Gender‐specific Research for Emergency Diagnosis and Management of Ischemic Heart Disease: Proceedings from the 2014 Academic Emergency Medicine Consensus Conference Cardiovascular Research Workgroup

Coronary artery disease (CAD) is the most common cause of death for both men and women. However, over the years, emergency physicians, cardiologists, and other health care practitioners have observed varying outcomes in men and women with symptomatic CAD. Women in general are 10 to 15 years older than men when they develop CAD, but suffer worse postinfarction outcomes compared to age‐matched men. This article was developed by the cardiovascular workgroup at the 2014 Academic Emergency Medicine (AEM) consensus conference to identify sex‐ and gender‐specific gaps in the key themes and research questions related to emergency cardiac ischemia care. The workgroup had diverse stakeholder representation from emergency medicine, cardiology, critical care, nursing, emergency medical services, patients, and major policy‐makers in government, academia, and patient care. We implemented the nominal group technique to identify and prioritize themes and research questions using electronic mail, monthly conference calls, in‐person meetings, and Web‐based surveys between June 2013 and May 2014. Through three rounds of nomination and refinement, followed by an in‐person meeting on May 13, 2014, we achieved consensus on five priority themes and 30 research questions. The overarching themes were as follows: 1) the full spectrum of sex‐specific risk as well as presentation of cardiac ischemia may not be captured by our standard definition of CAD and needs to incorporate other forms of ischemic heart disease (IHD); 2) diagnosis is further challenged by sex/gender differences in presentation and variable sensitivity of cardiac biomarkers, imaging, and risk scores; 3) sex‐specific pathophysiology of cardiac ischemia extends beyond conventional obstructive CAD to include other causes such as microvascular dysfunction, takotsubo, and coronary artery dissection, better recognized as IHD; 4) treatment and prognosis are influenced by sex‐specific variations in biology, as well as patient–provider communication; and 5) the changing definitions of pathophysiology call for looking beyond conventionally defined cardiovascular outcomes to patient‐centered outcomes. These emergency care priorities should guide future clinical and basic science research and extramural funding in an area that greatly influences patient outcomes.     

Sex‐ and Gender‐specific Research Priorities in Cardiovascular Resuscitation: Proceedings from the 2014 Academic Emergency Medicine Consensus Conference Cardiovascular Resuscitation Research Workgroup

Significant sex and gender differences in both physiology and psychology are readily acknowledged between men and women; however, data are lacking regarding differences in their responses to injury and treatment and in their ultimate recovery and survival. These variations remain particularly poorly defined within the field of cardiovascular resuscitation. A better understanding of the interaction between these important factors may soon allow us to dramatically improve outcomes in disease processes that currently carry a dismal prognosis, such as sudden cardiac arrest. As part of the 2014 Academic Emergency Medicine consensus conference “Gender‐Specific Research in Emergency Medicine: Investigate, Understand, and Translate How Gender Affects Patient Outcomes,” our group sought to identify key research questions and knowledge gaps pertaining to both sex and gender in cardiac resuscitation that could be answered in the near future to inform our understanding of these important issues. We combined a monthly teleconference meeting of interdisciplinary stakeholders from largely academic institutions with a focused interest in cardiovascular outcomes research, an extensive review of the existing literature, and an open breakout session discussion on the recommendations at the consensus conference to establish a prioritization of the knowledge gaps and relevant research questions in this area. We identified six priority research areas: 1) out‐of‐hospital cardiac arrest epidemiology and outcome, 2) customized resuscitation drugs, 3) treatment role for sex steroids, 4) targeted temperature management and hypothermia, 5) withdrawal of care after cardiac arrest, and 6) cardiopulmonary resuscitation training and implementation. We believe that exploring these key topics and identifying relevant questions may directly lead to improved understanding of sex‐ and gender‐specific issues seen in cardiac resuscitation and ultimately improved patient outcomes.     

