Emergency Department Evaluation Research Articles

An Elusive Case of Tuberculous Meningitis in a Young Man With Altered Mental Status

BackgroundTuberculous meningitis (TBM) is a rare, frequently elusive diagnosis, often characterized by vague symptoms and associated with high rates of morbidity and mortality. Case ReportWe present a case of TBM in a young man with a headache and altered mental status. In addition, we provide a brief history of TBM, review the pathophysiology of the disease, discuss clinical and radiologic features, and detail the management of TBM both emergently and throughout our patient's hospital course. Why Should an Emergency Physician Be Aware of This?Our patient's lack of pulmonary symptoms, initially unremarkable head computed tomography, and two prior emergency department evaluations for headache without concerning historical features or physical examination findings collectively highlight the challenges of diagnosing TBM early in its symptom course. We encourage emergency physicians to consider TBM in appropriate patients, particularly those with risk factors for tuberculosis infection.

Reducing Unnecessary 'Admission' Chest X-rays: An Initiative to Minimize Low-Value Care.

Introduction Internal medicine admission services often request a baseline admission chest X-ray (CXR) for patients already admitted to the emergency department (ED) and who are waiting for inpatient beds, despiterarely providing clinical value. Adverse consequences of such CXRs include unnecessary radiation exposure, cost, time, and false positives, which can trigger a diagnostic cascade. Extraneous CXRs performed on already-admitted ED patients can delay inpatient transfer, thereby increasing boarding and crowding, whichin turnmay affect mortality and satisfaction. In 2016, our ED and internal medicine hospitalist services implemented guidelines (reflecting those of the American College of Radiology) to reduce unnecessary admission CXRs. All relevant providers were educated on the guideline. The primary aim of this study was to determine if there were changes in the percentage of patients with pre-admission and admission CXRs following guideline implementation. Our secondary aim was to determine which patient characteristics predict getting a CXR. Methods All ED and internal medicine hospitalist providers were educated once about the guideline. We performed a retrospective analysis of pre- vs. post-guideline data. Patients were included if admitted to the internal medicine service during those timeframes with an admission diagnosis unrelated to the cardiac or pulmonary systems. A CXR performed during ED evaluation prior to the admission disposition time was recorded as "pre-admission," andif performed after disposition time it was recorded as "admission." A CXR was "unwarranted" if the admission diagnosis did not suggest a CXR was necessary. The numerator was the number of unnecessary admissionCXRs ordered on patients with diagnoses unrelated to the cardiac or pulmonary systems (minus those with a pre-admission CXR); the denominator was the number of such admissions (minus those with a pre-admission CXR). Variables of interest that might influence whether a CXR was ordered were age, gender, respiratory rate ≥20,cardiac- or pulmonary-related chief complaint, ED diagnosis category, or past medical history. Results Among admitted patients with diagnoses that did not suggest a CXR was warranted, there was no change in the percentage of admission CXRs (21.7% to 25.6%, p = 0.2678), whereas the percentage with pre-admission CXRs decreased (66.6% to 60.7%, p = 0.0152). This decrease was driven by fewer CXRs being performed on patients whose chief complaint did not suggest one was indicated (p = .0121). In multivariate analysis, risk factors for an unwarranted CXR were age >40 (risk ratio (RR) = 2.9) and past medical history of cardiovascular disease (e.g., myocardial infarction, atrial fibrillation), renal disease, or hyperkalemia. Conclusion This educational initiative was not associated with the intended decrease in ordering unwarranted admission CXRs among ED boarding patients, though there was an unanticipated decrease in pre-admission CXRs. This decrease was driven by fewer CXRs being performed on patients whose chief complaint did not suggest one was indicated. Organizations interested in reducing processes with little clinical value might adopt a similar program while emphasizing the lack of benefit to admitted patients through iterative educational programs on hospital admitting services.

Utility of telemedicine in tracheostomy-dependent children.

