Improving the Reporting of Primary Care Research: Consensus Reporting Items for Studies in Primary Care-the CRISP Statement.

Primary care (PC) is a unique clinical specialty and research discipline with its own perspectives and methods. Research in this field uses varied research methods and study designs to investigate myriad topics. The diversity of PC presents challenges for reporting, and despite the proliferation of reporting guidelines, none focuses specifically on the needs of PC. The Consensus Reporting Items for Studies in Primary Care (CRISP) Checklist guides reporting of PC research to include the information needed by the diverse PC community, including practitioners, patients, and communities. CRISP complements current guidelines to enhance the reporting, dissemination, and application of PC research findings and results. Prior CRISP studies documented opportunities to improve research reporting in this field. Our surveys of the international, interdisciplinary, and interprofessional PC community identified essential items to include in PC research reports. A 2-round Delphi study identified a consensus list of items considered necessary. The CRISP Checklist contains 24 items that describe the research team, patients, study participants, health conditions, clinical encounters, care teams, interventions, study measures, settings of care, and implementation of findings/results in PC. Not every item applies to every study design or topic. The CRISP guidelines inform the design and reporting of (1) studies done by PC researchers, (2) studies done by other investigators in PC populations and settings, and (3) studies intended for application in PC practice. Improved reporting of the context of the clinical services and the process of research is critical to interpreting study findings/results and applying them to diverse populations and varied settings in PC.Annals "Online First" article.

Qualitative Exploration of Emergency Department Care Experiences Among People With Opioid Use Disorder.

STUDY OBJECTIVE: We described the experiences and preferences of people with opioid use disorder who access emergency department (ED) services regarding ED care and ED-based interventions. METHODS: Between June and September 2020, we conducted phone or in-person semistructured qualitative interviews with patients recently discharged from 2 urban EDs in Vancouver, BC, Canada, to explore experiences and preferences of ED care and ED-based opioid use disorder interventions. We recruited participants from a cohort of adults with opioid use disorder who were participating in an ED-initiated outreach program. We transcribed audio recordings verbatim. We iteratively developed a thematic coding structure, with interim analyses to assess for thematic saturation. Two team members with lived experience of opioid use provided feedback on content, wording, and analysis throughout the study. RESULTS: We interviewed 19 participants. Participants felt discriminated against for their drug use, which led to poorer perceived health care and downstream ED avoidance. Participants desired to be treated like ED patients who do not use drugs and to be more involved in their ED care. Participants nevertheless felt comfortable discussing their substance use with ED staff and valued continuous ED operating hours. Regarding opioid use disorder treatment, participants supported ED-based buprenorphine/naloxone programs but also suggested additional options (eg, different initiation regimens and settings and other opioid agonist therapies) to facilitate further treatment uptake. CONCLUSION: Based on participant experiences, we recommend addressing potentially stigmatizing practices, increasing patient involvement in their care during ED visits, and increasing access to various opioid use disorder-related treatments and community support.

Validating the Remote First Aid Self-Efficacy Scale for Use in Evaluation and Training of First Responders in Remote Contexts.

INTRODUCTION: The purpose of this study was to investigate the psychometric properties of the remote first aid self-efficacy scale (RFA SES). The RFA SES is a 30-item self-report scale developed in response to emerging evidence showing that self-efficacy is predictive of performance. METHODS: Trained alumni from Wilderness Medical Associates (WMA) training courses and less trained students from Laurentian University (LU) were recruited via email to complete an online questionnaire at 2 different periods (T1 and T2). The questionnaire included demographic questions, the 30-item RFA SES, the 10-item Connor-Davidson resilience scale (CD-RISC), and the 10-item generalized self-efficacy scale (GSES). Data analysis included assessment of the dimensionality, reliability, and validity of the scale. RESULTS: There were 448 alumni from WMA and 1106 students from LU who participated in the study. The RFA SES demonstrated a clear unidimensional structure. The mean interitem correlation was 0.75 at T1. Test-retest reliability (T1 to T2) was high for both the LU group (intraclass correlation [ICC]=0.90) and the WMA group (ICC=0.92). Moderate correlations were found between RFA SES and CD-RISC (r=0.42, P<0.001), a general measure of resilience, and the GSES (r=0.48, P<0.001), a general measure of self-efficacy. Wilderness Medical Associates participants showed higher mean scores than LU students at T1 (t [569]=16.2, P<0.001). CONCLUSIONS: The RFA SES is a unidimensional, reliable, and potentially valid scale. Further research should focus on item reduction followed by additional tests of reliability and validity.

