- Email: [email protected]
EMF-3 Genetic Architecture of Human Ischemic Stroke
Research Forum Abstracts
EMF-1
Palliative Medicine Competency Education in Emergency Medicine Residency Training: A Survey of Emergency Medicine Education Leaders
Kraus CK, Ray DE, Greenberg MR, Dy SM/LVHN, Allentown, PA; JHSPH, Baltimore, MD
Background: Emergency physicians care for patients with palliative and hospice needs. More than 75% of patients visit the ED in the last 6 months of their life, and two-thirds of those patients die while hospitalized. Emergency medicine (EM) residents need specific skills to care for patients with terminal illness and those conditions requiring end-of-life care. Study Objectives: To assess the current state of hospice and palliative medicine (HPM) competency instruction in EM residency training programs and to identify barriers and opportunities for integrating instruction in HPM competencies into EM training. Methods: IRB-approved, cross-sectional, mixed-mode survey of American Osteopathic Association and Accreditation Committee on Graduate Medical Education accredited EM residency program directors (PDs), associate PDs (APDs), and assistant PDs (aPDs). The survey was pilot tested among EM residency faculty from several institutions in distinct regions of the US. The survey was emailed to 402 subjects, and subsequently via US mail and in-person at a scientific meeting. Demographic variables and specific questions based on previously published HPM competencies for emergency physicians were collected. A five-point Likert scale (1¼least, 5¼most) was used to assess the following Four Domains of HPM training in EM programs: D1 - Importance of HPM competency for senior EM residents; D2 - Senior resident skill level in HPM competencies; D3 - Effectiveness of educational methods for HPM training; and D4 - Barriers to HPM training. Results: There was a 50 percent response rate, with half of respondents being PDs, a 60/40 percent distribution between paper and Web-based modes, and no statistical differences in demographic variables between groups. Responses represented 100 programs, with geographic distribution representative of locations of EM residencies. A majority of respondents (59 percent) identified HPM training as important and reported teaching HPM in their programs. In Domain 1, crucial conversations (mean 4.88, SD 0.40), management of pain (4.77, 0.53), and management of the imminently dying (4.74, 0.53) had the highest mean Likert scores for importance. In Domain 2, residents were reported to be most proficient in crucial conversations (4.28, 0.66), management of pain (4.17, 0.72), and management of the imminently dying (3.91, 0.88). In Domain 3, bedside teaching (4.53, 0.81), mentoring from HPM faculty (4.11, 0.97), and case-based simulation were identified as the most effective educational training methods. In Domain 4, lack of HPM expertise among faculty (3.57, 1.21), lack of faculty interest in HPM (3.42, 1.20), lack of resident interest in HPM (3.04, 1.20) were identified as the greatest barriers. Six competencies (withholding/withdrawal of non-beneficial interventions, management of imminently dying, HPM referrals, ethical/legal issues, spiritual/cultural issues, management of dying child) showed large differences in mean Likert scores between perceived importance and reported senior resident skill level. Conclusion: This study is the first comprehensive description of the state of HPM competency training in EM residencies. The results provide a foundation for focused educational and policy interventions and future research that can close curriculum gaps and improve HPM competency training for EM residents.