Telemedicine can improve access to pediatric otolaryngology care by decreasing travel time and cost, and lowering the risk of viral transmission during the SARS-CoV-2 (COVID-19) pandemic. This study aims to identify the clinical role and outcomes of telemedicine for tracheostomy-dependent children before and during the COVID-19 pandemic. Retrospective chart review of 42 tracheostomy-dependent pediatric patients who utilized telemedicine between October 2013 and April 2020 (pre-COVID-19), and 111 patients who utilized telemedicine between May 2020 and July 2021 (during COVID-19) at a tertiary free-standing children's hospital outpatient clinic. The majority of pre-COVID-19 telecommunication solely addressed tracheostomy stomal concerns as compared with during COVID-19 (99% vs. 3%, p < .001), while telecommunication during COVID-19 was mainly used for routine follow-up as compared with pre-COVID-19 (99% vs. 0%, p < .001). Telemedicine visits during COVID-19 were significantly less likely to result in the need for in-person office visits as compared with those pre-COVID-19 (4% vs. 22%; p < .001). There was no significant difference in urgent emergency department (ED) evaluation following telemedicine pre- and during COVID-19 (16% vs. 11%). The most common reasons for ED presentation both pre- and during COVID-19 following telemedicine visit included respiratory distress, dislodged tracheostomy tube, and tracheostomy bleeding. The clinical role of telemedicine has evolved from problem-based evaluation to routine follow-up during the COVID-19 pandemic. Although telemedicine can decrease the need for in-person office evaluation of routine tracheostomy concerns, respiratory complications and tracheostomy bleeding still require urgent in-person ED evaluation. Level 4.

47 A Host Protein Test Based on TRAIL, IP-10 and CRP for Differentiating Between Bacterial and Viral Infection Has Potential to Improve Patient Selection for Blood Culture Utilization

47 A Host Protein Test Based on TRAIL, IP-10 and CRP for Differentiating Between Bacterial and Viral Infection Has Potential to Improve Patient Selection for Blood Culture Utilization

25 Derivation and Validation of a Clinical Decision Rule to Risk Stratify Emergency Department Patients Diagnosed With Seasonal Influenza

25 Derivation and Validation of a Clinical Decision Rule to Risk Stratify Emergency Department Patients Diagnosed With Seasonal Influenza

81 Development of a Novel Emergency Department Quality Measure to Reduce Very Low-Risk Syncope Hospitalizations

Emergency department (ED) evaluations for syncope are common, representing 1.3 million annual US visits and $2 billion in related hospitalizations. Despite a growing evidence-base supporting clinical risk stratification and outpatient management, wide variation in syncope hospitalization rates persist. In order to address low-yield hospitalizations, we sought to develop a new quality measure for very low risk ED adult syncope patients who can be incorporated into performance improvement programs using national administrative data.

131 Adulterated Heroin: Presentations and Outcomes of a Large Case Series of Contaminated Heroin

Cocaine and heroin frequently undergo dilution and adulteration along the distribution path to increase the number of doses available as well as to modify the drugs effect. Diluents, such as talc, are pharmacologically inactive. Adulterants are pharmacologically active and multiple agents with disparate mechanisms of action are often present together. This case series of adulterated heroin resulted in an epidemic of emergency department (ED) evaluations. The causative adulterants are currently undergoing analysis.

67 Tele-Emergency Care May Improve Access to Emergency Care Resources While Reducing Need for In-Person Emergency Department Evaluation

Access to timely emergency medical care is essential to the US health care system but can be particularly challenging for individuals in rural communities and those with physical impediments, strained economic resources, and increased susceptibility to nosocomial COVID-19 infection. Emergency care access is further impacted by emergency department (ED) crowding and limited resources. Telemedicine presents an innovative solution towards improving this access. We aim to evaluate the final disposition of patients utilizing the Veterans Health Administration Desert Pacific Veterans Integrated Service Network’s (VISN 22) novel Tele-Emergency Care program (TEC) to describe the efficacy of this innovative option in increasing Veterans’ access to care and conserving ED resource utilization.

164 The Impact of Hallway Placement on Emergency Department Operations for Discharged Patients with Abdominal Pain

Emergency department (ED) crowding is a constant and relentless operational challenge facing hospitals across the country. In response to limited capacity many EDs increasingly care for patients in hallways to provide timely access to ED evaluation and facilitate ED flow. We sought to examine the impact of patient placement in the hallway on common ED throughput and quality measures for discharged abdominal pain patients.

37 Inequities Among Emergency Department Hallway Utilization

Emergency department (ED) crowding is a constant and relentless operational challenge facing hospitals across the country. In response to limited capacity, many EDs increasingly care for patients in hallways to provide timely access to ED evaluation. However, hallway placement can also lead to lower patient satisfaction and lower quality of care. We sought to explore social risk factors and ED operations features that may be associated with the hallway placement decision.

