Reforming the health care system to address structural racism
The real number of organs from uncontrolled donation after circulatory determination of death donors
Emergency Medicine's Role in the Crossroads of Social Revolution and the COVID-19 Pandemic
Extended-release naltrexonewas feasible, acceptable, and reduced drinking in patients with alcohol use disorders who frequent the emergency department [Meeting Abstract]
Purpose: Almost uniformly, patients with frequent Emergency Department (ED) use and severe alcohol use disorders (AUDs) do not receive alcohol pharmacotherapy and are excluded from research as they are difficult to engage and retain and suffer from myriad bio-psychosocial comorbidities. We assessed the feasibility and acceptability of initiating and continuing treatment with extended-release naltrexone (XR-NTX) as well as studying its effects in this challenging population and clinical setting.
Method(s): In this randomized, open-label study, ED patient-participants with > 4 ED visits and moderate- severe AUD were randomized (1:1) to XR-NTX and research assistant-delivered care management or treatment as usual enhanced by a one-time warm referral and motivation enhancement. XR-NTX was first administered during the index ED visit. Thereafter, participants could receive up to 11 additional doses at clinic visits with arrangements to allow unscheduled visits. Non-clinical research visits (both arms) were scheduled at 3, 6, and 12 months with a considerable date variation permitted and expected. Drinking was assessed via 30-day timeline followback with heavy drinking day (HDD) thresholds of 5 for males and 4 for females. Resuts: The 48 participants were aged 55.0 +/- 8.2, 88% male, 51% white, 79% homeless, and reported an average of 23.4 HDDs in the priormonth and 24.4 standard drinks/drinking day. Approximately 70%lacked reliable contact information. Research visit attendance was 70.8%, 77.1%, and 70.8%with a median time to first visit of 126 days [Interquartile Range: 89-242]. In the XR-NTX arm (N = 24), a total of 173 injections were administered with amean of 7.2 per participant; 20 (83%) participants received 2 or more injections, 14 (56%) received 6 or more injections, and 6 (24%) received 12 injections. There was a significantly greater decrease in HDDs per month among those receiving XR-NTX compared to those who did not: 15.3 (95%CI 9.7-21.0) and 9.6 (95%CI 1.5-17.6), respectively. Baseline rates were imputed for two missing participants in each arm.
Conclusion(s): Among this population whose complicated AUDs pose considerable challenges from clinical and research perspectives, initiating and continuing treatment with XR-NTX was feasible, acceptable, and demonstrated promising preliminary drinking outcomes. Additional sensitivity analyses and evaluation of other outcomes of interest are underway. Further study on a larger scale is warranted
The unique moral permissibility of uncontrolled lung donation after circulatory death
Implementing uncontrolled donation after circulatory determination of death (uDCDD) in the United States could markedly improve supply of donor lungs for patients in need of transplants. Evidence from U.S. pilot programs suggests families support uDCDD, but only if they are asked permission for using invasive organ preservation procedures prior to initiation. However, non-invasive strategies that confine oxygenation to lungs may be applicable to the overwhelming majority of potential uDCDD donors that have airway devices in place as part of standard resuscitation. We propose an ethical framework for lung uDCDD by: (1) initiating post mortem preservation without requiring prior permission to protect the opportunity for donation until an authorized party can be found; (2) using non-invasive strategies that confine oxygenation to lungs; and (3) maintaining strict separation between the healthcare team and the organ preservation team. Attempting uDCDD in this way has great potential to obtain more transplantable lungs while respecting donor autonomy and family wishes, securing public support, and enabling authorized persons to affirm or cease preservation decisions without requiring evidence of prior organ donation intent. It ensures prioritization of life-saving, the opportunity to allow willing donors to donate, and respect for bodily integrity while adhering to current ethical norms.
Reflections on Mortality and Uncertainty in Emergency Medicine
EXTENDED-RELEASE NALTREXONE WAS FEASIBLE, ACCEPTABLE, AND REDUCED DRINKING IN PATIENTS WITH ALCOHOL USE DISORDERS WHO FREQUENT THE EMERGENCY DEPARTMENT [Meeting Abstract]
Forty years of poison control center research: does pollyanna still live? [Meeting Abstract]
Background: The "Pollyanna Phenomenon," an optimism for useful interventions appearing as efficacious as useless ones, was first described in 1992. An editorial written in 1997 highlighted this phenomenon regarding passive data collection from Poison Control Centers (PCCs) and its limitations related to minimally symptomatic or asymptomatic patients. PCCs continue to collect data passively with an immense data pool. Despite these "big data," limitations to PCC research persist. The term toxicovigilance was borne from this editorial and suggestions were made to improve PCC data fidelity and to overcome the "Pollyanna Phenomenon." We investigated PCC research over the past 40+ years to determine the impact of this editorial on toxicovigilance.
Method(s): We searched PubMed and EMBASE for PCC research from 1978 to 2020 using these search terms: "Poison Center", "Poison Control Center", "Poison Centre", "Poison Control Centre." Research articles before 1997 established a baseline for research quality. Research articles from 1997 to April 2020, served as the intervention group assessing for changes in the quality of research and were examined for evidence of toxicovigilance. Articles were included in this study based on the following criteria: written in English; classified as original research; performed in a PCC setting, and the study objective was focused on an identifiable xenobiotic or xenobiotics. Each article was assessed for toxicovigilance based on the following criteria: confirmation of said xenobiotic(s) either qualitatively or quantitatively, study methodology (retrospective or prospective), and clinical recommendations made "beyond the scope of study methodology." If a study did not confirm xenobiotics' presence analytically, the study was considered to make recommendations beyond the scope of the study methodology.
Result(s): Our search initially identified 1614 articles. A random sample of 400 articles was chosen for review. From 1978-1997, 88 articles were initially identified. Twenty-five studies met inclusion criteria. Fifteen were retrospective and ten were prospective. Two studies confirmed exposure confirmation analytically in each group. Ten retrospective studies made clinical recommendations based on their conclusions, none of which confirmed the analytical presence of xenobiotic(s). Ten prospective studies made clinical recommendations with only two analytically confirming the presence of the xenobiotic. From 1998-2020, 138 research studies met inclusion criteria of which 117 were retrospective and 19 were prospective. Of these two groups, 19 and 7 had analytically confirmed xenobiotic presence in the retrospective and prospective studies, respectively. Sixty-eight retrospective studies and ten prospective studies made clinical recommendations without analytically confirming xenobiotic exposures. Comparing the baseline and intervention groups, we observed an increase in the frequency of retrospective studies with a similar proportion making clinical recommendations while lacking confirmation of exposures. There was an increase in rates of xenobiotic confirmation by 2% in the intervention period.
Conclusion(s): Toxicovigilance appears to be lacking in many PCC studies. Despite vast advancements in analytical techniques and the ability to gather and record data, the "Pollyanna Phenomenon" remains vibrant in PCC research. Efforts towards improving the frequency of analytical testing and confirmation of xenobiotic exposure are essential to improve PCC data collection and research and must be considered prerequisites for journal publication. (Table Presented)
Principles of Social Emergency Medicine
Principles of Managing the Acutely Poisoned or Overdosed Patient
New York : McGraw-Hill Education,