EMF-2
The Use of Prescription Drug Monitoring Programs and Geographic Information Systems to Identify Communities at Risk of Prescription Opioid Overdose Fatalities
Hoppe J, Monte A, Sasson C, Nassel A, Heard S, Kile D, Heard K/University of Colorado, Aurora, CO; University of Alabama-Birmingham, Birmingham, AL; Rocky Mountain Poison and Drug Center, Denver, CO
Study Objectives: Prescription drug abuse and misuse is a public health epidemic in the United States. Prescription drug monitoring programs (PDMPs) represent an excellent source of objective information for the evaluation of opioid prescribing and patterns of opioid use. Geographic Information Systems (GIS) are ideal for identifying areas at risk in order to appropriately guide interventions. Little is known about the geographic distribution and traits of the communities in which people die from prescription opioids. Our objective is to evaluate prescription opioid deaths through the application of GIS spatial analysis using readily available data from our state death
Volume 64, no. 4s : October 2014
registry and PDMP to (a) describe the PDMP histories of persons dying of prescription overdose and (b) identify and characterize communities at the highest risk for prescription opioid mortality in our state. Methods: This is a retrospective, cohort study of prescription overdose death cases from 2008-2012. The department of health identified cases by querying death records for specific ICD 9 codes; they then geocoded the decedents to the last known address. Prescription medication histories were collected for each case by querying our state’s PDMP using automated data searches. The searches were then verified with manual abstraction of ten percent of the cases with an agreement of 92%. The geocoded decedent addresses were plotted and evaluated using three separate spatial statistic methods: Empirical Bayes, Local Moran’s I, and Getis Ord GI*. Empirical Bayes smoothed incidence rates were calculated for prescription opioid death using Geoda, Local Moran’s I and GI* were calculated using ArcGIS. Results: A total of 4,028 prescription opioid deaths were included for analysis. 355 (9%) of decedents were not able to be geocoded, of these only 156 (4%) were state residents. 2,730 (68%) had an opioid prescription in our PDMP at any time. 1,527 (38%) filled an opioid prescription within 30 days before they died. 2,357 (59%) filled a prescription in the year before they died. In the cohort of patients that filled an opioid prescription in the year before death the median number of opioid prescriptions was 12 (range 1-169), the median number of pills was 649 (range 3-19,950), the median number for pharmacies was 2 (range 1-35), and the median number of prescribers was 3 (range 1-41). Maps of census tracts identified using each of three spatial statistic methods as having clusters of high prescription opioid deaths were overlaid to identify high-risk census tracts. Tracts identified by all three methods were identified and designated as Tier 1 high-risk tracts (n¼9), while census tracts identified by 2 out of 3 methods were designated Tier 2 high-risk tracts (n¼20). Conclusion: This is the first study to combine the use of death records, PDMP data and GIS spatial analysis to describe the type and distribution of prescription overdose deaths for our state. The high-risk census tracts identified using these spatial cluster analysis methods are possible sites for targeted community-based interventions to improve both health education and prescribing interventions.
EMF-3
Genetic Architecture of Human Ischemic Stroke
Heitsch L, Guilliams K, Ford A, Khoury N, Connor L, Cruchaga C, Lee J-M/Washington University, St Louis, MO
Study Objectives: Acute ischemic stroke (AIS) is a devastating disease that affects approximately 795,000 patients per year in the United States. In the hours following an acute ischemic stroke, neurological deficits can be highly unstable with some patients improving while others deteriorate. These early neurological changes are important due to their influence on long-term outcome and a number of potential mechanisms may affect these early changes. We performed a genome-wide association study (GWAS) on DNIHSS24h (NIH stroke scale (NIHSS) change from baseline to 24 hours after stroke onset) in AIS patients in order to identify genetic variants and genes associated with early neurologic improvement or deterioration. Methods: DNA from 191 AIS patients presenting within 6 hours of stroke onset was genotyped using an Affymetrix Exome-chip and rare variant analyses were performed. Single variant analysis was performed using PLINK, including age, baseline NIHSS and principal component factors as covariates. European- and AfricanAmericans were analyzed separately, with p-values combined by meta-analysis. Genebased analysis was performed using SKAT-O, including only non-synonymous variants, and the same covariates. Pathway analysis was performed using ALIGATOR to identify pathways with single nucleotide polymorphisms with significant associations. Results: Single variant analysis did not reveal genome-wide significant associations. One gene, IFIT1 (interferon-induced protein with tetratricopeptide repeats), passed the gene-based genome-wide multiple test correction. All three polymorphic variants in IFIT1 associated with neurologic deterioration with an average DNIHSS24h 9.5 points lower in carriers versus non-carriers. Pathway analysis, including 21 interferon-related genes but excluding IFIT1, showed a highly significant association (p¼2.3010-3) with DNIHSS24h. Conclusion: These data suggest that IFIT1 and other interferon-related genes may function in endogenous neuroprotective responses during acute ischemic stroke. Replication studies, as well as additional discovery analyses, are currently underway in a cohort of 1000 AIS subjects.