Evaluating caretaker satisfaction with same‐day discharge after gastrostomy tube placement

BackgroundSame-day discharge (SDD) after laparoscopic gastrostomy tube (G-tube) placement, using written and video-based preoperative education, has been our standard institutional practice since 2017. We aim to evaluate caretaker satisfaction with this protocol. MethodsAll patients planned for SDD after G-tube placement from February 2021-February 2022 were identified. Chart review was performed to identify demographic information, successful same-day discharge or reason for postoperative admission, time to first postoperative feed, length of stay (LOS), and complications requiring emergency department evaluation, readmission, or reoperation. Telephone follow-up at two weeks postoperatively was conducted to evaluate satisfaction with the SDD protocol. ResultsForty-nine patients were eligible for SDD with a median age of 1.1 years [0.7, 4.4]. Forty-two (86%) patients were successfully discharged the same day with a median LOS of 7.5 h [6.7, 8.1], and 7 (14%) were admitted postoperatively for further education or emesis with a median LOS of 30.4 h [26.9, 31.2]. Median time to initiation of feeds was 2.3 h [1.7, 2.9]. 8 (16%) patients were evaluated in the emergency department within 30 days postoperatively, resulting in two re-admissions: one for peri‑stomal erythema and fever requiring oral antibiotics at 21 days and one for G-tube dislodgement requiring reoperation and replacement at 28 days. On two-week telephone follow-up, 42 caretakers (100%) felt that their education was adequate for same-day discharge and felt comfortable with the same-day discharge protocol. Six (14%) caretakers stated their child's pain was not well controlled at some point between discharge and survey follow-up, and three caretakers (7%) called a provider within the first 24 h for issues with pain. Forty-one caretakers (98%) expressed satisfaction going home the day of surgery. ConclusionCaretaker satisfaction and comfort with same-day discharge following laparoscopic G-tube placement are high, ascribed to comprehensive preoperative education and anticipatory guidance. Type of studyPrognostic. Level of evidenceLevel 1.

Performance Evaluation of the Hospital's Emergency Department: An Integrated Approach based on Resilience Engineering and Lean Management

بخش اورژانس یکی از شلوغ‌ترین بخش‌های یک بیمارستان است و بهبود عملکرد این بخش تأثیر بسیاری در بهبود کیفیت ارائه خدمات بیمارستان دارد. اخیراً پژوهشگران به­‌دلیل تمرکز مهندسی تاب‌آوری و مدیریت ناب بر کارایی سیستم‌ها توجه بسیار زیادی به این دو دیدگاه در کنار یکدیگر داشته‌اند. هدف این پژوهش، ارائه رویکردی یکپارچه برای ارزیابی عملکرد مبتنی بر شاخص‌های مهندسی تاب‌آوری و مدیریت ناب با هدف ارتقای رضایت شغلی و کاهش هزینه‌های درمانی در واحد اورژانس یک بیمارستان خصوصی است. به این منظور، ابتدا با شناسایی شاخص‌های مؤثر، مدل مفهومی مسئله طراحی شد؛ سپس داده‌های موردنیاز با استفاده از پرسشنامه‌ای استاندارد جمع‌آوری شدند. در گام بعدی، با استفاده از الگوریتم مبتنی بر تحلیل پوششی داده‌ها و با حضور تمام شاخص‌ها، مقادیر کارایی محاسبه شد؛ همچنین مقادیر کارایی پس از حذف هر یک از عوامل مجدداً محاسبه شد. نتایج نشان می‌دهد که شاخص‌های تعهد مهندسی در گروه تاب‌آوری و بهبود عملیاتی در گروه مدیریت ناب، بیشترین تأثیر را دارند؛ بنابراین با تمرکز بر این شاخص‌ها می‌توان بهبود زیادی در سطح رضایت کارکنان و درنتیجه عملکرد سازمان ایجاد کرد.

Evaluation of Diagnostic and Triage Accuracy and Usability of a Symptom Checker in an Emergency Department: Observational Study.

