Faculty Bibliography

Background. Only half of the 3.5 million individuals with chronic hepatitis C (HCV) in the US are aware of their infection. Emergency departments (ED) provide a primary point of entry to the healthcare system for marginalized populations who are traditionally at elevated risk for HCV and are becoming an important venue for screening and linkage efforts. Optimal methods for HCV screening (universal versus targeted) in ED remain undefined. We aim to ascertain the relative prevalence of HCV infection by age and other risk factors through non-targeted screening for HCV in our high-volume urban ED. Methods. In this ongoing prospective observational cohort study, consenting adult ED patients participate in a researcher-administered structured interview and are offered a rapid HCV antibody (HCV Ab) screening test. If reactive, confirmatory serologic HCV Ab and HCV RNA are sent immediately and a clinic appointment is scheduled within 4 weeks. Participants are contacted with HCV RNA PCR results; those with detectable viral load are encouraged to attend follow-up appointment and receive a reminder call one week prior to appointment. Successful linkage to care is defined as appointment attendance. Results. A total of 2018 eligible patients were approached July 2015-April 2016. Seven hundred thirty-two participated in a structured interview. Seven hundred seven accepted an HCVAb rapid test. HCV antibody prevalence in the ED was 3.8% (0.43% in non-baby boomers without injection drug use (IDU), 7.6% in baby boomers, 34% in persons endorsing IDU). Twenty-three HCVAb-reactive participants submitted blood for confirmatory testing. A total of 12 of 23 (52%) had detectable HCV RNA, corresponding to 1.7% prevalence of chronic infection. Targeted screening of the birth cohort and those with IDU would have missed 7.4% (2 of 27) of HCVAb positive patients and 8.3% (1 of 12) with chronic infection. A total of 4 of 12 (33.3%) with chronic infection were linked to care, 2 have upcoming appointments, 1 died before appointment. Conclusion. Prevalence of HCV in our ED was higher than the national estimate of 3.4% among baby boomers used to justify national birth cohort screening. Optimal ED HCV screening methods should target baby boomers and those endorsing IDU, but a modest proportion of infections will be missed without universal screening

For 2013-2014, we prospectively identified US adults with flank pain, temperature >38.0°C, and a diagnosis of acute pyelonephritis, confirmed by culture. Cultures from 453 (86.9%) of 521 patients grew Escherichia coli. Among E. coli isolates from 272 patients with uncomplicated pyelonephritis and 181 with complicated pyelonephritis, prevalence of fluoroquinolone resistance across study sites was 6.3% (range by site 0.0%-23.1%) and 19.9% (0.0%-50.0%), respectively; prevalence of extended-spectrum β-lactamase (ESBL) production was 2.6% (0.0%-8.3%) and 12.2% (0.0%-17.2%), respectively. Ten (34.5%) of 29 patients with ESBL infection reported no exposure to antimicrobial drugs, healthcare, or travel. Of the 29 patients with ESBL infection and 53 with fluoroquinolone-resistant infection, 22 (75.9%) and 24 (45.3%), respectively, were initially treated with in vitro inactive antimicrobial drugs. Prevalence of fluoroquinolone resistance exceeds treatment guideline thresholds for alternative antimicrobial drug strategies, and community-acquired ESBL-producing E. coli infection has emerged in some US communities.

BACKGROUND: Hepatitis C virus (HCV) is responsible for the most common chronic bloodborne infection in the United States. The Centers for Disease Control (CDC) recently recommended screening all patients born between 1945-1965 (baby boomers) at least once for HCV infection. New York State has since mandated screening of baby boomers for HCV in nearly all patient care settings and encouraged it in the emergency department (ED). OBJECTIVES: This pilot study aimed to ascertain acceptability of an HCV screening test among the 1945-1965 birth cohort presenting to the ED in advance of a study investigating the prevalence of HCV infection in this birth cohort in the ED setting. METHODS: We conducted a cross-sectional study of health knowledge about HCV and government recommendations regarding HCV testing using a convenience sample of baby boomers in an ED in a large public hospital in the New York metropolitan area. Surveys were administered via a series of semistructured interviews. RESULTS: There were 81 patient participants. Fifty-two percent of patients were born outside of the United States, 69% had a high school diploma level of education or lower, and 37% were unemployed. Patients demonstrated misconceptions about HCV transmission and curability and poor knowledge about the necessity of testing in their age cohort. Knowledge that "HCV can cause the liver to stop working" was significantly associated with acceptance of testing. CONCLUSIONS: Baby boomers showed limited knowledge about the necessity of HCV screening in their age group, but testing for HCV infection in the ED was acceptable for the majority.

INTRODUCTION: The US Preventive Services Task Force recommends one-time screening of the 1945-1965 birth cohort (baby boomers) for hepatitis C (HCV) infection. New York State legislation mandates screening of baby boomers for HCV in most patient care settings except the emergency department (ED). This cross-sectional study explores baby boomer knowledge of HCV, prevalence of HCV infection, and linkage to care from a large urban ED. METHOD: Patients participated in a researcher-administered structured interview and were offered an HCV screening test. If HCV antibody reactive, a follow-up clinic appointment was made within 6 weeks. Reminder telephone calls were made a week before the appointment. Attendance at the follow-up appointment was considered successful linkage to care. RESULTS: A total of 915 eligible patients were approached between October 21, 2014, and July 13, 2015. A total of 427 patients participated in the structured interview; 383 agreed to an HCV rapid test. Prevalence of HCV antibody reactivity was 7.3%. Four patients were successfully linked to care. General knowledge about HCV was fair. Misconceptions about transmission were apparent. Beliefs that "if someone is infected with HCV they will most likely carry the virus all their lives unless treated" and that "someone with hepatitis can look and feel fine" were significantly associated with agreement to testing. CONCLUSIONS: Better linkage to care is needed to justify HCV screening in the 1945-1965 birth cohort in this particular ED setting. Linkage to care from the ED is challenging but can potentially be improved with specific measures including simplified screening algorithms and supportive resources.