Opioid-Associated Out-of-Hospital Cardiac Arrest: Distinctive Clinical Features and Implications for Health Care and Public Responses: A Scientific Statement From the American Heart Association.

Opioid overdose is the leading cause of death for Americans 25 to 64 years of age, and opioid use disorder affects >2 million Americans. The epidemiology of opioid-associated out-of-hospital cardiac arrest in the United States is changing rapidly, with exponential increases in death resulting from synthetic opioids and linear increases in heroin deaths more than offsetting modest reductions in deaths from prescription opioids. The pathophysiology of polysubstance toxidromes involving opioids, asphyxial death, and prolonged hypoxemia leading to global ischemia (cardiac arrest) differs from that of sudden cardiac arrest. People who use opioids may also develop bacteremia, central nervous system vasculitis and leukoencephalopathy, torsades de pointes, pulmonary vasculopathy, and pulmonary edema. Emergency management of opioid poisoning requires recognition by the lay public or emergency dispatchers, prompt emergency response, and effective ventilation coupled to compressions in the setting of opioid-associated out-of-hospital cardiac arrest. Effective ventilation is challenging to teach, whereas naloxone, an opioid antagonist, can be administered by emergency medical personnel, trained laypeople, and the general public with dispatcher instruction to prevent cardiac arrest. Opioid education and naloxone distributions programs have been developed to teach people who are likely to encounter a person with opioid poisoning how to administer naloxone, deliver high-quality compressions, and perform rescue breathing. Current American Heart Association recommendations call for laypeople and others who cannot reliably establish the presence of a pulse to initiate cardiopulmonary resuscitation in any individual who is unconscious and not breathing normally; if opioid overdose is suspected, naloxone should also be administered. Secondary prevention, including counseling, opioid overdose education with take-home naloxone, and medication for opioid use disorder, is important to prevent recurrent opioid overdose.

2020 International Consensus on First Aid Science With Treatment Recommendations.

This is the summary publication of the International Liaison Committee on Resuscitation's 2020 International Consensus on First Aid Science With Treatment Recommendations. It addresses the most recent published evidence reviewed by the First Aid Task Force science experts. This summary addresses the topics of first aid methods of glucose administration for hypoglycemia; techniques for cooling of exertional hyperthermia and heatstroke; recognition of acute stroke; the use of supplementary oxygen in acute stroke; early or first aid use of aspirin for chest pain; control of life-threatening bleeding through the use of tourniquets, hemostatic dressings, direct pressure, or pressure devices; the use of a compression wrap for closed extremity joint injuries; and temporary storage of an avulsed tooth. Additional summaries of scoping reviews are presented for the use of a recovery position, recognition of a concussion, and 6 other first aid topics. The First Aid Task Force has assessed, discussed, and debated the certainty of evidence on the basis of Grading of Recommendations, Assessment, Development, and Evaluation criteria and present their consensus treatment recommendations with evidence-to-decision highlights and identified priority knowledge gaps for future research.

Emergency care with lay responders in underserved populations: a systematic review.

OBJECTIVE: To assess the individual and community health effects of task shifting for emergency care in low-resource settings and underserved populations worldwide. METHODS: We systematically searched 13 databases and additional grey literature for studies published between 1984 and 2019. Eligible studies involved emergency care training for laypeople in underserved or low-resource populations, and any quantitative assessment of effects on the health of individuals or communities. We conducted duplicate assessments of study eligibility, data abstraction and quality. We synthesized findings in narrative and tabular format. FINDINGS: Of 19 308 papers retrieved, 34 studies met the inclusion criteria from low- and middle-income countries (21 studies) and underserved populations in high-income countries (13 studies). Targeted emergency conditions included trauma, burns, cardiac arrest, opioid poisoning, malaria, paediatric communicable diseases and malnutrition. Trainees included the general public, non-health-care professionals, volunteers and close contacts of at-risk populations, all trained through in-class, peer and multimodal education and public awareness campaigns. Important clinical and policy outcomes included improvements in community capacity to manage emergencies (14 studies), patient outcomes (13 studies) and community health (seven studies). While substantial effects were observed for programmes to address paediatric malaria, trauma and opioid poisoning, most studies reported modest effect sizes and two reported null results. Most studies were of weak (24 studies) or moderate quality (nine studies). CONCLUSION: First aid education and task shifting to laypeople for emergency care may reduce patient morbidity and mortality and build community capacity to manage health emergencies for a variety of emergency conditions in underserved and low-resource settings.

