Design and Implementation of a Curriculum for Emergency Medicine Residents to Address Medications and Treatment Referral for Opioid Use Disorder.

Background: Medications for Opioid Use Disorder (MOUD) are recognized as successful treatments for Opioid Use Disorder (OUD). The Emergency Department is well situated to initiate MOUD and begin the referral process. Unfortunately, uptake of this practice among Emergency Medicine (EM) physicians has been slow. EM physicians may feel inadequately prepared to provide MOUD and addiction referral services due to lack of previous training and experience. The goal of this pilot study was to create, implement, and evaluate an OUD management curriculum for EM residents and measure impact on knowledge, practice, and empathy. Methods: A 4.5-hour curriculum was developed, incorporating the Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment mission statement as well as the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine resident physician milestones. The curriculum was inserted into an existing EM residency didactic block at an urban, tertiary care, residency program. Surveys were obtained pre- and post-intervention. Results: Post curriculum surveys demonstrated improved knowledge of buprenorphine/naloxone including indications, clinical effects and side-effects (p < 0.05). Surveys also noted increased comfort prescribing buprenorphine/naloxone for opioid withdrawal and misuse and instructing patients on home induction (p < 0.05). Additionally, residents responded positively regarding the impact of the curriculum on their understanding of the topic and their subsequent confidence in managing patients with OUD in the ED setting. Conclusion: A dedicated brief MOUD and referral curriculum can be effectively integrated into EM resident education to provide valuable clinical knowledge that may affect clinical practice.

On-chip sub-wavelength Bragg grating design based on novel low loss phase-change materials.

We propose a reconfigurable and non-volatile Bragg grating in the telecommunication C-band based on the combination of novel low-loss phase-change materials (specifically Ge2Sb2Se4Te1 and Sb2S3) with a silicon nitride platform. The Bragg grating is formed by arrayed cells of phase-change material, whose crystallisation fraction modifies the Bragg wavelength and extinction ratio. These devices could be used in integrated photonic circuits for optical communications applications in smart filters and Bragg mirrors and could also find use in tuneable ring resonators, Mach-Zehnder interferometers or frequency selectors for future laser on chip applications. In the case of Ge2Sb2Se4Te1, crystallisation produces a Bragg resonance shift up to ∼ 15 nm, accompanied with a large amplitude modulation (insertion loss of 22 dB). Using Sb2S3, low losses are presented in both states of the phase change material, obtaining a ∼ 7 nm red-shift in the Bragg wavelength. The gratings are evaluated for two period numbers, 100 and 200 periods. The number of periods determines the bandwidth and extinction ratio of the filters. Increasing the number of periods increases the extinction ratio and reflected power, also narrowing the bandwidth. This results in a trade-off between device size and performance. Finally, we combine both phase-change materials in a single Bragg grating to provide both frequency and amplitude modulation. A defect is introduced in the Sb2S3 Bragg grating, producing a high quality factor resonance (Q ∼ 104) which can be shifted by 7 nm via crystallisation. A GSST cell is then placed in the defect which can modulate the transmission amplitude from low loss to below -16 dB.

Development of a measure of stigma towards occupational stress for mental health professionals.

PURPOSE: Stigma is a common barrier to mental health professionals (MHPs) seeking help for occupational stress and burnout, although there is a lack of psychometrically sound tools to measure this construct. The current study aimed to develop and validate a scale (the Mental Health Professional Stigma Scale; MHPSS) for this purpose. METHODS: The MHPSS and related measures were completed by 221 Australian MHPs via online survey, with a subsample completing the MHPSS again 2 weeks after initial completion. RESULTS: Exploratory factor analysis revealed a four-factor solution, comprising of 13 items and accounting for 50.16% of variance. Factors were Perceived Other Stigma, Perceived Structural Stigma, Personal Stigma, and Self stigma. The internal consistency, test-retest reliability, and validity of the scale were supported. CONCLUSIONS: The MHPSS has utility to capture stigmatising attitudes and beliefs related to occupational stress and burnout among MHPs. It may be used to assist in the development and evaluation of initiatives to reduce stigma and increase help-seeking among MHPs.

Chest pain triage: Current trends in the emergency departments in the United States.

Chest pain is one of the most common complaints in the emergency department (ED). Over the past decade, there has been a significant shift in the approach to patients with chest pain in the ED. With the development of improved cardiac biomarkers, the validation of clinical scoring systems, and an increasing emphasis on shared patient medical decision making, increasing numbers of patients in the ED are being evaluated without requiring admission to the hospital.

Intestine-enriched apolipoprotein b orthologs are required for stem cell progeny differentiation and regeneration in planarians.