Annals of Emergency Medicine S143
EMF-1
Palliative Medicine Competency Education in Emergency Medicine Residency Training: A Survey of Emergency Medicine Education Leaders
Kraus CK, Ray DE, Greenberg MR, Dy SM/LVHN, Allentown, PA; JHSPH, Baltimore, MD
Background: Emergency physicians care for patients with palliative and hospice needs. More than 75% of patients visit the ED in the last 6 months of their life, and two-thirds of those patients die while hospitalized. Emergency medicine (EM) residents need specific skills to care for patients with terminal illness and those conditions requiring end-of-life care. Study Objectives: To assess the current state of hospice and palliative medicine (HPM) competency instruction in EM residency training programs and to identify barriers and opportunities for integrating instruction in HPM competencies into EM training. Methods: IRB-approved, cross-sectional, mixed-mode survey of American Osteopathic Association and Accreditation Committee on Graduate Medical Education accredited EM residency program directors (PDs), associate PDs (APDs), and assistant PDs (aPDs). The survey was pilot tested among EM residency faculty from several institutions in distinct regions of the US. The survey was emailed to 402 subjects, and subsequently via US mail and in-person at a scientific meeting. Demographic variables and specific questions based on previously published HPM competencies for emergency physicians were collected. A five-point Likert scale (1¼least, 5¼most) was used to assess the following Four Domains of HPM training in EM programs: D1 - Importance of HPM competency for senior EM residents; D2 - Senior resident skill level in HPM competencies; D3 - Effectiveness of educational methods for HPM training; and D4 - Barriers to HPM training. Results: There was a 50 percent response rate, with half of respondents being PDs, a 60/40 percent distribution between paper and Web-based modes, and no statistical differences in demographic variables between groups. Responses represented 100 programs, with geographic distribution representative of locations of EM residencies. A majority of respondents (59 percent) identified HPM training as important and reported teaching HPM in their programs. In Domain 1, crucial conversations (mean 4.88, SD 0.40), management of pain (4.77, 0.53), and management of the imminently dying (4.74, 0.53) had the highest mean Likert scores for importance. In Domain 2, residents were reported to be most proficient in crucial conversations (4.28, 0.66), management of pain (4.17, 0.72), and management of the imminently dying (3.91, 0.88). In Domain 3, bedside teaching (4.53, 0.81), mentoring from HPM faculty (4.11, 0.97), and case-based simulation were identified as the most effective educational training methods. In Domain 4, lack of HPM expertise among faculty (3.57, 1.21), lack of faculty interest in HPM (3.42, 1.20), lack of resident interest in HPM (3.04, 1.20) were identified as the greatest barriers. Six competencies (withholding/withdrawal of non-beneficial interventions, management of imminently dying, HPM referrals, ethical/legal issues, spiritual/cultural issues, management of dying child) showed large differences in mean Likert scores between perceived importance and reported senior resident skill level. Conclusion: This study is the first comprehensive description of the state of HPM competency training in EM residencies. The results provide a foundation for focused educational and policy interventions and future research that can close curriculum gaps and improve HPM competency training for EM residents.
