Prehospital central venous catheters.

The use of whole blood in the prehospital setting is increasing. Currently available intraosseous and peripheral venous catheters limit the flow of blood products and fluid during resuscitation. Central venous catheters can be effectively placed in the prehospital environment. Rapid, high-volume infusion of blood products can be lifesaving.

From Rhetoric to Action: Justice, Equity, Diversity, and Inclusion in Coordinated Specialty Care for Early Psychosis.

Attention to inclusivity and equity in health research and clinical practice has grown in recent years; however, coordinated specialty care (CSC) for early psychosis lags in efforts to improve equity despite evidence of ongoing disparities and inequities in CSC care. This Open Forum argues that marginalization and disparities in early psychosis research and clinical care are interrelated, and the authors provide suggestions for paths forward. Commitment to equity and justice demands recentering the perspectives of those most affected by early psychosis services and investing in the integration of historically excluded perspectives across all aspects of practice, policy, and research.

Reasons for Discharge in a National Network of Early Psychosis Intervention Programs.

BACKGROUND: Discharge from early psychosis intervention is a critical stage of treatment that may occur for a variety of reasons. This study characterizes reasons for discharge among participants in early psychosis intervention programs participating in the Early Psychosis Intervention Network (EPINET) which comprises >100 programs in the United States organized under 8 academic hubs. STUDY DESIGN: We analyzed 1787 discharges, focusing on program completion, unilateral termination by the client/family, and lost contact with the client/family. We performed exploratory analyses of demographic, clinical, and functional predictors of discharge reason. Variables predictive of discharge type were included in multilevel logistic regressions, allowing for the estimation of predictors of discharge reason and variability in rates by program and hub. STUDY RESULTS: An estimated 20%-30% of enrolled patients completed the program. Program completion rates were higher among participants who were older on admission, had lower negative symptoms severity, spent more time in education, employment, or training, and who were covered by private insurance (a close proxy for socioeconomic status). Programs were more likely to lose contact with male participants, Black participants, and participants who were never covered by private insurance. After accounting for patient-level factors, there was substantial program-level variation in all 3 discharge outcomes, and hub-level variability in the proportion of participants who completed the program. The impact of race on program completion varied substantially by program. CONCLUSIONS: Participants were discharged from early psychosis intervention services for diverse reasons, some of which were associated with sociocultural factors. Disengagement is a widespread problem affecting all hubs.

Wilderness Medical Society Clinical Practice Guidelines for the Treatment of Acute Pain in Austere Environments: 2024 Update.

The Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for the management of pain in austere environments. Recommendations are graded based on the quality of supporting evidence as defined by criteria put forth by the American College of Chest Physicians. This is an update of the 2014 version of the "WMS Practice Guidelines for the Treatment of Acute Pain in Remote Environments" published in Wilderness & Environmental Medicine 2014; 25:41-49.

Tobacco smoking and nicotine vaping in persons with first episode psychosis.

Tobacco smoking is highly prevalent in persons with psychosis and is the leading cause of preventable mortality in this population. Less is known about tobacco smoking in persons with first episode psychosis (FEP) and there have been no estimates about the prevalence of nicotine vaping in FEP. This study reports rates of tobacco smoking and nicotine vaping in young people with FEP enrolled in Coordinated Specialty Care programs in Pennsylvania and Maryland. Using data collected from 2021 to 2023, we examined lifetime and recent smoking and vaping and compared smokers and vapers to nonusers on symptoms, functioning, and substance use. The sample included 445 participants aged 13-35 with recent psychosis onset. Assessments were collected by program staff. Overall, 28 % of participants engaged in either smoking or vaping within 30 days of the admission assessment. Smokers and vapers were disproportionately male, cannabis users, and had lower negative symptom severity than non-smokers. Vapers had higher role and social functioning. Both smoking and vaping were related to a longer time from psychosis onset to program enrollment. We compare these findings to previous studies and suggest steps for addressing smoking and vaping in this vulnerable population.