BackgroundSymptom checkers are clinical decision support apps for patients, used by tens of millions of people annually. They are designed to provide diagnostic and triage advice and assist users in seeking the appropriate level of care. Little evidence is available regarding their diagnostic and triage accuracy with direct use by patients for urgent conditions.ObjectiveThe aim of this study is to determine the diagnostic and triage accuracy and usability of a symptom checker in use by patients presenting to an emergency department (ED).MethodsWe recruited a convenience sample of English-speaking patients presenting for care in an urban ED. Each consenting patient used a leading symptom checker from Ada Health before the ED evaluation. Diagnostic accuracy was evaluated by comparing the symptom checker’s diagnoses and those of 3 independent emergency physicians viewing the patient-entered symptom data, with the final diagnoses from the ED evaluation. The Ada diagnoses and triage were also critiqued by the independent physicians. The patients completed a usability survey based on the Technology Acceptance Model.ResultsA total of 40 (80%) of the 50 participants approached completed the symptom checker assessment and usability survey. Their mean age was 39.3 (SD 15.9; range 18-76) years, and they were 65% (26/40) female, 68% (27/40) White, 48% (19/40) Hispanic or Latino, and 13% (5/40) Black or African American. Some cases had missing data or a lack of a clear ED diagnosis; 75% (30/40) were included in the analysis of diagnosis, and 93% (37/40) for triage. The sensitivity for at least one of the final ED diagnoses by Ada (based on its top 5 diagnoses) was 70% (95% CI 54%-86%), close to the mean sensitivity for the 3 physicians (on their top 3 diagnoses) of 68.9%. The physicians rated the Ada triage decisions as 62% (23/37) fully agree and 24% (9/37) safe but too cautious. It was rated as unsafe and too risky in 22% (8/37) of cases by at least one physician, in 14% (5/37) of cases by at least two physicians, and in 5% (2/37) of cases by all 3 physicians. Usability was rated highly; participants agreed or strongly agreed with the 7 Technology Acceptance Model usability questions with a mean score of 84.6%, although “satisfaction” and “enjoyment” were rated low.ConclusionsThis study provides preliminary evidence that a symptom checker can provide acceptable usability and diagnostic accuracy for patients with various urgent conditions. A total of 14% (5/37) of symptom checker triage recommendations were deemed unsafe and too risky by at least two physicians based on the symptoms recorded, similar to the results of studies on telephone and nurse triage. Larger studies are needed of diagnosis and triage performance with direct patient use in different clinical environments.

High sensitivity troponin - Six hours is the magic number

BackgroundHigh sensitivity troponin assays have become widespread for emergency department evaluation of acute chest pain. We assessed if a high sensitivity troponin under the 99th percentile upper reference limit drawn at 6 h or greater from symptom onset could safely rule out acute coronary syndrome in patients who did not meet the rapid rule-out strategy. MethodsWe conducted a multicenter retrospective study examining emergency department patients with chest pain who did not meet rapid-rule out criteria and were admitted for further evaluation. Among these admitted patients, we assessed the rate of clinically relevant adverse cardiac events (death, cardiac or respiratory arrest, STEMI, or life-threatening arrhythmia) and NSTEMI in patients with high sensitivity troponin less than the 99th percentile value obtained after at least 6 h of chest pain. ResultsOut of 1187 patients admitted, we found 30 clinically relevant adverse cardiac events, all of which occurred in patients admitted for another compelling reason or ischemic ECG. 36 patients had an NSTEMI, of which 33 were identified with high sensitivity troponin greater than 99th percentile upper reference limit within 6 h of chest pain onset. This left 0 clinically relevant adverse cardiac events and 3 NSTEMI among the 429 patients with high sensitivity troponin less than the 99th percentile at 6 h and nonischemic ECG and no other compelling reason for admission. ConclusionThis study assessed patients with chest pain with high sensitivity troponin values between 3 ng/L and the 99th percentile upper reference limit after 6 h of chest pain and found that they have a low rate of clinically relevant adverse cardiac events and NSTEMI.