Lipid metabolism plays an instructive role in regulating stem cell state and differentiation. However, the roles of lipid mobilization and utilization in stem cell-driven regeneration are unclear. Planarian flatworms readily restore missing tissue due to injury-induced activation of pluripotent somatic stem cells called neoblasts. Here, we identify two intestine-enriched orthologs of apolipoprotein b, apob-1 and apob-2, which mediate transport of neutral lipid stores from the intestine to target tissues including neoblasts, and are required for tissue homeostasis and regeneration. Inhibition of apob function by RNAi causes head regression and lysis in uninjured animals, and delays body axis re-establishment and regeneration of multiple organs in amputated fragments. Furthermore, apob RNAi causes expansion of the population of differentiating neoblast progeny and dysregulates expression of genes enriched in differentiating and mature cells in eight major cell type lineages. We conclude that intestine-derived lipids serve as a source of metabolites required for neoblast progeny differentiation.

Community-acquired pneumonia in the emergency department.

As recommendations for the diagnosis, treatment, and disposition of patients with community-acquired pneumonia continue to evolve, this issue reviews the current evidence and guidelines for managing these patients in the emergency department. The various clinical decision aids are compared, as they assist in determining the level of inpatient care required and allow for a greater proportion of patients to be treated successfully as outpatients. A clinical pathway for emergency department management delineates optimal antibiotic regimens based on severity, comorbidities, and risk factors.

Myocarditis and pericarditis after vaccination for COVID-19.

Two previously healthy males presented to the emergency symptoms with signs of pericarditis/myocarditis after being vaccinated with an mRNA vaccine for COVID-19.

Nonvolatile programmable silicon photonics using an ultralow-loss Sb2Se3 phase change material.

The next generation of silicon-based photonic processors and neural and quantum networks need to be adaptable, reconfigurable, and programmable. Phase change technology offers proven nonvolatile electronic programmability; however, the materials used to date have shown prohibitively high optical losses, which are incompatible with integrated photonic platforms. Here, we demonstrate the capability of the previously unexplored material Sb2Se3 for ultralow-loss programmable silicon photonics. The favorable combination of large refractive index contrast and ultralow losses seen in Sb2Se3 facilitates an unprecedented optical phase control exceeding 10π radians in a Mach-Zehnder interferometer. To demonstrate full control over the flow of light, we introduce nanophotonic digital patterning as a previously unexplored conceptual approach with a footprint orders of magnitude smaller than state-of-the-art interferometer meshes. Our approach enables a wealth of possibilities in high-density reconfiguration of optical functionalities on silicon chip.

Development of an Emergency Department-Based Intervention to Expand Access to Medications for Opioid Use Disorder in a Medicaid Nonexpansion Setting: Protocol for Engagement and Community Collaboration.

BACKGROUND: The opioid epidemic has disproportionately impacted areas in the Appalachian region of the United States. Characterized by persistent Medicaid nonexpansion, higher poverty rates, and health care access challenges, populations residing in these areas of the United States have experienced higher opioid overdose death rates than those in other parts of the country. Jefferson County, Alabama, located in Southern Appalachia, has been especially affected, with overdose rates over 2 times greater than the statewide average (48.8 vs 19.9 overdoses per 10,000 persons). Emergency departments (EDs) have been recognized as a major health care source for persons with opioid use disorder (OUD). A program to initiate medications for OUD in the ED has been shown to be effective in treatment retention. Likewise, continued patient engagement in a recovery or treatment program after ED discharge has been shown to be efficient for long-term treatment success. OBJECTIVE: This protocol outlines a framework for ED-initiated medications for OUD in a resource-limited region of the United States; the study will be made possible through community partnerships with referral resources for definitive OUD care. METHODS: When a patient presents to the ED with symptoms of opioid withdrawal, nonfatal opioid overdose, or requesting opioid detoxification, clinicians will consider the diagnosis of OUD using the Diagnostic and Statistical Manual of Mental Disorders (fifth edition) criteria. All patients meeting the diagnostic criteria for moderate to severe OUD will be further engaged and assessed for study eligibility. Recruited subjects will be evaluated for signs and symptoms of withdrawal, treated with buprenorphine-naloxone as appropriate, and given a prescription for take-home induction along with an intranasal naloxone kit. At the time of ED discharge, a peer navigator from a local substance use coordinating center will be engaged to facilitate patient referral to a regional substance abuse coordinating center for longitudinal addiction treatment. RESULTS: This project is currently ongoing; it received funding in February 2019 and was approved by the institutional review board of the University of Alabama at Birmingham in June 2019. Data collection began on July 7, 2019, with a projected end date in February 2022. In total, 79 subjects have been enrolled to date. Results will be published in the summer of 2022. CONCLUSIONS: ED recognition of OUD accompanied by buprenorphine-naloxone induction and referral for subsequent long-term treatment engagement have been shown to be components of an effective strategy for addressing the ongoing opioid crisis. Establishing community and local partnerships, particularly in resource-limited areas, is crucial for the continuity of addiction care and rehabilitation outcomes. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/18734.