Sex‐ and Gender‐specific Research Priorities for the Emergency Management of Heart Failure and Acute Arrhythmia: Proceedings from the 2014 Academic Emergency Medicine Consensus Conference Cardiovascular Research Workgroup

The emergency department (ED) is the point of first contact for patients with acute heart failure and arrhythmias, with 1 million annual ED visits in the United States. Although the total numbers of men and women living with heart failure are similar, female patients are underrepresented in clinical studies, with current knowledge predominantly based on data from male patients. This has led to an underappreciation of the sex‐specific differences in clinical characteristics and pathophysiology‐based management of heart failure. Similar disparities have been found in management of acute arrhythmias, especially atrial arrhythmias that lead to an increased risk of stroke in women. Additionally, peripartum and postpartum cardiomyopathy represent a diagnostic and treatment dilemma. This article is the result of a breakout session in the cardiovascular and resuscitation work group of the 2014 Academic Emergency Medicine consensus conference “Gender‐Specific Research in Emergency Medicine: Investigate, Understand, and Translate How Gender Affects Patient Outcomes.” A nominal group technique was used to identify and prioritize themes and research questions using electronic mail, monthly conference calls, in‐person meetings, and Web‐based surveys between June 2013 and May 2014. Consensus was achieved through three rounds of nomination followed by the meeting on May 13, 2014, and resulted in seven priority themes that are essential to the common complex clinical syndrome of heart failure for both men and women and include the areas of pathophysiology; presentation and symptomatology; and diagnostic strategies using biomarkers, treatment, and mortality, with special consideration to arrhythmia management and pregnancy.     

Untying the Gordian Knot: What We Do and Don't Know About Gender‐specific Medicine—Keynote Address for the 2014 Academic Emergency Medicine Consensus Conference

Over the past two decades, a burgeoning interest in women's health, the direct consequence of the feminist movement, has inspired a worldwide interest in the differences between the normal function of men and women and their unique experiences of the same illnesses. The scope and significance of what we have discovered and continue to find has fundamentally changed the way we prevent, diagnose, and treat diseases. Important questions remain, however, and deserve specific investigation and analysis.     

Organization,Execution and Evaluation of the 2014 Academic Emergency Medicine Consensus Conference on Gender‐Specific Research in Emergency Care – An Executive Summary

With the goal of reducing inequalities in patient care, the 2014 Academic Emergency Medicine (AEM) consensus conference, “Gender‐Specific Research in Emergency Care: Investigate, Understand, and Translate How Gender Affects Patient Outcomes,” convened a diverse group of researchers, clinicians, health care providers, patients, and representatives of federal agencies and policy‐makers in Dallas, Texas, in May 2014. The executive and steering committees identified seven clinical domains as key to gender‐specific emergency care: cardiovascular, neurological, trauma/injury, substance abuse, pain, mental health, and diagnostic imaging. The main aims of the conference were to: 1) summarize and consolidate current data related to sex‐ and gender‐specific research for acute care and identify critical gender‐related gaps in knowledge to inform an EM research agenda; 2) create a consensus‐driven research agenda that advances sex‐ and gender‐specific research in the prevention, diagnosis, and management of acute diseases and identify strategies to investigate them; and 3) build a multinational interdisciplinary consortium to disseminate and study the sex and gender medicine of acute conditions. Over a 2‐year period, this collaborative network of stakeholders identified key areas where sex‐ and gender‐specific research is most likely to improve clinical care and ultimately patient outcomes. The iterative consensus process culminated in a daylong conference on May 13, 2014, with a total of 133 registrants, with the majority being between ages 31 and 50 years (57%), females (71%), and whites (79%). Content experts led the consensus‐building workshops at the conference and used the nominal group technique to consolidate consensus recommendations for priority research. In addition, panel sessions addressed funding mechanisms for gender‐specific research as well as gender‐specific regulatory challenges to product development and approval. This special issue of AEM reports the results of the 2014 consensus conference as well as related original research with the goal of bringing high‐quality equitable care to male and female emergency patients.     

Emergency Medicine Gender‐specific Education

The 2014 Academic Emergency Medicine consensus conference has taken the first step in identifying gender‐specific care as an area of importance to both emergency medicine (EM) and research. To improve patient care, we need to address educational gaps in this area concurrent with research gaps. In this article, the authors highlight the need for sex‐ and gender‐specific education in EM and propose guidelines for medical student, resident, and faculty education. Specific examples of incorporating this content into grand rounds, simulation, bedside teaching, and journal club sessions are reviewed. Future challenges and strategies to fill the gaps in the current education model are also described.     

Safety Net Research in Emergency Medicine Proceedings of the Academic Emergency Medicine Consensus Conference on "The Unraveling Safety Net"

A primary goal of the Academic Emergency Medicine Consensus Conference, "The Unraveling Safety Net: Research Opportunities and Priorities," was to explore a formal research agenda for safety net research in emergency medicine. This paper represents the thoughts of active health services researchers regarding the structure and direction of such work, including some examples from their own research. The current system for safety net care is described, and the emergency department is conceptualized as a window on safety net patients and systems, uniquely positioned to help study and coordinate integrated processes of care.     