The Ethics of Risk Prediction for Psychosis and Suicide Attempt in Youth Mental Health.

OBJECTIVE: To identify potential clinical utility of polygenic risk scores (PRS) and exposomic risk scores (ERS) for psychosis and suicide attempt in youth and assess the ethical implications of these tools. STUDY DESIGN: We conducted a narrative literature review of emerging findings on PRS and ERS for suicide and psychosis as well as a literature review on the ethics of PRS. We discuss the ethical implications of the emerging findings for the clinical potential of PRS and ERS. RESULTS: Emerging evidence suggests that PRS and ERS may offer clinical utility in the relatively near future but that this utility will be limited to specific, narrow clinical questions, in contrast to the suggestion that population-level screening will have sweeping impact. Combining PRS and ERS might optimize prediction. This clinical utility would change the risk-benefit balance of PRS, and further empirical assessment of proposed risks would be necessary. Some concerns for PRS, such as those about counseling, privacy, and inequities, apply to ERS. ERS raise distinct ethical challenges as well, including some that involve informed consent and direct-to-consumer advertising. Both raise questions about the ethics of machine-learning/artificial intelligence approaches. CONCLUSIONS: Predictive analytics using PRS and ERS may soon play a role in youth mental health settings. Our findings help educate clinicians about potential capabilities, limitations, and ethical implications of these tools. We suggest that a broader discussion with the public is needed to avoid overenthusiasm and determine regulations and guidelines for use of predictive scores.

Use of SGLT2 Inhibitors Reduces Heart Failure and Hospitalization: A Multicenter, Real-World Evidence Study.

Background New research has produced evidence to support the use of diabetic drugs to prevent heart failure (HF). However, evidence of their effect in real-world clinical practice is limited. Objective The objective of this study is to establish whether real-world evidence supports clinical trial findings that use of sodium-glucose cotransporter-2 inhibitor (SGLT2i) reduces rate of hospitalization and incidence of HF for patients with cardiovascular disease and type 2 diabetes. Methods This retrospective study used electronic medical records to compare rate of hospitalization and incidence of HF among 37,231 patients with cardiovascular disease and type 2 diabetes under treatment with SGLT2i, glucagon-like peptide-1 receptor agonist (GLP1-RA), both, or neither. Results Significant differences were found between medication class prescribed and number of hospitalizations (p < 0.0001) and incidence of HF (p < 0.0001). Post-hoc tests revealed reduced incidence of HF in the group treated with SGLT2i relative to GLP1-RA alone (p = 0.004) or neither of these key drugs (p < 0.001). No significant differences were observed between the group receiving both drug classes compared to SGLT2i alone. Discussion Results of this real-world analysis are consistent with clinical trial findings that SGLT2i therapy reduces incidence of HF. The findings also suggest the need for further points of research in demographic and socioeconomic status differences. Conclusion Real-world evidence supports clinical trial findings of SGLT2i reducing both incidence of HF and rate of hospitalization.

Religious pluralism and the ethics of healthcare.

Democratic societies that separate church and state face major challenges in accommodating religious convictions. This applies especially to determining healthcare policies. Building on our prior work on the demands and limits of religious accommodation in democratic societies, we propose a set of ethical standards that can guide societies in meeting this challenge. In applying and defending these standards, we explore three topics: vaccine resistance, abortion, and concerns about rights to healthcare. We clarify these and other issues of religious accommodation and propose ethical standards for approaching these and other problems.

Addressing Substance Use in Psychiatric Care: An Old Problem With Renewed Urgency.