A retrospective validation study of the STUMBL score for emergency department patients with blunt thoracic trauma

IntroductionBlunt thoracic trauma (BTT) is a leading cause of emergency department (ED) trauma-related attendance. Risk prediction tools are commonly to predict patients' outcomes and assign them to the most appropriate care setting. The STUMBL score is a prognostic model for BTT, derived and validated in the United Kingdom; items comprising the score are age, number of rib fractures, use of pre-injury anticoagulants, chronic lung disease and oxygen saturation levels. This study's aim was to validate the STUMBL score in an Italian ED. MethodsThis single-centre retrospective validation study was conducted in the ED of Santa Croce and Carle hub hospital in Cuneo, north-western Italy. All patients with an ED attendance for isolated BTT from 2018 to 2021 were included. Exclusion criteria were an age of under eighteen and the presence of any immediately life-threatening lesion. The primary outcome was the development of trauma-related complications, defined by the occurrence of one or more of the following: in-hospital mortality, pulmonary complications (infection, pleural effusion, haemothorax, pneumothorax, pleural empyema), need for intensive care unit admission, hospital length of stay equal to or greater than seven days. The performance of the STUMBL score was analysed in terms of discrimination with the evaluation of the receiver operating characteristic curve and calibration with the Hosmer-Lemeshow test and with the calibration belt. Results745 patients were enroled (median age 64 [25th;75th percentile: 50;78], male/female ratio 1:4, median Charlson comorbidity index 2 [1;4], median STUMBL score 11 [6;17]). 65.2% of patients were discharged home after ED evaluation. 203 patients (27.2%) developed the primary outcome. The STUMBL score was significantly different in patients with complications compared to those without complications (9 [5;13] vs 21 [17;25], p < 0.001). The C index of the score for the primary outcome was 0.90 (95% CI 0.88–0.93), and the result of the Hosmer-Lemeshow test was 9.01 (p = 0.34). STUMBL score = 16 has a sensitivity of 0.80 (95% CI 0.75–0.85), specificity of 0.87 (95% CI 0.84–0.90), a positive predictive value of 0.70 (95% CI 0.64–0.76), and a negative predictive value of 0.92 (95% CI 0.90–0.94). ConclusionIn this validation study, the STUMBL score demonstrated excellent discrimination and calibration in predicting the outcome of patients attending the ED with a BTT.

Pediatric emergency department to primary care transfer protocol: Transforming access for patients’ needs

BackgroundPrevious interventions to reduce emergency department (ED) overutilization from non-urgent visits have shown little success. At our hospital, we created an ED to primary care clinic (PCC) transfer protocol for non-urgent ED visits of established patients. Our study analyzed the impact of this protocol on patient encounters. MethodsChart reviews were conducted for a retrospective cohort of transfers from the ED to PCC from 9/01/17–8/31/18. Primary outcomes included length of stay (LOS), cost, and need for return to the ED. Cost savings were calculated by comparing encounters with identical primary diagnoses in the ED with internal technical and professional financial data. Secondary outcomes were final diagnoses and primary care services provided. Results374 patient encounters were transferred from ED to PCC. The five most common diagnoses were viral upper respiratory infection (n=80, 21.4%), dermatologic diagnoses (n=37, 9.9%), acute otitis media (n=35, 9.4%), pharyngitis (n=34, 9.1%), and influenza (n=34, 9.1%). Overall, total cost savings equaled approximately $100,000. For the top 10 diagnoses, costs were reduced from $29-$46 per $100 of ED costs and LOS was reduced by a mean of 49 min/encounter. For 9 of these 10 conditions, costs exceeded reimbursement in both settings; however, evaluation in PCC versus ED reduced the loss of revenue by 10–68%. Sixty-four encounters (17.1%) received additional primary care services. There were no safety events or inappropriate transfers. ConclusionsThis protocol provided a safe, efficient method for patients to be evaluated in their medical home while reducing non-urgent emergency visits in the ED. Level of evidenceVI.

Occipital Lobe Status Epilepticus, A Stroke Mimic with Novel Imaging Findings: A Case Report

IntroductionStroke mimics are a major diagnostic challenge during the initial evaluation of patients presenting with an acute focal neurological deficit. This case reviews a patient who presented to the emergency department (ED) with homonymous hemianopsia, a rare manifestation of focal status epilepticus of the occipital lobe. Her initial brain computed axial tomographic perfusion scan and magnetic resonance imaging revealed novel findings associated with this diagnosis.Case ReportA 70-year-old female presented to our ED with left visual field hemianopsia, dyskinesia, dysmetria, and facial droop. Her initial diagnosis was left posterior fossa circulation cerebrovascular accident. However, her neuroimaging indicated hypervascularity of the left occipital lobe without evidence of infarct or structural lesion. A cerebral angiogram excluded arteriovenous malformation. Subsequently, an electroencephalogram showed left occipital lobe status epilepticus.ConclusionHemianopsia is a rare presentation of focal status epilepticus mimicking stroke. Hypervascularity seen on advanced neuroimaging may have suggested this diagnosis on initial ED evaluation.