Conceptual framework for task shifting and task sharing: an international Delphi study.

BACKGROUND: Task shifting and sharing (TS/S) involves the redistribution of health tasks within workforces and communities. Conceptual frameworks lay out the key factors, constructs, and variables involved in a given phenomenon, as well as the relationships between those factors. Though TS/S is a leading strategy to address health worker shortages and improve access to services worldwide, a conceptual framework for this approach is lacking. METHODS: We used an online Delphi process to engage an international panel of scholars with experience in knowledge synthesis concerning TS/S and develop a conceptual framework for TS/S. We invited 55 prospective panelists to participate in a series of questionnaires exploring the purpose of TS/S and the characteristics of contexts amenable to TS/S programmes. Panelist responses were analysed and integrated through an iterative process to achieve consensus on the elements included in the conceptual framework. RESULTS: The panel achieved consensus concerning the included concepts after three Delphi rounds among 15 panelists. The COATS Framework (Concepts and Opportunities to Advance Task Shifting and Task Sharing) offers a refined definition of TS/S and a general purpose statement to guide TS/S programmes. COATS describes that opportunities for health system improvement arising from TS/S programmes depending on the implementation context, and enumerates eight necessary conditions and important considerations for implementing TS/S programmes. CONCLUSION: The COATS Framework offers a conceptual model for TS/S programmes. The COATS Framework is comprehensive and adaptable, and can guide refinements in policy, programme development, evaluation, and research to improve TS/S globally.

Guidelines for Reporting Trial Protocols and Completed Trials Modified Due to the COVID-19 Pandemic and Other Extenuating Circumstances: The CONSERVE 2021 Statement.

Importance: Extenuating circumstances can trigger unplanned changes to randomized trials and introduce methodological, ethical, feasibility, and analytical challenges that can potentially compromise the validity of findings. Numerous randomized trials have required changes in response to the COVID-19 pandemic, but guidance for reporting such modifications is incomplete. Objective: As a joint extension for the CONSORT and SPIRIT reporting guidelines, CONSERVE (CONSORT and SPIRIT Extension for RCTs Revised in Extenuating Circumstances) aims to improve reporting of trial protocols and completed trials that undergo important modifications in response to extenuating circumstances. Evidence: A panel of 37 international trial investigators, patient representatives, methodologists and statisticians, ethicists, funders, regulators, and journal editors convened to develop the guideline. The panel developed CONSERVE following an accelerated, iterative process between June 2020 and February 2021 involving (1) a rapid literature review of multiple databases (OVID Medline, OVID EMBASE, and EBSCO CINAHL) and gray literature sources from 2003 to March 2021; (2) consensus-based panelist meetings using a modified Delphi process and surveys; and (3) a global survey of trial stakeholders. Findings: The rapid review yielded 41 673 citations, of which 38 titles were relevant, including emerging guidance from regulatory and funding agencies for managing the effects of the COVID-19 pandemic on trials. However, no generalizable guidance for all circumstances in which trials and trial protocols might face unanticipated modifications were identified. The CONSERVE panel used these findings to develop a consensus reporting guidelines following 4 rounds of meetings and surveys. Responses were received from 198 professionals from 34 countries, of whom 90% (n = 178) indicated that they understood the concept definitions and 85.4% (n = 169) indicated that they understood and could use the implementation tool. Feedback from survey respondents was used to finalize the guideline and confirm that the guideline's core concepts were applicable and had utility for the trial community. CONSERVE incorporates an implementation tool and checklists tailored to trial reports and trial protocols for which extenuating circumstances have resulted in important modifications to the intended study procedures. The checklists include 4 sections capturing extenuating circumstances, important modifications, responsible parties, and interim data analyses. Conclusions and Relevance: CONSERVE offers an extension to CONSORT and SPIRIT that could improve the transparency, quality, and completeness of reporting important modifications to trials in extenuating circumstances such as COVID-19.

