The Ethical Obligation to Treat Infectious Patients: A Systematic Review of Reasons.

During pandemics, healthcare providers struggle with balancing obligations to self, family, and patients. While HIV/AIDS seemed to settle this issue, coronavirus disease 2019 (COVID-19) rekindled debates regarding treatment refusal. We searched MEDLINE, Embase, CINAHL Complete, and Web of Science using terms including obligation, refusal, HIV/AIDS, COVID-19, and pandemics. After duplicate removal and dual, independent screening, we analyzed 156 articles for quality, ethical position, reasons, and concepts. Diseases in our sample included HIV/AIDS (72.2%), severe acute respiratory syndrome (SARS) (10.2%), COVID-19 (10.2%), Ebola (7.0%), and influenza (7.0%). Most articles (81.9%, n = 128) indicated an obligation to treat. COVID-19 had the highest number of papers indicating ethical acceptability of refusal (60%, P < .001), while HIV had the least (13.3%, P = .026). Several reason domains were significantly different during COVID-19, including unreasonable risks to self/family (26.7%, P < .001) and labor rights/workers' protection (40%, P < .001). A surge in ethics literature during COVID-19 has advocated for permissibility of treatment refusal. Balancing healthcare provision with workforce protection is crucial in effectively responding to a global pandemic.

Child Firearm-Related Homicide and Suicide by State Legislation in the US (2009-2020).

BACKGROUND: Firearms are the leading cause of death among U.S. children and adolescents. This study evaluates whether state gun laws are associated with firearm suicides and homicides in children. STUDY DESIGN: This is a cross-sectional database study comparing childhood firearm mortality with 36 state firearm laws using data from CDC WONDER and the RAND state firearm law database. Primary outcomes were firearm-related suicide and homicide mortalities per 100,000 persons. We examined suicide deaths by all firearms, including intentional self-harm by handguns only, intentional self-harm by rifles, shotguns, or large firearms only, and intentional self-harm by other or unspecified firearms, as well as homicide deaths for the same firearm types in each state. Welch's t-tests compared mean rates of suicide and homicide mortalities between states with and without these laws. States that either enacted or rescinded firearm legislation during this period were excluded. RESULTS: From 2009-2020, there were 6,735 suicides and 10,278 homicides by firearm totaling 17,013 child deaths (<18) by firearm. States with "child access prevention- negligent storage" laws demonstrated lower suicide mortality rates across all firearm types (handguns) N=13, M (mean per 100,000)=0.68, SD=0.27, p<0.001; (long guns) N=12, M=0.65, SD=0.25, p<0.001). There were no significant differences in mean suicide death rates across all firearm types when comparing states with or without firearm laws related to "minimum age youth possession", "minimum age youth purchase and sale", or "child access prevention - intentional." Comparing homicide mortality rates for all firearm types revealed no notable distinctions between states with and without the identified laws. CONCLUSIONS: Firearm legislation is associated with decreased suicide rates for individuals under 18, but its influence on homicides is less certain. Comprehensive research and thoughtful policy formulation are essential for addressing this pressing public health concern.

Firearm Ownership: A Key Factor to Consider in Firearm Suicide Deaths in Children, Despite State Gun Laws.

INTRODUCTION: Firearm-related suicides among children present a significant public health concern and a tragic loss of young lives. This study explores the relationship between firearm-related suicides, gun ownership, and state-specific gun laws. METHODS: This retrospective cohort study collected data from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research on children under 18 who died by firearm-related suicides between 2009 and 2016 in all 50 states and D.C. It also utilized data from the RAND State-Level Estimates of Household Firearm Ownership. The study focused on the rate of child firearm suicide deaths per 100,000 individuals. The key variable of interest was the percentage of guns owned per household in each state. Univariable analysis was conducted to examine the association between individual gun laws and child firearm suicide mortalities, while multivariable regression, adjusting for household gun ownership and significant firearm legislation, was employed to assess connection to child firearm suicide mortality. RESULTS: From 2009 to 2016, 3903 children died from firearm-related suicides in the United States. In our analysis, 15 out of 44 firearm laws were found to be associated with reducing the rates of firearm suicides among children (P < 0.05). However, multivariable regression showed that higher state gun ownership rates were the primary predictor of increased child fatalities from firearms, with children in such states being 325% more likely to die when analyzing handgun laws and 337% more likely when analyzing long gun laws, as indicated by coefficients of 4.25 and 4.37, respectively. No state laws alone notably improved death rates. CONCLUSIONS: Gun ownership has a stronger association with child suicide rates than state-specific gun laws. Given the weight of gun ownership, future research should prioritize comprehensive public health initiatives to prevent child firearm-related suicides.

