METHADONE INITIATION IN THE EMERGENCY DEPARTMENT FOR OPIOID USE DISORDER: A CASE SERIES.

BACKGROUND: In an era of fentanyl and continually rising rates of opioid overdose deaths, increasing access to evidence-based treatment for opioid use disorder (OUD) should be prioritized. Emergency department (ED) buprenorphine initiation for patients with OUD is considered best-practice. Methadone, though also evidence-based and effective, is under-utilized due to strict federal regulation, significant stigma, and lack of physician training. We describe the novel utilization of CFR Title 21 1306.07 (b), also known as the "72-hour rule," to initiate methadone for OUD in the ED. CASE SERIES: We describe the cases of 3 patients with a history of OUD who were initiated on methadone for OUD in the ED, linked to an opioid treatment program, and attended an intake appointment. Why Should an Emergency Physician Be Aware of This? The ED can be a crucial point of intervention for vulnerable patients with OUD who may not interact with the health care system in other settings. Methadone and buprenorphine are both first-line options for medication for OUD, and methadone may be preferred in patients who have been unsuccessful with buprenorphine in the past or those at higher risk of treatment dropout. Patients may also prefer methadone to buprenorphine based on previous experience or understanding of the medications. ED physicians may utilize the "72-hour rule" to administer and initiate methadone for up to 3 consecutive days while arranging referral to treatment. EDs can develop methadone initiation and bridge programs utilizing similar strategies to those that have been described in developing buprenorphine programs.

Prevalence and prediction of PTSD and depression in mothers of children surviving a motor vehicle crash.

Introduction: Few studies have examined the psychopathological consequences for parents of children who were survivors of a motor vehicle crash (MVC). This study assessed the impact of dissociation and peritraumatic distress on the severity of PTSD and post-traumatic major depressive episode (MDE) symptoms in mothers during the first years after the MVC and the role that cortisol response might play in this association. Methods: 125 mothers were included. Peritraumatic distress and dissociation were assessed. Morning salivary cortisol was tested at the baseline. Participants were assessed for a probable diagnosis of PTSD and MDE at 5 weeks, 6 months and 12 months. Results: At 5 weeks, 12 (13.6%) mothers exhibited probable PTSD. During the first year, the PCL score was higher when the (i) Peritraumatic Distress Inventory (PDI) score increased and (ii) the Peritraumatic Dissociation Experience Questionnaire (PDEQ) score increased. Cortisol levels were lower when the PDI score increased. Conclusion: This is the first study to assess the mothers of MVC survivors for one year following the trauma. We confirm that peritraumatic responses are useful for predicting the severity of PTSD symptoms. These results could encourage the implementation of follow-up programmes not only for survivors but also for their mothers. HIGHLIGHTS Mothers of children involved in motor vehicle accident are at risk for developing PTSD.Peritraumatic responses (distress and dissociation) are associated to the severity of PTSD symptoms.Low salivary cortisol levels were associated with high peritraumatic distress.

Antecedentes: Pocos estudios han examinado las consecuencias psicopatológicas para los padres de niños que fueron sobrevivientes de un accidente automovilístico (MVC, por sus siglas en inglés).Objetivo: Este estudio evaluó el impacto de la disociación y la angustia peritraumática en la gravedad del TEPT y los síntomas del episodio depresivo mayor (EDM) postraumático en las madres durante los primeros años después del MVC y el papel que podría desempeñar la respuesta del cortisol en esta asociación.Métodos: Se incluyeron 125 madres. Se evaluó la angustia peritraumática y la disociación. El cortisol salival matutino se analizó al inicio del estudio. Los participantes fueron evaluados para un diagnóstico probable de TEPT y EDM a las 5 semanas, 6 meses y 12 meses.Resultados: A las 5 semanas, 12 (13,6%) madres exhibieron TEPT probable. Durante el primer año, la puntuación PCL (lista de chequeo para TEPT) fue mayor cuando i) aumentó la puntuación del Inventario de angustia peritraumática (PDI, por sus siglas en inglés) y ii) aumentó la puntuación del Cuestionario de experiencias de disociación peritraumática (PDEQ, por sus siglas en inglés). Los niveles de cortisol fueron más bajos cuando aumentó la puntuación PDI.Conclusión: Este es el primer estudio que evalúa a las madres de sobrevivientes de MVC un año después del trauma. Confirmamos que las respuestas peritraumáticas son útiles para predecir la gravedad de los síntomas del TEPT. Estos resultados podrían incentivar la implementación de programas de seguimiento no solo para las sobrevivientes sino también para sus madres.

Utility of Point-of-Care Ultrasound in the Diagnosis of Idiopathic Intracranial Hypertension in the Emergency Department.