2019 American Heart Association and American Red Cross Focused Update for First Aid: Presyncope: An Update to the American Heart Association and American Red Cross Guidelines for First Aid.

This 2019 focused update to the American Heart Association and American Red Cross first aid guidelines follows the completion of a systematic review of treatments for presyncope of vasovagal or orthostatic origin. This review was commissioned by the International Liaison Committee on Resuscitation and resulted in the development of an international summary statement of the International Liaison Committee on Resuscitation First Aid Task Force Consensus on Science With Treatment Recommendations. This focused update highlights the evidence supporting specific interventions for presyncope of orthostatic or vasovagal origin and recommends the use of physical counterpressure maneuvers. These maneuvers include the contraction of muscles of the body such as the legs, arms, abdomen, or neck, with the goal of elevating blood pressure and alleviating symptoms. Although lower-body counterpressure maneuvers are favored over upper-body counterpressure maneuvers, multiple methods can be beneficial, depending on the situation.

One-Year Mortality After Emergency Department Visit for Nonfatal Opioid Poisoning: A Population-Based Analysis.

STUDY OBJECTIVE: We aim to characterize the incidence and risk factors for opioid-related and all-cause mortality in the year after an emergency department (ED) visit for nonfatal opioid poisoning by conducting a population-based study. METHODS: We used linked health care databases in Ontario, Canada, to identify individuals who attended an ED for nonfatal opioid poisoning between January 1, 2015, and December 31, 2016. Using Cox proportional hazards regression, we examined predictors of mortality in the year after discharge (ED or hospital, if admitted). RESULTS: In this cohort (n=6,140), 327 individuals (5.3%) died of any cause and 118 (1.9%) died of opioid-related causes within 1 year. Adjusting for other covariates, we found that health service use in the first week was not protective for opioid-related death (hazard ratio [HR] 0.70; 95% confidence interval [CI] 0.47 to 1.06) or all-cause mortality (HR 0.98; 95% CI 0.78 to 1.24). In exploring other covariates, predictors of opioid-related mortality included male sex (HR 1.98; 95% CI 1.32 to 2.97) and using opioid agonist therapy (HR 1.79; 95% CI 1.15 to 2.80) or benzodiazepine (HR 1.54; 95% CI 1.02 to 2.31) in the 12 months before the index event. Assessment by a family physician in the previous 12 months was associated with a lower risk of opioid-related and all-cause mortality (HR 0.58, 95% CI 0.39 to 0.86; and HR 0.63, 95% CI 0.49 to 0.82, respectively). CONCLUSION: We identified predictors of opioid-related and all-cause mortality after ED presentation for opioid poisoning. Several predictors of mortality may facilitate targeted interventions.

Improving Health and Healthcare Access for People Who Experience Imprisonment in Ontario.

People who experience imprisonment have worse health status than other Ontarians - about 40% lack access to primary care in the community, and the period after release from prison is associated with high risks of adverse health outcomes. Population-based correctional and health administrative data suggest that access to quality healthcare in prison and in the community needs to improve if we are to improve population health and deliver on healthcare obligations to people experiencing imprisonment.

Primary care utilization in people who experience imprisonment in Ontario, Canada: a retrospective cohort study.

BACKGROUND: Access to primary care is an important determinant of health, and data are sparse on primary care utilization for people who experience imprisonment. We aimed to describe primary care utilization for persons released from prison, and to compare utilization with the general population. METHODS: We linked correctional data for all persons released from provincial prison in Ontario, Canada in 2010 with health administrative data. We matched each person by age and sex with four general population controls. We compared primary care utilization rates using generalized estimating equations. We adjusted rate ratios for aggregated diagnosis groups, to explore this association independent of comorbidity. We examined the proportion of people using primary care using chi squared tests and time to first primary care visit post-release using the Kaplan-Meier method. RESULTS: Compared to the general population controls, the prison release group had significantly increased relative rates of primary care utilization: at 6.1 (95% CI 5.9-6.2) in prison, 3.7 (95% CI 3.6-3.8) in the week post-release and between 2.4 and 2.6 in the two years after prison release. All rate ratios remained significantly increased after adjusting for comorbidity. In the month after release, however, 66.3% of women and 75.5% of men did not access primary care. CONCLUSIONS: Primary care utilization is high in prison and post-release for people who experience imprisonment in Ontario, Canada. Increased use is only partly explained by comorbidity. The majority of people do not access primary care in the month after prison release. Future research should identify reasons for increased use and interventions to improve care access for persons who are not accessing care post-release.

