Degree of Bystander-Patient Relationship and Prehospital Care for Opioid Overdose.

BACKGROUND: Across the spectrum of patient care for opioid overdose, an important, yet frequently overlooked feature is the bystander, or witness to the overdose event. For other acute medical events such as cardiac arrest and stroke, research supports that the presence of a bystander is associated with better outcomes. Despite the similarities, however, this well-established conceptual framework has yet to be applied in the context of overdose patient outcomes. The objective of this study was to assess the association between the nature of the bystander-patient relationship and prehospital care measures in patients being treated for opioid overdose. METHODS: A retrospective cohort study was conducted among adults who received naloxone in the prehospital setting for suspected opioid overdose. Patients were identified using a preexisting, longitudinal registry documenting all prehospital administrations of naloxone by first responders in a midsized community. Individuals who received at least one naloxone administration for a suspected opioid overdose between June 1st, 2016 to July 31st, 2018, with available EMS and medical record data were eligible for study inclusion. Bystander type was defined referencing psychology literature and were categorized as: close (spouse/family), proximal (friends), and distal (no relation to patient). The association between bystander type and prehospital patient care measures were estimated using logistic and linear regression models. RESULTS: A total of 602 opioid overdose encounters among 545 patients were identified. Patents tended to be male (67.2%), white (73.6%), and aged 25-44 years (57.1%). Among patients with proximal bystanders present, average time to naloxone administration was 2.4 min less (95% CI = -4.7, -0.2), compared to distal bystanders, after adjusting for covariates. Overdose encounters with 911 dispatch codes more indicative of opioid overdose (i.e., 'overdose/poisoning' vs 'unconscious/fainting') were associated with having a close or proximal bystander present compared to a distal bystander (ORclose vs. distal = 1.8, 95% CI = 1.0, 3.3; ORproximal vs. distal = 3.6, 95% CI = 1.8, 7.1). CONCLUSION: Presence of a proximal bystander during an overdose event is associated with dispatch codes indicative of an overdose and shorter times to naloxone administration compared with those with distal bystanders. These findings offer opportunities for public education and engagement of overdose harm reduction strategies.

S100B outperforms clinical decision rules for the identification of intracranial injury on head CT scan after mild traumatic brain injury.

Objective: To compare the classification accuracy of S100B to two clinical decision rules- Canadian CT Head Rule (CCHR) and New Orleans Criteria (NOC)-for predicting traumatic intracranial injuries (ICI) after mild traumatic brain injury (mild TBI).Methods: A secondary analysis of a prospective observational study of mild TBI patients was performed. The diagnostic performance of S100B for predicting ICI on head CT was compared to both the CHRR and NOC. Area under receiver operator characteristic (AUC) curves were used and multivariable analysis was used to create a new decision rule based on a combination of S100B and decision rule-related variables.Results: S100B had the highest negative predictive value (97.3%), positive predictive value (7.21%), specificity (33.6%) and positive likelihood ratio (1.3), and the lowest negative likelihood ratio (0.5). The proportion of mild TBI subjects with potentially avoidable head CT scans was highest using S100B (37.7%). The addition of S100B to both clinical decision rules significantly increased AUC. A novel decision rule adding S100B to three decision rule-related variables significantly improved prediction (p < 0.05).Conclusion: Serum S100B outperformed clinical decision rules for identifying mild TBI patients with ICI. Incorporating clinical variables with S100B maximized ICI prediction, but requires validation in an independent cohort.

Recognition-induced forgetting is caused by episodic, not semantic, memory retrieval tasks.

Recognition-induced forgetting is a within-category forgetting effect that results from accessing memory representations. Advantages of this paradigm include the possibility of testing the memory of young children using visual objects before they can read, the testing of multiple types of stimuli, and use with animal models. Yet it is unknown whether just episodic memory tasks (Have you seen this before?) or also semantic memory tasks (Is this bigger than a loaf of bread?) will lead to this forgetting effect. This distinction will be critical in establishing a model of recognition-induced forgetting. Here, we implemented a design in which both these tasks were used in the same experiment to determine which was leading to recognition-induced forgetting. We found that episodic memory tasks, but not semantic memory tasks, created within-category forgetting. These results show that the difference-of-Gaussian forgetting function of recognition-induced forgetting is triggered by episodic memory tasks and is not driven by the same underlying memory signal as semantic memory.