BACKGROUND: Emergency physicians are frequently required to identify and triage patients with increased intracranial pressure (ICP). Idiopathic intracranial hypertension (IIH) is a possible cause that must be considered. Its prognosis depends on prompt recognition and treatment, and progression of the disease can lead to permanent vision loss and considerable morbidity. Point-of-care ultrasound can rapidly identify elevated ICP. Measurements of the optic nerve sheath diameter (ONSD) and optic disc elevation (ODE) can act as surrogates for ICP. CASE SERIES: We describe five cases in which ultrasound was used to identify increased ICP and aid clinical decision-making. In several of the cases, ultrasound was used to confirm a suspicion for IIH and initiate therapy while awaiting the results of a more time-consuming and technically challenging test, such as lumbar puncture or optical coherence tomography. One of the patients was pregnant, and sonographic evidence of elevated ICP helped avoid exposing the patient to unnecessary radiation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Ultrasound is a quick and versatile tool for screening patients with neurologic symptoms, and when integrated into the proper clinical context, can reduce the use of more invasive tests. It can be particularly useful in patients with pathology that may not show abnormalities on computed tomography scan or in whom lumbar puncture is technically difficult, making patients at risk for IIH well-suited to examination by ultrasound. We use a cutoff of 5 mm for ONSD and 0.6 mm for ODE, though there are no universally agreed on cutoff values.

The Homeless Hospital Liaison Program: An Interprofessional Program to Improve Students' Skills at Facilitating Transitions of Care for Patients Experiencing Homelessness.

PROBLEM: Traditional medical school curricula lack specific training on caring for individuals experiencing homelessness, and the literature suggests that medical students' attitudes toward these individuals become increasingly negative during medical school. APPROACH: To increase discharge planning support for individuals experiencing homelessness, the Homeless Hospital Liaison (HHL) program was developed at the University Medical Center New Orleans in January 2017-May 2017. Student liaisons are recruited from all 4 years of medical school and a graduate-level social work program. Liaisons administer a social needs questionnaire to assess patients' connections to services and identify gaps in care, coordinate with hospital social workers to avoid duplicating work, coordinate with the medical team, help patients complete any needed documentation or applications for social benefits, provide patients with referrals to outpatient resources, and provide patients assistance with a variety of basic needs. OUTCOMES: As of December 2017, HHL has trained 70 students (65 medical students and 5 social work students) to serve as liaisons and has enrolled 99 patients. For the majority of these patients, student liaisons were able to facilitate successful referrals to community-based services. NEXT STEPS: Future directions of the HHL program include developing a formal, staffed consult service at the hospital (e.g., the HHL program was awarded hospital funding for 2 full-time staff in the summer of 2019, which will increase the HHL's capacity); assessing the program's effect on student knowledge, attitudes, and proficiency related to individuals experiencing homelessness and/or interprofessional collaboration; and assessing the impact of the program on patients' experiences.

Treatment of Men for "Low Testosterone": A Systematic Review.

Testosterone products are recommended by some prescribers in response to a diagnosis or presumption of "low testosterone" (low-T) for cardiovascular health, sexual function, muscle weakness or wasting, mood and behavior, and cognition. We performed a systematic review of 156 eligible randomized controlled trials in which testosterone was compared to placebo for one or more of these conditions. We included studies in bibliographic databases between January 1, 1950 and April 9, 2016, and excluded studies involving bodybuilding, contraceptive effectiveness, or treatment of any condition in women or children. Studies with multiple relevant endpoints were included in all relevant tables. Testosterone supplementation did not show consistent benefit for cardiovascular risk, sexual function, mood and behavior, or cognition. Studies that examined clinical cardiovascular endpoints have not favored testosterone therapy over placebo. Testosterone is ineffective in treating erectile dysfunction and controlled trials did not show a consistent effect on libido. Testosterone supplementation consistently increased muscle strength but did not have beneficial effects on physical function. Most studies on mood-related endpoints found no beneficial effect of testosterone treatment on personality, psychological well-being, or mood. The prescription of testosterone supplementation for low-T for cardiovascular health, sexual function, physical function, mood, or cognitive function is without support from randomized clinical trials.

Incidence and descriptive epidemiology of injuries to college ultimate players.

CONTEXT: The burden of injuries to college ultimate players has never been fully described. OBJECTIVE: To quantify the injury rate in ultimate players and describe the diagnoses, anatomic locations, and mechanisms of injuries. DESIGN: Descriptive epidemiology study. SETTING: College ultimate teams in the United States during the 2012 season. MAIN OUTCOME MEASURE(S): Initial injury rate per 1000 athlete-exposures. RESULTS: The initial injury rate in college ultimate players was 12.64 per 1000 athlete-exposures; the rate did not differ between men and women (P = .5). Bivariate analysis indicated that injuries occurred twice as often during games as during practices, men were more likely than women to be injured when laying out for the disc, and men were more likely to incur strains and sprains than women. CONCLUSIONS: Injury patterns to college ultimate players were similar to those for athletes in other National Collegiate Athletic Association sports. This is the first study to systematically describe injuries to ultimate players.

Comparison of four model for end-stage liver disease-based prognostic systems for cirrhosis.

