES: This study examined whether an online course would lead to increased knowledge about the medical issues volunteers encounter during a marathon. MATERIALS AND METHODS: Health care professionals who volunteered to provide medical coverage for an annual marathon were eligible for the study. Demographic information about medical volunteers including profession, specialty, education level and number of marathons they had volunteered for was collected. A 15-question test about the most commonly encountered medical issues was created by the authors and administered before and after the volunteers took the online educational course and compared to a pilot study the previous year. RESULTS: Seventy-four subjects completed the pre-test. Those who participated in the pilot study last year (N = 15) had pre-test scores that were an average of 2.4 points higher than those who did not (mean ranks: pilot study = 51.6 vs. non-pilot = 33.9, p = 0.004). Of the 74 subjects who completed the pre-test, 54 also completed the post-test. The overall post-pre mean score difference was 3.8 ± 2.7 (t = 10.5 df = 53 p < 0.001). While subjects with all levels of volunteer experience demonstrated improvement, only change among first time marathon volunteers was significantly different from the others. Subjects reporting all degree/certification levels demonstrated improvement, but no difference in improvement was found between degree/certification levels. CONCLUSION: In this follow-up to the previous year's pilot study, online education demonstrated a long-term (one-year) increase in test scores. Testing also continued to show short-term improvement in post-course test scores, compared to pre-course test scores. In general, marathon medical volunteers who had no volunteer experience demonstrated greater improvement than those who had prior volunteer experience.

Alcohol Use at the Time of Traumatic Brain Injury: Screening and Brief Intervention in a Community Hospital.

The use of screening and brief interventions (SBI) has been proposed to reduce future alcohol misuse and injury in traumatic brain injury (TBI) patients. As a result a SBI protocol for TBI patients was introduced with nursing training at a community hospital. In the 2 years following the implementation of a SBI protocol and nursing training, the number of patients with positive alcohol results decreased. The number of brief interventions increased to 83 (40.1%, 95% confidence limit [CL] = 33.4, 46.8), and CAGE questionnaire screenings decreased to 88 (42.5%, 95% CL = 35.8, 49.2), with 31 (35.2%) having positive results. These results highlight the need to assess processes and training in the emergency department to ensure that SBIs occur.

Enhancing Risk Assessment in Patients Receiving Chronic Opioid Analgesic Therapy Using Natural Language Processing.

OBJECTIVES: Clinical guidelines for the use of opioids in chronic noncancer pain recommend assessing risk for aberrant drug-related behaviors prior to initiating opioid therapy. Despite recent dramatic increases in prescription opioid misuse and abuse, use of screening tools by clinicians continues to be underutilized. This research evaluated natural language processing (NLP) together with other data extraction techniques for risk assessment of patients considered for opioid therapy as a means of predicting opioid abuse. DESIGN: Using a retrospective cohort of 3,668 chronic noncancer pain patients with at least one opioid agreement between January 1, 2007, and December 31, 2012, we examined the availability of electronic health record structured and unstructured data to populate the Opioid Risk Tool (ORT) and other selected outcomes. Clinician-documented opioid agreement violations in the clinical notes were determined using NLP techniques followed by manual review of the notes. RESULTS: Confirmed through manual review, the NLP algorithm had 96.1% sensitivity, 92.8% specificity, and 92.6% positive predictive value in identifying opioid agreement violation. At the time of most recent opioid agreement, automated ORT identified 42.8% of patients as at low risk, 28.2% as at moderate risk, and 29.0% as at high risk for opioid abuse. During a year following the agreement, 22.5% of patients had opioid agreement violations. Patients classified as high risk were three times more likely to violate opioid agreements compared with those with low/moderate risk. CONCLUSION: Our findings suggest that NLP techniques have potential utility to support clinicians in screening chronic noncancer pain patients considered for long-term opioid therapy.

Neuromuscular Training Availability and Efficacy in Preventing Anterior Cruciate Ligament Injury in High School Sports: A Retrospective Cohort Study.

OBJECTIVE: To document neuromuscular training (NMT) availability and its relationship to anterior cruciate ligament (ACL) injuries in 4 major high school sports by gender, sport, and rural/urban geography, with the hypothesis that increased exposure to NMT would be associated with fewer ACL injuries. DESIGN: A retrospective cohort study. SETTING: All Minnesota high schools identified in the Minnesota State High School League (MSHSL) database for fall 2014 boys' football and soccer, and girls' volleyball and soccer. PARTICIPANTS: All high school athletic directors were surveyed to report their school's fall 2014 experience; 53.5% returned the survey reporting experience with one or more of the sports. INTERVENTION: Athletic directors documented each sport's preseason and in-season exposure to NMT (plyometric exercises, proximal/core muscle strengthening, education and feedback regarding proper body mechanics, and aerobics) and licensed athletic trainers. MAIN OUTCOMES: Reported ACL injuries by sport, gender and rural/urban. RESULTS: More than two-thirds of teams incorporated facets of NMT into their sport. Among male athletes, soccer players exposed to licensed athletic trainers experienced significantly fewer ACL injuries (P < 0.005), and NMT was associated with significantly fewer ACL injuries in football (P < 0.05) and soccer (P < 0.05). Female athletes did not demonstrate similar associated improvements, with volleyball injuries associated with increased NMT (P < 0.001), and soccer injuries not associated with NMT. However, girl soccer players in rural settings reported fewer ACL injures compared with urban teams (P < 0.001). CONCLUSIONS: Most fall high school sports teams were exposed to NMT, which was associated with fewer ACL injuries for male, but not for female athletes. Improved gender- and sport-specific preventive training programs are indicated.