Abstract.Multicenter clinical trials require approval by multiple local institutional review boards (IRBs). The Multicenter Airway Research Collaboration mailed a clinical trial protocol to its U.S. investigators and 44 IRBs ultimately reviewed it. Objective: To describe IRB responses to one standard protocol and thereby gain insight into the advantages and disadvantages of local IRB review. Methods: Two surveys were mailed to participants, with telephone follow-up of nonrespondents. Survey 1 was mailed to 82 investigators across North America. Survey 2 was mailed to investigators from 44 medical centers in 17 U.S. states. Survey 1 asked about each investigator's local IRB (e.g., frequency of meetings, membership), whereas survey 2 asked about IRB queries and concerns related to the submitted clinical trial. Results: Both surveys had 100% response rate. Investigators submitted applications a median of 58 days (interquartile range [IQR], 40-83) after receipt of the pro-

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The theme of the 14th annual Academic Emergency Medicine consensus conference was "Global Health and Emergency Care: A Research Agenda." The goal of the conference was to create a robust and measurable research agenda for evaluating emergency health care delivery systems. The concept of health systems includes the organizations, institutions, and resources whose primary purpose is to promote, restore, and/or maintain health. This article further conceptualizes the vertical and horizontal delivery of acute and emergency care in low-resource settings by defining specific terminology for emergency care platforms and discussing how they fit into broader health systems models. This was accomplished through discussion surrounding four principal questions touching upon the interplay between health systems and acute and emergency care. This research agenda is intended to assist countries that are in the early stages of integrating emergency services into their health systems and are looking for guidance to maximize their development and health systems planning efforts.ACADEMIC EMERGENCY MEDICINE 2013; 20:1278-1288© 2013 by the Society for Academic Emergency Medicine A chieving the highest attainable standard of health requires universal access to essential services that are rationally distributed and utilized. Timely action in response to emergent disease presentations is one such essential health service. At present, many national health systems are oriented to specific diseases rather than cross-cutting "systems" interventions that might have a larger long-term effect by strengthening systemwide capacity. The natural history and epidemiology of emergencies emphasize that highly functional health systems, including intact and codified referral networks, are necessary to improve survival of patients with acute diseases. Failure to prioritize integration across disease-oriented programs and service delivery units, and failure to deliver emergency health services promptly, results in care that is poorly coordinated and poorly applied (e.g., delays in treating sepsis with antibiotics leading to death or disability). Such fragmentation of care reduces the disease burden that can be addressed with a given set of resources. Integration of emergency services has the potential to improve outcomes with fixed resource inputs by improving both organization of services and efficiency of service delivery. Given the nature of the problem, consensus is necessary both to define and to prioritize health problems and to decide which services are essential. Expert consensus conferences may usefully establish the boundaries of common understanding and determine which questions require further investigation; saving lives in times of emergency thus depends on action that is informed by consensus, validated by research, and executed in a standardized manner.,This article presents the research recommendations developed during the breakout session on global emergency care and health systems at the Academic Emergency Medicine consensus ...

Natural language processing (NLP) aims to program machines to interpret human language as humans do. It could quantify aspects of medical education that were previously amenable only to qualitative methods. The application of NLP to medical education has been accelerating over the past several years. This article has three aims. First, we introduce the reader to NLP. Second, we discuss the potential of NLP to help integrate FOAM (Free Open Access Medical Education) resources with more traditional curricular elements. Finally, we present the results of a systematic review. We identified 30 articles indexed by PubMed as relating to medical education and NLP, 14 of which were of sufficient quality to include in this review. We close by discussing potential future work using NLP to advance the field of medical education in emergency medicine.

During the last few years, a growing number of studies have shown the accuracy of lung ultrasound in the diagnosis of pulmonary diseases. The latest developments in lung ultrasound are not because of technological advance, but are based on new applications and discovering the meanings of sonographic artifacts. Real-time sonography of the lung in the emergency department saves time and cost, providing immediate information to the clinician, relying on very easy-to-acquire data. The bedside sonographic recognition of pulmonary diseases practically guides management and reduces the amount of negative radiologic image testings. This review describes some innovative practical applications of B-mode lung ultrasound in the diagnosis of alveolar consolidations and interstitial syndrome in the emergency department.