Opioid-related overdose deaths among people experiencing homelessness, 2017 to 2021: A population-based analysis using coroner and health administrative data from Ontario, Canada.

AIMS: To measure the change in proportion of opioid-related overdose deaths attributed to people experiencing homelessness and to compare the opioid-related fatalities between individuals experiencing homelessness and not experiencing homelessness at time of death. DESIGN, SETTING AND PARTICIPANTS: Population-based, time-trend analysis using coroner and health administrative databases from Ontario, Canada from 1 July 2017 and 30 June 2021. MEASUREMENTS: Quarterly proportion of opioid-related overdose deaths attributed to people experiencing homelessness. We also obtained socio-demographic and health characteristics of decedents, health-care encounters preceding death, substances directly contributing to death and circumstances surrounding deaths. FINDINGS: A total of 6644 individuals (median age = 40 years, interquartile range = 31-51; 74.1% male) experienced an accidental opioid-related overdose death, among whom 884 (13.3%) were identified as experiencing homelessness at the time of death. The quarterly proportion of opioid-related overdose deaths attributed to people experiencing homelessness increased from 7.2% (26/359) in July-September 2017 to 16.8% (97/578) by April-June 2021 (trend test P < 0.01). Compared with housed decedents, those experiencing homelessness were younger (61.3 versus 53.1% aged 25-44), had higher prevalence of mental health or substance use disorders (77.1 versus 67.1%) and more often visited hospitals (32.1 versus 24.5%) and emergency departments (82.6 versus 68.5%) in the year prior to death. Fentanyl and its analogues more often directly contributed to death among people experiencing homelessness (94.0 versus 81.4%), as did stimulants (67.4 versus 51.6%); in contrast, methadone was less often present (7.8 versus 12.4%). Individuals experiencing homelessness were more often in the presence of a bystander during the acute toxicity event that led to death (55.8 versus 49.7%); and where another individual was present, more often had a resuscitation attempted (61.7 versus 55.1%) or naloxone administered (41.2 versus 28.9%). CONCLUSIONS: People experiencing homelessness account for an increasing proportion of fatal opioid-related overdoses in Ontario, Canada, reaching nearly one in six such deaths in 2021.

"We are not invited": Australian focus group results on how to improve ethnic diversity in trials.

OBJECTIVES: Lack of ethnic diversity in trials may contribute to health disparities and to inequity in health outcomes. The primary objective was to investigate the experiences and perspectives of ethnically diverse populations about how to improve ethnic diversity in trials. STUDY DESIGN AND SETTING: Qualitative data were collected via 16 focus groups with participants from 21 ethnically diverse communities in Australia. Data collection took place between August and September 2022 in community-based settings in six capital cities: Sydney, Melbourne, Perth, Adelaide, Brisbane, and Darwin, and one rural town: Bordertown (South Australia). RESULTS: One hundred and fifty-eight purposively sampled adults (aged 18-85, 49% women) participated in groups speaking Tamil, Greek, Punjabi, Italian, Mandarin, Cantonese, Karin, Vietnamese, Nepalese, and Arabic; or English-language groups (comprising Fijian, Filipino, African, and two multicultural groups). Only 10 participants had previously taken part in medical research including three in trials. There was support for medical research, including trials; however, most participants had never been invited to participate. To increase ethnic diversity in trial populations, participants recommended recruitment via partnering with communities, translating trial materials and making them culturally accessible using audiovisual ways, promoting retention by minimizing participant burden, establishing trust and rapport between participants and researchers, and sharing individual results. Participants were reluctant to join studies on taboo topics in their communities (eg, sexual health) or in which physical specimens (eg, blood) were needed. Participants said these barriers could be mitigated by communicating about the topic in more culturally cognizant and safe ways, explaining how data would be securely stored, and reinforcing the benefit of medical research to humanity. CONCLUSION: Participants recognized the principal benefits of trials and other medical research, were prepared to take part, and offered suggestions on recruitment, consent, data collection mechanisms, and retention to enable this to occur. Researchers should consider these community insights when designing and conducting trials; and government, regulators, funders, and publishers should allow for greater innovation and flexibility in their processes to enable ethnic diversity in trials to improve.