The Use of Parenteral Nutrition and Disparities in Its Allocation Following Traumatic Injury.

INTRODUCTION: Severe traumatic injury requires rapid and extensive deployment of resources to save the lives of the critically injured. The sequelae of traumatic injuries frequently require extensive intervention obligating patients to a complicated recovery process devoid of meaningful nutrition. In this setting, parenteral nutrition (PN) is key in enabling appropriate wound healing, recovery, and rehabilitation. We sought to examine the use of PN in adult trauma management and to highlight any disparities in the utilization of PN in adult trauma patients. METHODS: We queried the 2017-2019 Trauma Quality Improvement Program (TQIP) for adult patients (aged > 18 y) who sustained blunt or penetrating traumatic injuries and received PN as part of their hospitalization. We compared time to PN administration based on demographics. We then used a multivariable logistic regression model to identify factors associated with the use of PN. We hypothesized that PN would be less commonly employed in the uninsured and minority groups. RESULTS: We identified 2,449,498 patients with sufficient data for analysis. Of these, 1831 patients were treated with PN. On univariate analysis, PN patients were more commonly male (74.7% PN versus 60.2% non-PN; P < 0.001). PN use was more frequent in the Black population (24.3% PN versus 15.5% non-PN; P < 0.001) and less frequent in the White population (72.7% PN versus 81.2% non-PN; P < 0.001). PN use was also much more common among patients covered by Medicaid. Penetrating trauma was over twice as common among PN recipients relative to non-PN patients (% PN versus % non-PN). PN patients had higher injury severity scores (ISSs), more intensive care unit days, longer hospitalizations, and increased mortality compared to non-PN patients. PN patients were half as likely to discharge home and twice as likely to discharge to a long-term care facility. Multivariable analysis including age, race, trauma mechanism, primary payer, and ISS, demonstrated an association of PN use with increasing age (OR 1.01, P < 0.001), cases of penetrating trauma (odds ratio [OR], 2.47; P < 0.001), and patients with high ISS (OR, 0.1.06; P < 0.001). There was decreased use in Uninsured patient (OR, 0.54; P < 0.001). CONCLUSIONS: PN use following traumatic injury is rarely required. Patients treated with PN typically have a resource-intense hospital course. More severe injuries, penetrating trauma, and increased age are more likely to result in PN use. Variations in PN use are apparent based on insurance payer, further examination into allocation of hospital and intensive care resources, as it pertains to patient socioeconomic status, is warranted in light of these findings.

Lipid emulsions in parenteral nutrition: does it matter?

PURPOSE OF REVIEW: Recently, clinicians have shown interest in switching patients to nonsoybean-based intravenous lipid emulsion (ILE) formulas for parental nutrition (PN) due to adverse outcomes related to high Omega-6 content in soybean oil (SO) ILE's. This review summarizes recent literature on improved clinical outcomes with new Omega-6 lipid-sparing ILE's in PN management. RECENT FINDINGS: Although there is a paucity of large-scale studies directly comparing Omega-6 lipid sparing ILE's with SO-based lipid emulsion use in PN in ICU patients, there is strong translational and meta-analysis evidence to suggest that lipid formulations containing fish oil (FO) and/or olive oil (OO) have favorable effects on immune function and improve clinical outcomes in ICU populations. SUMMARY: More research is needed to directly compare omega-6-sparing PN formulas with FO and/or OO versus traditional SO ILE's. However, current evidence is promising for improved outcomes using newer ILE's including reduced infections, shorter lengths of stay, and reduced costs.

Optimal Nutrition in the Older Adult: Beneficial Versus Ineffective Supplements.

PURPOSE OF REVIEW: Proper nutrition in older adults is essential, as nutritional deficiencies are common in this population. This review aims to summarize the benefits and risks of nutritional supplementation in the older adult population including the efficacy of various supplements, their risks, and common drug interactions with frequently prescribed medications. RECENT FINDINGS: In recent years, a growing percentage of older adults have been found to take multiple daily nutritional supplements. This population has complex nutritional needs due to the physiology of aging and the presence of comorbidities. However, many primary care providers are unaware of the benefits and drawbacks of nutritional supplementation in the elderly. This review summarizes the current literature to provide more clarity to providers on how to support this population's nutritional needs. Nutritional supplementation is essential for elderly populations who may not be able to obtain adequate nutrition from dietary sources. Supplements vary widely in efficacy and safety. As such, supplementation should be individualized and guided by a qualified healthcare provider to ensure patients receive effective, beneficial nutrition.