Gender‐ and Sex‐specific Sports‐related Injury Research in Emergency Medicine: A Consensus on Future Research Direction and Focused Application

Title IX, the commercialization of sports, the social change in sports participation, and the response to the obesity epidemic have contributed to the rapid proliferation of participation in both competitive organized sports and nontraditional athletic events. As a consequence, emergency physicians are regularly involved in the acute diagnosis, management, disposition, and counseling of a broad range of sports‐related pathology. Three important and highly publicized mechanisms of injury in sports relevant to emergency medicine (EM) include concussion, heat illness, and sudden cardiac death. In conjunction with the 2014 Academic Emergency Medicine consensus conference “Gender‐specific Research in Emergency Care: Investigate, Understand, and Translate How Gender Affects Patient Outcomes,” a consensus group consisting of experts in EM, emergency neurology, sports medicine, and public health convened to deliberate and develop research questions that could ultimately advance the field of sports medicine and allow for meaningful application in the emergency department (ED) clinical setting. Sex differences in injury risk, diagnosis, ED treatment, and counseling are identified in each of these themes. This article presents the consensus‐based priority research agenda.     

Future Directions in Sex‐ and Gender‐specific Emergency Medicine

The 2014 Academic Emergency Medicine (AEM) consensus conference “Gender‐Specific Research in Emergency Medicine: Investigate, Understand, and Translate How Gender Affects Patient Outcomes” convened a diverse group of stakeholders to target gaps in emergency medicine (EM) sex‐ and gender‐specific research and identify research priorities. At the close of the conference, the executive committee sought feedback from group leaders and conference attendees about the next critical steps in EM sex‐ and gender‐specific research, goals for their own future research, and anticipated barriers in pursuing this research. This article summarizes this feedback on the future directions in sex‐ and gender‐specific research in emergency care and strategies to overcome barriers.     

Gender‐specific Regulatory Challenges to Product Approval: A Panel Discussion

On May 13, 2014, a 1‐hour panel discussion session titled “Gender‐specific Regulatory Challenges to Product Approval” was held during the Academic Emergency Medicine consensus conference, “Gender‐specific Research in Emergency Medicine: Investigate, Understand, and Translate How Gender Affects Patient Outcomes.” The session sought to bring together leaders in emergency medicine (EM) research, authors, and reviewers in EM research publications, as well as faculty, fellows, residents, and students engaged in research and clinical practice. A panel was convened involving a representative from the Office of Women's Health of the U.S. Food and Drug Administration, two pharmaceutical executives, and a clinical EM researcher. The moderated discussion also involved audience members who contributed significantly to the dialogue. Historical background leading up to the session along with the main themes of the discussion are reproduced in this article. These revolve around sex‐ and gender‐specific research, statistical analysis of sex and gender, clinical practice, financial costs associated with pharmaceutical development, adaptive design, and specific recommendations on the regulatory process as it affects the specialty of EM.     

2018 Academic Emergency Medicine Consensus Conference: A Workforce Development Research Agenda for Pediatric Care in the Emergency Department

Each year, more than 30 million children visit U.S. emergency departments (EDs). Although the number of pediatric emergency medicine specialists continues to rise, the vast majority of children are cared for in general EDs outside of children's hospitals. The diverse workforce of care providers for children must possess the knowledge, experience, skills, and systemic support necessary to deliver excellent pediatric emergency care. There is a crucial need to understand the factors that drive the professional development and support systems of this diverse workforce. Through the iterative process culminating with the 2018 Academic Emergency Medicine consensus conference, we have identified five key research themes and prioritized a specific research agenda. These themes represent critical gaps in our understanding of the development and maintenance of the pediatric emergency care workforce and allow for a prioritization of future research efforts. Only by more fully understanding the gaps in workforce needs, and the necessary steps to address these gaps, can outcomes be optimized for children in need of emergency care.     

The Role of Graduate Medical Education in Global Health: Proceedings From the 2013 Academic Emergency Medicine Consensus Conference

The past 40 years have seen expanded development of emergency medicine (EM) postgraduate residency training programs worldwide. An important part of this educational experience is the ability of resident trainees to participate in experiences abroad. However, little is known about how these experiences shape trainees and the populations they serve. During the 2013 Academic Emergency Medicine consensus conference, a group of educators met to define and outline current trends in graduate medical education (GME) emergency care research. The authors discuss future research questions bridging the gap of GME and global health.