Does QBank participation impact in-training examination performance?

BACKGROUND: Performance on the annual in-training examination (ITE) for emergency medicine (EM) residents has been shown to correlate with performance on the American Board of Emergency Medicine (ABEM) qualifying examination. As such, significant planning is often committed to ITE preparation, from an individual resident and a residency program perspective. Online specialty-specific question banks (QBanks) represent a popular medium for ITE preparation; however, the impact of QBanks on ITE performance is unclear. We sought to assess the impact of QBank participation on EM resident ITE performance. METHODS: ITE and QBank performance results were collated over 2 academic years, 2019 and 2020, from a 3-year EM residency program. The QBank was provided as a self-study option in 2019 and incorporated as a mandatory component of the curriculum in 2020. ITE raw scores and percentile rank for training level scores were compared with performance on the QBank, including QBank average performance score as well as number of QBank questions completed. The Pearson correlation coefficient was used to measure association between ITE performance and QBank correlates. Additional descriptive demographics, to include gender, PGY level, and USMLE step 1 and 2 scores were also considered. RESULTS: Sixty-two sets (30 residents in 2019, 32 residents in 2020) of ITE performance data and QBank correlates were included. Overall, raw ITE scores and number of QBank questions completed were found to have a significant, positive correlation, (r(60) = 0.34, p < 0.05); correlation was stronger for 2019 (r[28] = 0.39, p < 0.05) compared to 2020 (r[30] =0.25, p = 0.16). Overall, ITE percentile rank for training level scores were also found to have a significant, positive correlation with number of QBank questions completed (r(60) = 0.35, p < 0.05); correlation was again stronger for 2019 (r(28) = 0.42, p < 0.05) compared to 2020 (r(30) = 0.29, p = 0.12). Finally, ITE percentile rank for training level correlated positively with QBank average performance (as a percentage), albeit weakly, and was not found to be significant overall (r[60] = 0.20, p = 0.16); in this instance, 2019 did not show a correlation (r[28] =0.12, p = 0.54); however, 2020 did (r[30] =0.55, p < 0.05). Academic year 2020 raw ITE scores also demonstrated a significant correlation with QBank average performance (r[30] = 0.66, p < 0.0001) while 2019 did not (r[28] = 0.08, p = 0.68). CONCLUSION: Participation and engagement in a QBank are associated with improved EM resident performance on the ABEM ITE. Utilization of a QBank may be an effective mode of ITE preparation for EM residents.

Assisting with air travel medical emergencies: responsibilities and pitfalls.

When medical emergencies arise in flight, commercial airline flight crews may ask for help from onboard medical professionals. Qualified, active, licensed, and sober providers should volunteer to assist in the event of a medical emergency rather than decline out of fear of medicolegal reprisal. An understanding of the typically available resources, the hierarchy of authority, and medicolegal precedents can help providers feel confident in responding to these situations. This review addresses the pathophysiology related to air travel and common causes of in-flight medical emergencies and discusses the medications and equipment commonly stocked by commercial airlines. In addition, the complexity of flight diversion and the medicolegal concerns surrounding volunteering to provide medical care are addressed.

Young Man With Suspected Foreign Body Ingestion.

As United States emergency departments (ED) and hospitals continue to contend with increasing numbers of patients presenting with complications of substance abuse, emergency physicians should also be aware of patients who may be smuggling illicit drugs. We report the case of a 26-year-old man who was transported to the ED for suspected drug smuggling. Abdominal computed tomography was notable for the presence of multiple tubular foreign bodies throughout the colon that were later identified as packets containing heroin. Body-packing patients present a high-risk clinical scenario that may result in massive, inadvertent drug exposure.

Risks associated with the use of fluoroquinolones.

Fluoroquinolones are a widely used class of antibiotic that are effective in treating a wide variety of pathogens. Despite their popularity there is increasing concern regarding the potential complications associated with these agents. Patients who take a fluoroquinolone have an increased risk of developing tendinopathy, peripheral neuropathy, and aortic aneurysm or dissection. Providers should consider the risk of these potential complications before using these medications.

Should Programs Designed to Help IPV Survivors Screen for Mental Health-Related Problems: Voices From the Field.

Qualitative responses that 187 service providers gave to a question assessing whether agencies designed to help intimate partner violence (IPV) survivors should screen for mental health-related problems were analyzed using a version of the concept mapping approach. Nine central clusters emerged from the data analysis, which can be linked to three underlying themes: how the identification of mental health-related problems (i.e., labeling) could be misused when working with IPV survivors, ways screening can be appropriately used to help IPV survivors, and barriers that prevent screening. Findings highlight the importance of trauma-informed approaches across all aspects of service delivery.