Management pathway for emergency department patients in the setting of the opioid epidemic and emergency department overcrowding

Kiersten Gurley,Churchill Onyeii,Jonathan Burstein,Shamai Grossman 대한응급의학회 2020 Clinical and Experimental Emergency Medicine Vol.7 No.2

Objective The United States is currently in the midst of a major opioid addiction epidemic, of which the primary drivers are a sharp increase in prescription opioid pain medications, their misuse, and the inordinate illicit use of opioids. Declared a national health emergency, the opioid crisis puts enormous pressure on various systems, including increasing overcrowding in emergency departments (EDs) and forced changes in prescribing practices. We are piloting a newly-developed ED opiate pathway to streamline ED care for patients who frequently present at the ED for chronic pain management or other recurrent pain-causing medical problems. Methods Patients at risk of possible opioid addiction are identified and their records are reviewed. If there is no narcotics agreement in place, the ED care team contacts the primary care physician and any other service providers involved in the patient’s care to create a comprehensive pain management program. Results Our pathway is simple and geared toward streamlining and improving care for patients with opioid addiction and misuse. We looked at seven patients in this pilot study with mixed results regarding decreasing future ED visits. Conclusion This strategy may both limit opioid usage and abuse as well as limit ED visits and overcrowding by streamlining ED care for patients who frequently present for chronic pain management or other recurrent medical problems.

Roof tile frangibility and puncture of metal window shutters

Laboy-Rodriguez, Sylvia T.,Smith, Daniel,Gurley, Kurtis R.,Masters, Forrest J. Techno-Press 2013 Wind and Structures, An International Journal (WAS Vol.17 No.2

The goal of this study was to investigate the vulnerability of roof tile systems and metal shutters to roof tile debris. Three phases addressed the performance of tile roof systems and metal shutters impacted by roof tile debris. The first phase experimentally evaluated the tile fragment size and quantity generated by a tile striking a tile roof system. The second phase experimentally quantified the puncture vulnerability of common metal panel shutter systems as a function of tile fragment impact speed. The third phase provided context for interpretation of the experimental results through the use of a tile trajectory model. The results provide supporting evidence that while metal panel window shutters provide significant protection against a prevalent form of windborne debris, these systems are vulnerable to tile fragment puncture in design level tropical cyclones. These findings correlate with field observations made after Hurricane Charley (2004).

Roof tile frangibility and puncture of metal window shutters

Sylvia T. Laboy-Rodriguez,Kurtis R. Gurley,Daniel Smith,Forrest J. Masters 한국풍공학회 2013 한국풍공학회지 Vol.17 No.2

The goal of this study was to investigate the vulnerability of roof tile systems and metal shutters to roof tile debris. Three phases addressed the performance of tile roof systems and metal shutters impacted by roof tile debris. The first phase experimentally evaluated the tile fragment size and quantity generated by a tile striking a tile roof system. The second phase experimentally quantified the puncture vulnerability of common metal panel shutter systems as a function of tile fragment impact speed. The third phase provided context for interpretation of the experimental results through the use of a tile trajectory model. The results provide supporting evidence that while metal panel window shutters provide significant protection against a prevalent form of windborne debris, these systems are vulnerable to tile fragment puncture in design level tropical cyclones. These findings correlate with field observations made after Hurricane Charley (2004).

Hurricane vulnerability model for mid/high-rise residential buildings

Gonzalo L. Pita,Jean-Paul Pinelli,Kurt Gurley,Johann Weekes,Steve Cocke,Shahid Hamid 한국풍공학회 2016 Wind and Structures, An International Journal (WAS Vol.23 No.5

Catastrophe models appraise the natural risk of the built-infrastructure simulating the interaction of its exposure and vulnerability with a hazard. Because of unique configurations and reduced number, mid/high-rise buildings present singular challenges to the assessment of their damage vulnerability. This paper presents a novel approach to estimate the vulnerability of mid/high-rise buildings (MHB) which is used in the Florida Public Hurricane Loss Model, a catastrophe model developed for the state of Florida. The MHB vulnerability approach considers the wind pressure hazard exerted over the building's height as well as accompanying rain. The approach assesses separately the damages caused by wind, debris impact, and water intrusion on building models discretized into typical apartment units. Hurricane-induced water intrusion is predicted combining the estimates of impinging rain with breach and pre-existing building defect size estimates. Damage is aggregated apartment-by-apartment and story-by-story, and accounts for vertical water propagation. The approach enables the vulnerability modeling of regular and complex building geometries in the Florida exposure and elsewhere.