Peer and lay health work for people experiencing homelessness: A scoping review.

Homelessness poses complex health obstacles for individuals and communities. Peer and lay health worker programs aim to increase access to health care and improve health outcomes for PEH by building trust and empowering community-based workers. The scope and breadth of peer and lay health worker programs among PEH has not been synthesized. The primary objective of this scoping review is to understand the context (setting, community, condition or disease) encompassing peer and lay health worker programs within the homelessness sector. The secondary objective is to examine the factors that either facilitate or hinder the effectiveness of peer and lay health worker programs when applied to people experiencing homelessness (PEH). We searched CINHAL, Cochrane, Web of Science Core Collection, PsycINFO, Google Scholar and MEDLINE. We conducted independent and duplicate screening of titles and abstracts, and extracted information from eligible studies including study and intervention characteristics, peer personnel characteristics, outcome measures, and the inhibitors and enablers of effective programs. We discuss how peer and lay health work programs have successfully been implemented in various contexts including substance use, chronic disease management, harm reduction, and mental health among people experiencing homelessness. These programs reported four themes of enablers (shared experiences, trust and rapport, strong knowledge base, and flexibility of role) and five themes of barriers and inhibitors (lack of support and clear scope of role, poor attendance, precarious work and high turnover, safety, and mental well-being and relational boundaries). Organizations seeking to implement these interventions should anticipate and plan around the enablers and barriers to promote program success. Further investigation is needed to understand how peer and lay health work programs are implemented, the mechanisms and processes that drive effective peer and lay health work among PEH, and to establish best practices for these programs.

Virtual opioid poisoning education and naloxone distribution programs: A scoping review.

The global opioid poisoning crisis is a complex issue with far-reaching public health implications. Opioid Poisoning Education and Naloxone Distribution (OPEND) programs aim to reduce stigma and promote harm reduction strategies, enhancing participants' ability to apply life-saving interventions, including naloxone administration and cardiopulmonary resuscitation (CPR) to opioid poisoning. While virtual OPEND programs have shown promise in improving knowledge about opioid poisoning response, their implementation and evaluation have been limited. The COVID-19 pandemic has sparked renewed interest in virtual health services, including OPEND programs. Our study reviews the literature on fully virtual OPEND programs worldwide. We analyzed 7,722 articles, 30 of which met our inclusion criteria. We extracted and synthesized information about the interventions' type, content, duration, the scales used, and key findings. Our search shows a diversity of interventions being implemented, with different study designs, duration, outcomes, scales, and different time points for measurement, all of which hinder a meaningful analysis of interventions' effectiveness. Despite this, virtual OPEND programs appear effective in increasing knowledge, confidence, and preparedness to respond to opioid poisoning while improving stigma regarding people who use opioids. This effect appears to be true in a wide variety of populations but is significantly relevant when focused on laypersons. Despite increasing efforts, access remains an issue, with most interventions addressing White people in urban areas. Our findings offer valuable insights for the design, implementation, and evaluation of future virtual OPEND programs.

Factors associated with frequent buprenorphine / naloxone initiation in a national survey of Canadian emergency physicians.

OBJECTIVE: To identify individual and site-related factors associated with frequent emergency department (ED) buprenorphine/naloxone (BUP) initiation. BUP initiation, an effective opioid use disorder (OUD) intervention, varies widely across Canadian EDs. METHODS: We surveyed emergency physicians in 6 Canadian provinces from 2018 to 2019 using bilingual paper and web-based questionnaires. Survey domains included BUP-related practice, demographics, attitudes toward BUP, and site characteristics. We defined frequent BUP initiation (the primary outcome) as at least once per month, high OUD prevalence as at least one OUD patient per shift, and high OUD resources as at least 3 out of the following 5 resources: BUP initiation pathways, BUP in ED, peer navigators, accessible addiction specialists, and accessible follow-up clinics. We excluded responses from sites with <50% participation (to minimize non-responder bias) and those missing the primary outcome. We used univariate analysis to identify associations between frequent BUP initiation and factors of interest, stratifying by OUD prevalence. RESULTS: We excluded 3 responses for missing BUP initiation frequency and 9 for low response rate at one ED. Of the remaining 649 respondents from 34 EDs, 374 (58%) practiced in metropolitan areas, 384 (59%) reported high OUD prevalence, 312 (48%) had high OUD resources, and 161 (25%) initiated BUP frequently. Age, gender, board certification and years in practice were not associated with frequent BUP initiation. Site-specific factors were associated with frequent BUP initiation (high OUD resources [OR 6.91], high OUD prevalence [OR 4.45], and metropolitan location [OR 2.39],) as were individual attitudinal factors (willingness, confidence, and responsibility to initiate BUP.) Similar associations persisted in the high OUD prevalence subgroup. CONCLUSIONS: Individual attitudinal and site-specific factors were associated with frequent BUP initiation. Training to increase physician confidence and increasing OUD resources could increase BUP initiation and benefit ED patients with OUD.