Serum sodium (Na) has been suggested for incorporation into the Model for End-Stage Liver Disease (MELD) to enhance its prognostic ability for patients with cirrhosis. Three Na-containing models--the Model for End-Stage Liver Disease with the incorporation of serum sodium (MELD-Na), the integrated Model for End-Stage Liver Disease (iMELD), and the Model for End-Stage Liver Disease to sodium (MESO) index--were independently proposed for this purpose. This study investigated the accuracy of these 4 MELD-based models for outcome prediction. The c-statistic equivalent to the area under the receiver operating characteristic curve (AUC), used to predict 3- and 6-month mortality, was calculated and compared in 825 patients with cirrhosis. The MELD score tended to be lower with increasing Na level. At 3 months of enrollment, the iMELD had the highest AUC (0.807) and was followed by the MELD-Na (0.801), MESO (0.784), and MELD (0.773); the difference between the MESO and MELD was statistically significant (P = 0.013). At 6 months, the iMELD still had the highest AUC (0.797) and was followed by the MELD-Na (0.778), MESO (0.747), and MELD (0.735); all comparisons showed significant differences between each other (all P < 0.01), with the exception of iMELD and MELD-Na (P = 0.18). With the most discriminative cutoffs, the specificity and negative predictive value were 70%-85% and 89%-97%, respectively, at 3 and 6 months for the 4 models. Patients with spontaneous bacterial peritonitis (SBP) consistently had significantly higher MELD-derived scores in all 4 models compared to patients without SBP (all P < 0.01). Patients with hepatic encephalopathy also had higher scores in all 4 models, although the statistical significance was established only for the iMELD (41.0 +/- 11.5 versus 37.6 +/- 9.1, P = 0.037). In conclusion, the incorporation of Na into the MELD may enhance prognostic accuracy. Both the iMELD and MELD-Na are better prognostic models for outcome prediction in patients with cirrhosis. Patients with SBP have a higher MELD-derived score. Future studies are warranted to define the optimal MELD-based prognostic model for cirrhosis.

Validation of the HCC-MELD for dropout probability in patients with small hepatocellular carcinoma undergoing locoregional therapy.

BACKGROUND: The model for end-stage liver disease (MELD) is used in prioritizing cirrhotic patients awaiting liver transplantation. Patients with small hepatocellular carcinoma (HCC) are eligible candidates. An HCC-MELD equation was recently proposed to predict the dropout rate of HCC patients on the waiting list. This study aimed to validate the accuracy of this equation. METHODS: We investigated 390 patients with small HCC who were candidates for liver transplantation and underwent locoregional therapy. RESULTS: The estimated probability of dropout according to the equation was 8.2% for T1 stage and 13.5% for T2 stage HCC (p < 0.0001). The actual disease progression rate at three months was 2.1% for T1 and 3.0% for T2 stage HCC. At six months, the progression rate was 5.3% for T1 stage and 6.8% for T2 stage. The area under receiver operating characteristic curve of the HCC-MELD equation was 0.81 at three months and 0.80 at six months. Patients undergoing radiofrequency ablation (RFA) had significantly lower dropout rates compared with other treatment groups according to the equation (p = 0.0007). The actual tumor progression rate was also the lowest for the RFA group at both three and six months. CONCLUSION: The HCC-MELD equation is a feasible predictive model for patients with small HCC undergoing locoregional therapy.

Is the corrected-creatinine model for end-stage liver disease a feasible strategy to adjust gender difference in organ allocation for liver transplantation?

BACKGROUND: The Model for End-stage Liver Disease (MELD) scoring system is used for organ allocation in liver transplantation. Female cirrhotic patients have lower glomerular filtration rates (GFR) than males for the same creatinine (Cr) level. Correcting the Cr in females for the same GFR as in males shows that females have lower MELD scores and therefore a lower priority for liver transplantation; however, there has been no outcome data that justifies this modification. METHODS: We investigated 472 cirrhotic patients, comparing the mortality rate between males and females in relation to MELD and corrected-Cr MELD. RESULTS: Compared to females, male patients had a higher MELD (14.5+/-5.5 vs. 13.8+/-5.7) and significantly higher GFR (61.7+/-21.4 vs. 54.7+/-25.6 mlLmin/1.73 m, P=0.0002) because their Cr value was higher (1.4+/-0.4 vs. 1.3+/-0.5 mg/dL, P=0.0002). The corrected-Cr MELD score in females was higher (15.7+/-6.3) compared to the MELD in their original counterpart (P<0.0001) and the males (P=0.060). Female and male patients had a similar 3-month mortality rate (6.7% vs. 6.3%) and MELD (21.9+/-8.6 vs. 21.7+/-8.9) among deceased patients. At 6 months, female patients tended to have a lower mortality (12.5% vs. 14.7%) and a lower MELD (18.9+/-7.7 vs. 19.4+/-8.5) in deceased patients. However, at 9 and 12 months, females had a consistently higher mortality (25% vs. 21.2% and 37.5% vs. 31.3%, respectively) but lower MELD scores than males by 0.3-1 point. CONCLUSIONS: Using corrected-Cr MELD, which would prioritize female patients for liver transplantation, may only be justified in predicting intermediate-term (9- and 12-month), but not short-term (3- and 6-month) mortality.