Hurricane vulnerability model for mid/high-rise residential buildings

Pita, Gonzalo L.,Pinelli, Jean-Paul,Gurley, Kurt,Weekes, Johann,Cocke, Steve,Hamid, Shahid Techno-Press 2016 Wind and Structures, An International Journal (WAS Vol.23 No.5

Catastrophe models appraise the natural risk of the built-infrastructure simulating the interaction of its exposure and vulnerability with a hazard. Because of unique configurations and reduced number, mid/high-rise buildings present singular challenges to the assessment of their damage vulnerability. This paper presents a novel approach to estimate the vulnerability of mid/high-rise buildings (MHB) which is used in the Florida Public Hurricane Loss Model, a catastrophe model developed for the state of Florida. The MHB vulnerability approach considers the wind pressure hazard exerted over the building's height as well as accompanying rain. The approach assesses separately the damages caused by wind, debris impact, and water intrusion on building models discretized into typical apartment units. Hurricane-induced water intrusion is predicted combining the estimates of impinging rain with breach and pre-existing building defect size estimates. Damage is aggregated apartment-by-apartment and story-by-story, and accounts for vertical water propagation. The approach enables the vulnerability modeling of regular and complex building geometries in the Florida exposure and elsewhere.

Getting to the heart of the issue: senior emergency resident electrocardiogram interpretation and its impact on quality assurance events

Leslie A Bilello1,Céline Pascheles,Kiersten Gurley,Douglas Rappaport,David T Chiu,Shamai A. Grossman,Carlo L Rosen 대한응급의학회 2020 Clinical and Experimental Emergency Medicine Vol.7 No.3

Objective Electrocardiogram (ECG) interpretation skills are of critical importance for diagnostic accuracy and patient safety. In our emergency department (ED), senior third-year emergency medicine residents (EM3s) are the initial interpreters of all ED ECGs. While this is an integral part of emergency medicine education, the accuracy of ECG interpretation is unknown. We aimed to review the adverse quality assurance (QA) events associated with ECG interpretation by EM3s. Methods We conducted a retrospective study of all ED ECGs performed between October 2015 and October 2018, which were read primarily by EM3s, at an urban tertiary care medical center treating 56,000 patients per year. All cases referred to the ED QA committee during this time were reviewed. Cases involving a perceived error were referred to a 20-member committee of ED leadership staff, attendings, residents, and nurses for further consensus review. Ninety-five percent confidence intervals (CIs) were calculated. Results EM3s read 92,928 ECGs during the study period. Of the 3,983 total ED QA cases reviewed, errors were identified in 268 (6.7%; 95% CI, 6.0%–7.6%). Four of the 268 errors involved ECG misinterpretation or failure to act on an ECG abnormality by a resident (1.5%; 95% CI, 0.0%–2.9%). Conclusion A small percentage of the cases referred to the QA committee were a result of EM3 misinterpretation of ECGs. The majority of emergency medicine residencies do not include the senior resident as a primary interpreter of ECGs. These findings support the use of EM3s as initial ED ECG interpreters to increase their clinical exposure.

Antimicrobial and Anti-Inflammatory Effects of Cecropin A(1-8)–Magainin2(1-12) Hybrid Peptide Analog P5 against Malassezia furfur Infection in Human Keratinocytes

Ryu, Sunhyo,Choi, Soon-Yong,Acharya, Samudra,Chun, Young-Jin,Gurley, Catherine,Park, Yoonkyung,Armstrong, Cheryl A,Song, Peter I,Kim, Beom-Joon The Society for Investigative Dermatology, Inc 2011 The Journal of investigative dermatology Vol.131 No.8

The lipophilic fungus Malassezia furfur (M. furfur) is a commensal microbe associated with several chronic diseases such as pityriasis versicolor, folliculitis, and seborrheic dermatitis. Because M. furfur-related diseases are difficult to treat and require prolonged use of medications, the treatment for M. furfur-related skin diseases is supposed to gain control over M. furfur growth and the inflammation associated with it, as well as to prevent secondary infections. In this study, we investigated the antifungal and anti-inflammatory effects of cecropin A(1-8)–magainin 2(1-12) hybrid peptide analog P5 on M. furfur. The minimal inhibitory concentration of P5 against M. furfur was 0.39 μM, making it 3–4 times more potent than commonly used antifungal agents such as ketoconazole (1.5 μM) or itraconazole (1.14 μM). P5 efficiently inhibited the expression of IL-8 and Toll-like receptor 2 in M. furfur-infected human keratinocytes without eukaryotic cytotoxicity at its fungicidal concentration. Moreover, P5 significantly downregulated NF-κB activation and intracellular calcium fluctuation, which are closely related with enhanced responses of keratinocyte inflammation induced by M. furfur infection. Taken together, these observations suggest P5 may be a potential therapeutic agent for M. furfur-associated human skin diseases because of its distinct antifungal and anti-inflammatory action.