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Background Admission hyperglycemia has been reported as a mortality risk factor for septic nondiabetic patients; however, hyperglycemia’s known association with hyperlactatemia was not addressed in these analyses. Objectives The objective was to determine whether the association of hyperglycemia with mortality remains significant when adjusted for concurrent hyperlactatemia. Methods This was a post hoc, nested analysis of a retrospective cohort study performed at a single center. Providers had identified study subjects during their ED encounters; all data were collected from the electronic medical record (EMR). Nondiabetic adult ED patients hospitalized for suspected infection, two or more systemic inflammatory response syndrome (SIRS) criteria, and simultaneous lactate and glucose testing in the ED were enrolled. The setting was the ED of an urban teaching hospital from 2007 to 2009. To evaluate the association of hyperglycemia (glucose > 200 mg/dL) with hyperlactatemia (lactate ≥ 4.0 mmol/L), a logistic regression model was created. The outcome was a diagnosis of hyperlactatemia, and the primary variable of interest was hyperglycemia. A second model was created to determine if coexisting hyperlactatemia affects hyperglycemia’s association with mortality; the main outcome was 28-day mortality, and the primary risk variable was hyperglycemia with an interaction term for simultaneous hyperlactatemia. Both models were adjusted for demographics; comorbidities; presenting infectious source; and objective evidence of renal, respiratory, hematologic, or cardiovascular dysfunction. Results A total of 1,236 ED patients were included, and the median age was 77 years (interquartile range [IQR] = 60 to 87 years). A total of 115 (9.3%) subjects were hyperglycemic, 162 (13%) were hyperlactatemic, and 214 (17%) died within 28 days of their initial ED visits. After adjustment, hyperglycemia was significantly associated with simultaneous hyperlactatemia (odds ratio [OR] = 4.14, 95% confidence interval [CI] = 2.65 to 6.45). Hyperglycemia and concurrent hyperlactatemia were associated with increased mortality risk (OR = 3.96, 95% CI = 2.01 to 7.79), but hyperglycemia in the absence of simultaneous hyperlactatemia was not (OR = 0.78, 95% CI = 0.39 to 1.57). Conclusions In this cohort of septic adult nondiabetic patients, mortality risk did not increase with hyperglycemia unless associated with simultaneous hyperlactatemia. The previously reported association of hyperglycemia with mortality in nondiabetic sepsis may be due to the association of hyperglycemia with hyperlactatemia.

Objective To determine if metformin use affects the prevalence and prognostic value of hyperlactatemia to predict mortality in septic adult Emergency Department (ED) patients. Methods Single-center retrospective cohort study. ED providers identified study subjects; data was collected from the medical record. Patients Adult ED patients with suspected infection and 2 or more Systemic Inflammatory Response Syndrome Criteria. The outcome was 28-day mortality. The primary risk variable was serum lactate (< 2.0; 2.0–3.9; ≥4.0 mmol/L) categorized by metformin use; covariates-demographics, Predisposition, Infection, Response, Organ Dysfunction score, and metformin use contraindications. Setting Urban teaching hospital; 2/1/2007 to 10/31/2008. Results 1947 ED patients were enrolled; 192 (10%) were taking metformin; 305 (16%) died within 28-days. Metformin users had higher median lactate levels than non-users [2.2 mmol/L (IQR 1.6–3.2) vs. 1.9 mmol/L (IQR 1.3–2.8)] and a higher, though non-significant, prevalence of hyperlactatemia (lactate ≥ 4.0 mmol/L) (17% vs. 13%) (p=0.17). In multivariate analysis (reference group non-metformin users, lactate < 2.0 mmol/L), hyperlactatemia was associated with an increased adjusted 28-day mortality risk among non-metformin users (OR = 3.18, p < 0.01), but not among metformin users (OR = 0.54, p=0.33). Additionally, non-metformin users had a higher adjusted mortality risk than metformin users (OR = 2.49, p < 0.01). These differences remained significant when only diabetics were analyzed. Conclusions In this study of adult ED patients with suspected sepsis, metformin users had slightly higher median lactate levels and prevalence of hyperlactatemia. However, hyperlactatemia did not predict an increased mortality risk in patients taking metformin.