EMF-2
The Use of Prescription Drug Monitoring Programs and Geographic Information Systems to Identify Communities at Risk of Prescription Opioid Overdose Fatalities
Hoppe J, Monte A, Sasson C, Nassel A, Heard S, Kile D, Heard K/University of Colorado, Aurora, CO; University of Alabama-Birmingham, Birmingham, AL; Rocky Mountain Poison and Drug Center, Denver, CO
Study Objectives: Prescription drug abuse and misuse is a public health epidemic in the United States. Prescription drug monitoring programs (PDMPs) represent an excellent source of objective information for the evaluation of opioid prescribing and patterns of opioid use. Geographic Information Systems (GIS) are ideal for identifying areas at risk in order to appropriately guide interventions. Little is known about the geographic distribution and traits of the communities in which people die from prescription opioids. Our objective is to evaluate prescription opioid deaths through the application of GIS spatial analysis using readily available data from our state death
Volume 64, no. 4s : October 2014
registry and PDMP to (a) describe the PDMP histories of persons dying of prescription overdose and (b) identify and characterize communities at the highest risk for prescription opioid mortality in our state. Methods: This is a retrospective, cohort study of prescription overdose death cases from 2008-2012. The department of health identified cases by querying death records for specific ICD 9 codes; they then geocoded the decedents to the last known address. Prescription medication histories were collected for each case by querying our state’s PDMP using automated data searches. The searches were then verified with manual abstraction of ten percent of the cases with an agreement of 92%. The geocoded decedent addresses were plotted and evaluated using three separate spatial statistic methods: Empirical Bayes, Local Moran’s I, and Getis Ord GI*. Empirical Bayes smoothed incidence rates were calculated for prescription opioid death using Geoda, Local Moran’s I and GI* were calculated using ArcGIS. Results: A total of 4,028 prescription opioid deaths were included for analysis. 355 (9%) of decedents were not able to be geocoded, of these only 156 (4%) were state residents. 2,730 (68%) had an opioid prescription in our PDMP at any time. 1,527 (38%) filled an opioid prescription within 30 days before they died. 2,357 (59%) filled a prescription in the year before they died. In the cohort of patients that filled an opioid prescription in the year before death the median number of opioid prescriptions was 12 (range 1-169), the median number of pills was 649 (range 3-19,950), the median number for pharmacies was 2 (range 1-35), and the median number of prescribers was 3 (range 1-41). Maps of census tracts identified using each of three spatial statistic methods as having clusters of high prescription opioid deaths were overlaid to identify high-risk census tracts. Tracts identified by all three methods were identified and designated as Tier 1 high-risk tracts (n¼9), while census tracts identified by 2 out of 3 methods were designated Tier 2 high-risk tracts (n¼20). Conclusion: This is the first study to combine the use of death records, PDMP data and GIS spatial analysis to describe the type and distribution of prescription overdose deaths for our state. The high-risk census tracts identified using these spatial cluster analysis methods are possible sites for targeted community-based interventions to improve both health education and prescribing interventions.
EMF-3
Genetic Architecture of Human Ischemic Stroke
Heitsch L, Guilliams K, Ford A, Khoury N, Connor L, Cruchaga C, Lee J-M/Washington University, St Louis, MO
Study Objectives: Acute ischemic stroke (AIS) is a devastating disease that affects approximately 795,000 patients per year in the United States. In the hours following an acute ischemic stroke, neurological deficits can be highly unstable with some patients improving while others deteriorate. These early neurological changes are important due to their influence on long-term outcome and a number of potential mechanisms may affect these early changes. We performed a genome-wide association study (GWAS) on DNIHSS24h (NIH stroke scale (NIHSS) change from baseline to 24 hours after stroke onset) in AIS patients in order to identify genetic variants and genes associated with early neurologic improvement or deterioration. Methods: DNA from 191 AIS patients presenting within 6 hours of stroke onset was genotyped using an Affymetrix Exome-chip and rare variant analyses were performed. Single variant analysis was performed using PLINK, including age, baseline NIHSS and principal component factors as covariates. European- and AfricanAmericans were analyzed separately, with p-values combined by meta-analysis. Genebased analysis was performed using SKAT-O, including only non-synonymous variants, and the same covariates. Pathway analysis was performed using ALIGATOR to identify pathways with single nucleotide polymorphisms with significant associations. Results: Single variant analysis did not reveal genome-wide significant associations. One gene, IFIT1 (interferon-induced protein with tetratricopeptide repeats), passed the gene-based genome-wide multiple test correction. All three polymorphic variants in IFIT1 associated with neurologic deterioration with an average DNIHSS24h 9.5 points lower in carriers versus non-carriers. Pathway analysis, including 21 interferon-related genes but excluding IFIT1, showed a highly significant association (p¼2.3010-3) with DNIHSS24h. Conclusion: These data suggest that IFIT1 and other interferon-related genes may function in endogenous neuroprotective responses during acute ischemic stroke. Replication studies, as well as additional discovery analyses, are currently underway in a cohort of 1000 AIS subjects.
Annals of Emergency Medicine S143