Occipital Lobe Status Epilepticus; A Rare Stroke Mimic with Novel Imaging Findings: A Case Report

Introduction This case reviews a patient who presented to the emergency department (ED) with homonymous hemianopsia, a rare manifestation of partial status epilepticus of the occipital lobe. Her initial brain computerized axial tomographic (CT) perfusion scan and magnetic resonance imaging (MRI) revealed novel findings associated with this diagnosis. Case Report A 70-year-old female presented to our ED with left visual field hemianopsia, dyskinesia, dysmetria and facial droop. Her initial diagnosis was left posterior fossa circulation cerebrovascular accident. However, her neuroimaging indicated hypervascularity of the left occipital lobe without evidence of infarct or structural lesion. A cerebral angiogram excluded arterio-venous malformation. Subsequently, an electroencephalogram showed left occipital lobe status epilepticus. Conclusion Hemianopsia is a rare presentation of partial status epilepticus mimicking stroke. Hypervascularity seen on advanced neuroimaging may have suggested this diagnosis on initial ED evaluation.

Reduced coronary flow velocity reserve and blunted heart rate reserve identify a higher risk group in patients with chest pain and negative emergency department evaluation.

To estimate the prognostic value of stress echo (SE) with the assessment of coronary flow velocity reserve (CFVR) and heart rate reserve (HRR) in patients admitted for chest pain with non-diagnostic EKG, negative troponin, and without inducible regional wall motion abnormalities (RWMA). 658 patients (age 67 ± 12years) admitted to our Emergency Department with chest pain, non-diagnostic EKG, and negative serial troponin underwent dipyridamole (0.84mg/kg in 6') SE with simultaneous assessment of RWMA, CFVR in the left anterior descending artery, and HRR as peak/rest heart rate. The outcome measure was all-cause mortality. Of the 658 patients initially enrolled, 20 (3%) showed RWMA during SE and were referred to ischemia-driven revascularization. In the remaining 638, CFVR was abnormal (≤ 2.0) in 148 patients (23%). HRR was abnormal (≤ 1.22 in patients in sinus rhythm, or ≤ 1.17 in patients with permanent atrial fibrillation) in 196 patients (31%). During a follow-up of 7.3 ± 4.3years, 151 (24%) patients died. Survival at 8years was 93% in patients with normal CFVR and HRR, 76% in patients with abnormal CFVR only, 73% in patients with abnormal HRR only, and 38% in those with abnormal CFVR and HRR (p < 0.0001). At multivariable analysis, abnormal CFVR (HR 1.49, 95% CI 1.05-2.10, p = 0.02) and abnormal HRR (HR 2.01, 95% CI 1.43-2.84, p < 0.0001) were independent predictors of survival. In admitted patients with non-ischemic EKG, negative serial troponin, and without RWMA during dipyridamole SE, a reduced CFVR and blunted HRR independently identify a subset with worse survival in the long term. Upper panel: Color and pulsed-wave Doppler with the electrocardiographic lead tracing of Four different response patterns (from left to right): normal CFVR and HRR; normal CFVR, abnormal HRR; abnormal CFVR, normal HRR; abnormal CFVR and HRR. Lower panel: The annualized death rate for each of the four groups with negative SE for RWMA and stratified according to the presence of CFVR and HRR: none, one, or two abnormalities.

363 Analysis of dermatology consultation follow-up after emergency department evaluation: An assessment of disparities and potential interventions to increase post-discharge care among vulnerable populations

The emergency department(ED) is a frequent source of care for patients with dermatologic disease likely owing to limited access to routine and urgent outpatient dermatologic care. Patients without adequate follow-up planning are at risk for re-presentation to the ED. A retrospective chart review of 152 adult patients who received a dermatology consultation while in the ED for diagnosis and outcomes. 112(73.7%) patients were referred for outpatient dermatology follow-up. An electronic referral resulted in most appointments being scheduled(74.6%) and ultimately attended(90.1%).