BACKGROUND:The cause of cellulitis is unclear. Streptococcus pyogenes, and to a lesser extent, Staphylococcus aureus, are presumed pathogens. METHODS:We conducted a study of adults with acute cellulitis without drainage presenting to a US emergency department research network. Skin biopsy specimens were taken from the infected site and a comparable uninfected site on the opposite side of the body. Microbiology was evaluated using quantitative polymerase chain reaction (PCR), pyrosequencing, and standard culture techniques. To determine the cause, the prevalence and quantity of bacterial species at the infected and uninfected sites were compared. RESULTS:Among 50 subjects with biopsy specimens from infected and uninfected sites, culture rarely identified a bacterium. Among 49 subjects with paired specimens from infected and uninfected sites tested with PCR, methicillin-susceptible S. aureus was identified in 20 (41%) and 17 (34%), respectively. Pyrosequencing identified abundant atypical bacteria in addition to streptococci and staphylococci. Among 49 subjects with paired specimens tested by pyrosequencing, S. aureus was identified from 11 (22%) and 15 (31%) and streptococci from 15 (31%) and 20 (41%) of the specimens, respectively. Methicillin-resistant S. aureus was not found by culture or PCR, and S. pyogenes was not identified by any technique. CONCLUSIONS:The bacterial cause of cellulitis cannot be determined by comparing the prevalence and quantity of pathogens from infected and uninfected skin biopsy specimens using current molecular techniques. Methicillin-susceptible S. aureus was detected but not methicillin-resistant S. aureus or S. pyogenes from cellulitis tissue specimens. For now, optimal treatment will need to be guided by clinical trials. Noninfectious causes should also be explored.

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) is a prevalent cause of skin and soft tissue infections (SSTI), but the association between CA-MRSA colonization and infection remains uncertain. We studied the carriage frequency at several body sites and the diversity of S. aureus strains from patients with and without SSTI. Specimens from the nares, throat, rectum, and groin of case subjects with a closed skin abscess (i.e., without drainage) and matched control subjects without a skin infection (n = 147 each) presenting to 10 U.S. emergency departments were cultured using broth enrichment; wound specimens were cultured from abscess cases. Methicillin resistance testing and spa typing were performed for all S. aureus isolates. S. aureus was found in 85/147 (57.8%) of abscesses; 49 isolates were MRSA, and 36 were methicillin-susceptible S. aureus (MSSA). MRSA colonization was more common among cases (59/147; 40.1%) than among controls (27/147; 18.4%) overall (P < 0.001) and at each body site; no differences were observed for MSSA. S. aureus-infected subjects were usually (75/85) colonized with the infecting strain; among MRSA-infected subjects, this was most common in the groin. The CC8 lineage accounted for most of both infecting and colonizing isolates, although more than 16 distinct strains were identified. Nearly all MRSA infections were inferred to be USA300. There was more diversity among colonizing than infecting isolates and among those isolated from controls versus cases. CC8 S. aureus is a common colonizer of persons with and without skin infections. Detection of S. aureus colonization, and especially MRSA, may be enhanced by extranasal site culture.

Background: Airway management skills are an essential part of EM resident training. They are recognized as a key ACGME competency milestone. All EM trainees must achieve mastery in performing basic support of oxygenation and ventilation until a definitive airway can be secured. Junior residents frequently overlook these important fundamental skills. In our residency, no formalized program was in place to assess first year residents' airway skill retention or identify potential skill improvement and remediation. Objectives: The goal of our study is to demonstrate improvements in PGY1 residents' comfort with basic airway management skills using an immersive simulation-based curriculum. Methods: Residents participated in three high fidelity simulations. The scenarios required identification of risk factors for a difficult airway, demonstration of effective BVM skills, patient repositioning, and use of nasal trumpets, oral airways and PEEP valve if necessary. The cases included a patient with methadone overdose where naloxone was not yet available, a patient with pulmonary edema requiring ventilatory support, and a MVC patient requiring maintenance of C-spine immobilization during airway management. We utilized a survey-based design with pre- and post-session distribution assessing trainees' comfort with basic airway skills. The survey consisted of 5-point Likertscale questions, and we employed the paired Student t-test for data analysis. Results: A total of 13 PGY1 residents completed the one-on-one didactic session. All residents universally chose "strongly agree" when asked if the simulations were helpful. Instructors responded that the residents' airway techniques improved at the completion of the scenarios. The trainees reported significantly higher confidence in basic airway skills after training (mean score +1.13, p<0.005). During subsequent feedback, residents identified how cognitive stress impaired information retrieval, decision-making, and in some, fine motor skills. Adherence to an airway checklist mitigated these potential safety threats. Conclusion: An immersive simulation-based curriculum significantly improved PGY1 residents in their comfort level toward basic airway skills. As a secondary objective, program leadership was also able to assess and complete the level 1 ACGME milestones for airway skills for all PGY1 session attendees