Patients, clinicians, researchers, and policy makers have long called for greater integration of services for people with co-occurring mental and substance use disorders. Decades later, these services remain fragmented in psychiatry across much of the United States. Mounting deaths from drug-related overdoses call for renewed focus on bringing substance use into the center of psychiatric services. This Open Forum explores factors within the field of psychiatry, including insufficient training related to substance use, prevalent stigma surrounding substance use, and limited availability of co-occurring disorder specialists, that reinforce this divide and offers solutions for better addressing substance use disorders in psychiatric care.

Moral expertise without moral elitism.

Skepticism about ethical expertise has grown common, raising concerns that bioethicists' roles are inappropriate or depend on something other than expertise in ethics. While these roles may depend on skills other than those of expertise, overlooking the role of expertise in ethics distorts our conception of moral advising. This paper argues that motivations to reject ethical expertise often stem from concerns about elitism: either an intellectualist elitism, where some privileged elite have supposedly special access in virtue of expertise in moral theory; or an authoritarian elitism, where our reliance on experts in ethics risks violation of autonomy and democracy. The paper sketches an anti-elitist conception of ethics expertise in bioethics as continuous with an anti-elitist conception of ethics expertise in common moral practice, undercutting the intellectualism, and then uses this anti-elitist conception to reject arguments that ethical expertise violates autonomy or democracy. An anti-elitist picture of ethical expertise both renders it consistent with our general moral practice and allows us to resist skeptical concerns.

Novel ethical and policy issues in psychiatric uses of psychedelic substances.

Classic psychedelics and related substances have shown promising initial research results. However, they raise a number of relatively novel ethical and policy challenges in light of their psychoactive properties, their emergence from the unregulated "underground" settings in which they have been used, their rapid commercialization, and the means and speed with which they are moving from Schedule 1 status to legalized use. All of these issues are affected by the current limits to the evidence base on use of psychedelics. Here we survey these novel challenges, illustrating the issues raised regarding each, and offering suggestions for how to address them.

Atomistic simulation framework for molten salt vapor-liquid equilibrium prediction and its application to NaCl.

Knowledge of the vapor-liquid equilibrium (VLE) properties of molten salts is important in the design of thermal energy storage systems for solar power and nuclear energy production applications. The high temperatures involved make their experimental determination problematic, and the development of both macroscopic thermodynamic correlations and predictive molecular-based methodologies are complicated by the requirement to appropriately incorporate the chemically reacting vapor-phase species. We derive a general thermodynamic-based atomistic simulation framework for molten salt VLE prediction and show its application to NaCl. Its input quantities are temperature-dependent ideal-gas free energy data for the vapor phase reactions and density and residual chemical potential data for the liquid. If these are not available experimentally, the former may be predicted using standard electronic structure software, and the latter may be predicted by means of classical atomistic simulation methodology. The framework predicts the temperature dependence of vapor pressure, coexisting phase densities, vapor phase composition, and vaporization enthalpy. It also predicts the concentrations of vapor phase species present in minor amounts (such as the free ions), quantities that are extremely difficult to measure experimentally. We furthermore use the results to obtain an approximation to the complete VLE binodal dome and the critical properties. We verify the framework for molten NaCl, for which experimentally based density and chemical potential data are available in the literature. We then apply it to the analysis of NaCl simulation data for two commonly used atomistic force fields. The framework can be readily extended to molten salt mixtures and to ionic liquids.

Rapprochement and Reform: Overcoming Factionalism in Policy Making for Serious Mental Illness.

This article traces the history of factionalism in policy making and advocacy for persons with serious mental illness from deinstitutionalization to the present. The authors draw on deliberative democratic theory to illustrate how factionalist advocacy causes advocates and policy makers to fail in their duties to represent and develop policy in support of people with serious mental illness. The authors discuss how this factionalism has bred distrust and undermined efforts to address the needs of people with serious mental illness. They propose the formation of a Public Mental Health Policy Commission, guided by principles of deliberative democracy, to overcome factionalism and to improve policy making to meet the needs of people with serious mental illness. The commission must include a diverse array of stakeholders, especially individuals with lived experience of serious mental illness.