Emergency Medicine Intern Education for Best Practices in Opioid Prescribing.

INTRODUCTION: Opioid exposure has been identified as a contributing factor to the opioid epidemic. Reducing patient exposure, by altering heavy opioid prescribing patterns but appropriately addressing patient pain, may represent one approach to combat this public health issue. Our goal was to create and implement an opioid education program for emergency medicine (EM) interns as a means of establishing foundational best practices for safer and more thoughtful prescribing. METHODS: This was a retrospective study at an academic, urban emergency department (ED) comparing ED and discharge opioid prescribing practices over a 12-week time period for two 14-intern EM classes (2016 and 2018) to evaluate an early opioid reduction education program. The education program included opioid prescribing guidelines for common ED disease states associated with moderate pain, clinician talking points, and electronic education modules, and was completed by EM interns in July/August 2018. Opioid prescription rates per shift were calculated and opioid prescribing best practices described. We used chi-squared analysis for comparisons between the 2016 and 2018 classes. RESULTS: Overall, ED and discharge opioid orders prescribed by EM interns were fewer in the 2018 class that received education compared with the 2016 class. ED opioid orders were reduced by 64% (800 vs 291 orders, rate per shift 1.8 vs 0.7 orders) and opioid discharge prescriptions by 75% (279 vs 70 prescriptions, rate per shift 0.7 vs 0.2 prescriptions). The rate of prescribing combination opioid products compared to opioids alone was decreased for ED orders (32% vs 16%, P < 0.01) and discharge prescriptions (91% vs 74%, P < 0.01) between the groups. Also, the median tablets per discharge prescription (14.5 vs 10) and total tablets prescribed (4305 vs 749) were reduced, P < 0.01. There were no differences in selection of opioid product or total morphine milligram equivalents prescribed when an opioid was used. CONCLUSION: An opioid reduction education program targeting EM interns was associated with a reduction in opioid prescribing in the ED and at discharge. This may be an effective way to influence early prescribing patterns and best practices of EM interns.

Effect of pharmacist-led task force to reduce opioid prescribing in the emergency department.

PURPOSE: Results of a study to determine the effect of a pharmacist-led opioid task force on emergency department (ED) opioid use and discharge prescriptions are presented. METHODS: An observational evaluation was conducted at a large tertiary care center (ED volume of 115,000 visits per year) to evaluate selected opioid use outcomes before and after implementation of an ED opioid reduction program by interdisciplinary task force of pharmacists, physicians, and nurses. Volumes of ED opioid orders and discharge prescriptions were evaluated over the entire 25-month study period and during designated 1-month preimplementation and postimplementation periods (January 2017 and January 2018). Opioid order trends were evaluated using linear regression analysis and further investigated with an interrupted time series analysis to determine the immediate and sustained effects of the program. RESULTS: From January 2017 to January 2018, ED opioid orders were reduced by 63.5% and discharge prescriptions by 55.8% from preimplementation levels: from 246.8 to 90.1 orders and from 85.3 to 37.7 prescriptions per 1,000 patient visits, respectively. Over the entire study period, there were significant decreases in both opioid orders (ß, -78.4; 95% confidence interval [CI], -88.0 to -68.9; R2, 0.93; p < 0.0001) and ED discharge prescriptions (ß, -24.4; 95% CI, -27.9 to -20.9; R2, 0.90; p < 0.001). The efforts of the task force had an immediate effect on opioid prescribing practices; results for effect sustainability were mixed. CONCLUSION: A clinical pharmacist-led opioid reduction program in the ED was demonstrated to have positive results, with a more than 50% reduction in both ED opioid orders and discharge prescriptions.

Effect of vitamin K administration on rate of warfarin reversal.