Respiratory infectious disease outbreaks among people experiencing homelessness: a systematic review of prevention and mitigation strategies.

PURPOSE: People experiencing homelessness (PEH) are at increased risk of respiratory infections and associated morbidity and mortality. To characterize optimal intervention strategies, we completed a systematic review of mitigation strategies for PEH to minimize the spread and impact of respiratory infectious disease outbreaks, including COVID-19. METHODS: The study protocol was registered in PROSPERO (#2020 CRD42020208964) and was consistent with the preferred reporting in systematic reviews and meta-analyses guidelines. A search algorithm containing keywords that were synonymous to the terms "Homeless" and "Respiratory Illness" was applied to the six databases. The search concluded on September 22, 2020. Quality assessment was performed at the study level. Steps were conducted by two independent team members. RESULTS: A total of 4468 unique titles were retrieved with 21 meeting criteria for inclusion. Interventions included testing, tracking, screening, infection prevention and control, isolation support, and education. Historically, there has been limited study of intervention strategies specifically for PEH across the world. CONCLUSIONS: Staff and organizations providing services for people experiencing homelessness face specific challenges in adhering to public health guidelines such as physical distancing, isolation, and routine hygiene practices. There is a discrepancy between the burden of infectious diseases among PEH and specific research characterizing optimal intervention strategies to mitigate transmission in the context of shelters. Improving health for people experiencing homelessness necessitates investment in programs scaling existing interventions and research to study new approaches.

Efficacy of prescribed opioids for acute pain after being discharged from the emergency department: A systematic review and meta-analysis.

BACKGROUND: Opioids are often prescribed for acute pain to patients discharged from the emergency department (ED), but there is a paucity of data on their short-term use. The purpose of this study was to synthesize the evidence regarding the efficacy of prescribed opioids compared to nonopioid analgesics for acute pain relief in ED-discharged patients. METHODS: MEDLINE, EMBASE, CINAHL, PsycINFO, CENTRAL, and gray literature databases were searched from inception to January 2023. Two independent reviewers selected randomized controlled trials investigating the efficacy of prescribed opioids for ED-discharged patients, extracted data, and assessed risk of bias. Authors were contacted for missing data and to identify additional studies. The primary outcome was the difference in pain intensity scores or pain relief. All meta-analyses used a random-effect model and a sensitivity analysis compared patients treated with codeine versus those treated with other opioids. RESULTS: From 5419 initially screened citations, 46 full texts were evaluated and six studies enrolling 1161 patients were included. Risk of bias was low for five studies. There was no statistically significant difference in pain intensity scores or pain relief between opioids versus nonopioid analgesics (standardized mean difference [SMD] 0.12; 95% confidence interval [CI] -0.10 to 0.34). Contrary to children, adult patients treated with opioid had better pain relief (SMD 0.28, 95% CI 0.13-0.42) compared to nonopioids. In another sensitivity analysis excluding studies using codeine, opioids were more effective than nonopioids (SMD 0.30, 95% CI 0.15-0.45). However, there were more adverse events associated with opioids (odds ratio 2.64, 95% CI 2.04-3.42). CONCLUSIONS: For ED-discharged patients with acute musculoskeletal pain, opioids do not seem to be more effective than nonopioid analgesics. However, this absence of efficacy seems to be driven by codeine, as opioids other than codeine are more effective than nonopioids (mostly NSAIDs). Further prospective studies on the efficacy of short-term opioid use after ED discharge (excluding codeine), measuring patient-centered outcomes, adverse events, and potential misuse, are needed.