BACKGROUND: Vitamin K is reported to begin reversing warfarin within 6 to 12 hours, but this may occur sooner. We sought to determine the rate of international normalized ratio (INR) reversal following vitamin K and relationships with dose, route, and baseline INR. METHODS: We evaluated adult patients receiving vitamin K monotherapy for warfarin reversal. Post-vitamin K INRs through 48 hours were collected. Relationships between vitamin K dose and route and baseline INR on rate of reversal and complete reversal (INR < 1.5) were evaluated. Assessment was performed graphically using scatter plots with a line of best fit and a counting process model to determine variables associated with achieving complete reversal. RESULTS: A total of 469 post-vitamin K INRs from 235 patients were included. Time to first INR follow-up after vitamin K administration averaged 10.5 ± 4.2 hours. A significant decrease was detected in INR values in comparison to the baseline INR (3.0 ± 1.9 vs. 4.7 ± 2.2; p < 0.01). Rapid and steady INR change began immediately after vitamin K administration (0-4 hr). A high vitamin K dose and intravenous route were associated with rapid INR change and complete reversal (Vitamin K 10 mg [hazard ratio, 2.4; 95% confidence interval, 1.4-4.2] and IV route [hazard ratio, 1.8; 95% confidence interval, 1.3-2.6]); however, overall complete reversal at 24 and 48 hours was low (14.5% and 41.7%, respectively). Higher baseline INR was associated with rapid INR change and lower baseline INR with complete reversal. CONCLUSION: Vitamin K alone starts to reverse warfarin immediately. High vitamin K doses and intravenous route are associated with faster INR reversal. Baseline INR also influences rate of correction and frequency of achieving complete reversal.

Respondent driven sampling in a biomonitoring study of refugees from Burma in Buffalo, New York who eat Great Lakes fish.

BACKGROUND: Refugees from Burma who consume fish caught from local waterbodies have increased risk of exposure to environmental contaminants. We used respondent driven sampling (RDS) to sample this hard-to-reach population for the first Biomonitoring of Great Lakes Populations program. In the current study, we examined the interview data and assessed the effectiveness of RDS to sample the unique population. METHODS: In 2013, we used RDS to sample 205 Burmese refugees and immigrants residing in Buffalo, New York who consumed fish caught from Great Lakes waters. RDS-adjusted population estimates of sociodemographic characteristics, residential history, fish consumption related behaviors, and awareness of fish advisories were obtained. We also examined sample homophily and equilibrium to assess how well the RDS assumptions were met in the study. RESULTS: Our sample was diverse with respect to sex, age, years residing in Buffalo, years lived in a refugee camp, education, employment, and fish consumption behaviors, and each of these variables reached equilibrium by the end of recruitment. Burmese refugees in Buffalo consumed Great Lakes fish throughout the year; a majority of them consumed the fish more than two times per week during summer, and about one third ate local fish more than once per week in winter. An estimated 60% of Burmese refugees in Buffalo had heard about local fish advisories. CONCLUSIONS: RDS has the potential to be an effective methodology for sampling refugees and immigrants in conducting biomonitoring and environmental exposure assessment. Due to high fish consumption and limited awareness and knowledge of fish advisories, some refugee and immigrant populations are more susceptible to environmental contaminants. Increased awareness on local fish advisories is needed among these populations.

Head CT for Minor Head Injury Presenting to the Emergency Department in the Era of Choosing Wisely.

INTRODUCTION: The Choosing Wisely campaign currently recommends avoiding computed tomography (CT) of the head in low-risk emergency department (ED) patients with minor head injury, based on validated decision rules. However, the degree of adherence to this guideline in clinical practice is unknown. The objective of this study was to evaluate adherence to the Choosing Wisely campaign's recommendations regarding head CT imaging of patients with minor head injury in the ED. METHODS: We conducted a retrospective cohort study of adult ED patients at a Level I trauma center. Patients aged ≥ 18 years who presented to the ED with minor head injury were identified via International Classification of Diseases, 9th Revision, Clinical Modification codes. Medical record abstraction was conducted to determine the presence of clinical symptoms of the NEXUS II criteria, medical resource use, and head CT findings. We used descriptive statistics to characterize the study sample, and proportions were used to quantify guidelines adherence. RESULTS: A total of 489 subjects met inclusion criteria. ED providers appropriately applied the Choosing Wisely criteria for 75.5% of patients, obtaining head CTs when indicated by the NEXUS II rule (41.5%), and not obtaining head CTs when the NEXUS II criteria were not met (34.0%). However, ED providers obtained non-indicated CTs in 23.1% of patients. Less than 2% of the sample did not receive a head CT when imaging was indicated by NEXUS II. CONCLUSION: ED providers in our sample had variable adherence to the Choosing Wisely head-CT recommendation, especially for patients who did not meet the NEXUS II criteria.