Pandemic Rule-Breakers, Moral Luck, and Blaming the Blameworthy.

This paper takes under consideration a piece by Roger Crisp in which he questions what the problem of moral luck can teach us about COVID-19 lockdown rule-breakers. Taking the position that although such rule-breakers might seem to be new examples of moral luck, Crisp ends up denying the existence of moral luck and argues that moral luck is an outdated notion in so far as it relies on other questionable aspects of morality, that is, retributivist punishment and blame. Although the author agrees with Crisp that pandemic rule-breaker cases are putative examples of resultant moral luck, he proposes that Crisp has misconstrued what moral luck is and the paper examines in detail what he sees as the numerous problems with Crisp's claims. The author concludes that Crisp's analysis of pandemic rule-breaking does not shed any new light on the moral luck debate, and the difficult questions of luck, moral responsibility, and desert are not so easily resolved.

Effect of a High-Sensitivity Troponin I and Associated Diagnostic Protocol on Emergency Department Length of Stay: A Retrospective Cohort Study.

Background: The objective of this study was to assess the introduction of a high-sensitivity troponin I (hs-TnI) assay and its associated accelerated protocol on emergency department (ED) length of stay (LOS) for patients presenting with chest pain, compared to an accelerated diagnostic protocol using conventional troponin (TnI) testing. Methods: We conducted a retrospective cohort study of all adults with a primary presenting complaint of chest pain of cardiac origin and a Canadian Triage and Acuity Scale score of 2 or 3, between November 8, 2019 and November 9, 2021, to a tertiary-care urban Canadian ED. The primary outcome was ED LOS. Secondary outcomes included consultation proportions and major adverse cardiac events within 30 days of the index ED visit. Results: A total of 2640 patients presenting with chest pain were included, with 1333 in the TnI group and 1307 in the hs-TnI group. Median ED LOS decreased significantly, from 392 minutes for the TnI group, and 371 minutes for the hs-TnI group (median difference = 21 minutes; 95% confidence interval: 5.3, 36.7). The numbers of consultations and admissions were not statistically different between study periods. The major adverse cardiac events outcomes did not change following the implementation of the hs-TnI test (13.6% vs 13.1%; P = 0.71). Conclusions: The implementation of an accelerated chest pain protocol using an hs-TnI assay in a tertiary-care Canadian ED was associated with a modest reduction of LOS for all patients, and a substantial reduction of LOS for patients undergoing serial troponin testing. This strategy was safe, with no increase in adverse outcomes.

Contexte: Cette étude visait à évaluer l'introduction du dosage de la troponine I de haute sensibilité (hs-TnI) et le protocole accéléré qui lui est associé sur la durée des séjours aux urgences dans le cas des patients qui consultent pour une douleur thoracique, comparativement à un protocole diagnostique accéléré faisant appel à un test de troponine classique (TnI). Méthodologie: Nous avons mené une étude de cohorte rétrospective portant sur tous les adultes qui se sont présentés aux urgences d'un établissement urbain de soins tertiaires canadien entre le 8 novembre 2019 et le 9 novembre 2021 principalement pour une douleur thoracique d'origine cardiaque et dont le score était de 2 ou 3 à l'Échelle canadienne de triage et de gravité (ETG). Le principal critère d'évaluation était la durée du séjour au service des urgences. Les critères d'évaluation secondaires comprenaient la fréquence des consultations et les événements cardiaques indésirables majeurs dans les 30 jours ayant suivi la visite de référence aux urgences. Résultats: Au total, 2640 patients qui s'étaient présentés aux urgences pour une douleur thoracique ont été inclus, 1333 se trouvant dans le groupe TnI et 1307 dans le groupe hs-TnI. La durée médiane du séjour aux urgences a diminué considérablement, passant de 392 minutes dans le groupe TnI à 371 minutes dans le groupe hs-TnI (différence médiane de 21 minutes; intervalle de confiance [IC] à 95 % : 5,3-36,7). Les consultations et les admissions n'ont pas affiché de différence statistique entre les périodes de l'étude. Les événements cardiaques indésirables majeurs n'ont pas varié après l'introduction du dosage de la hs-TnI (13,6 % vs 13,1 %; p = 0,71). Conclusions: L'adoption d'un protocole accéléré pour la douleur thoracique à l'aide du dosage de la hs-TnI au service des urgences d'un établissement de soins tertiaires canadien a été associée à une légère réduction de la durée du séjour pour l'ensemble des patients et à une réduction substantielle de cette durée pour les patients soumis à des analyses de la troponine en série. De plus, cette stratégie était sûre sans hausse des événements indésirables.

Near-fatal pediatric methemoglobinemia secondary to intentional sodium nitrite ingestion.

Methemoglobinemia is the result of inappropriate oxidation of hemoglobin iron groups, leading to a failure of oxygen transport and delivery, resulting in a clinical state of refractory hypoxia. Methemoglobin levels above 70% are often considered fatal. Acquired methemoglobinemia can be caused by a variety of substances, including sodium nitrite, a commercially available food preservative and color fixative. This report describes a patient presenting with a methemoglobin level of 83% secondary to intentional sodium nitrite ingestion. The methemoglobin level recorded is amongst some of the highest found in surviving patients.

Emergency Medicine Journal Editorial Boards: Analysis of Gender, H-Index, Publications, Academic Rank, and Leadership Roles.

INTRODUCTION: Our goal in this study was to determine female representation on editorial boards of high-ranking emergency medicine (EM) journals. In addition, we examined factors associated with gender disparity, including board members' academic rank, departmental leadership position, h-index, total publications, total citations, and total publishing years. METHODS: In this retrospective study, we examined EM editorial boards with an impact factor of 1 or greater according to the Clarivate Journal Citations Report for a total of 16 journals. All board members with a doctor of medicine or doctor of osteopathic medicine degree, or international equivalent were included, resulting in 781 included board members. We analyzed board members' gender, academic rank, departmental leadership position, h-index, total publications, total citations, and total publishing years. RESULTS: Gender disparity was clearly notable, with men holding 87.3% (682/781) of physician editorial board positions and women holding 12.7% (99/781) of positions. Only 6.6% (1/15) of included editorial board chiefs were women. Male editorial board members possessed higher h-indices, total citations, and more publishing years than their female counterparts. Male board members held a greater number of departmental leadership positions, as well as higher academic ranks. CONCLUSION: Significant gender disparity exists on EM editorial boards. Substantial inequalities between men and women board members exist in both the academic and departmental realms. Addressing these inequalities will likely be an integral part of achieving gender parity on editorial boards.

Factors associated with hospital admission in adult patients with asthma exacerbations: A systematic review.

OBJECTIVES: A variable proportion of patients presenting to the emergency department (ED) with acute asthma require admission to hospital. Previous studies have identified select factors associated with admission following ED presentation; however, no review has synthesized the evidence in this regard. This systematic review summarizes the evidence regarding factors associated with hospital admission following ED presentation. METHODS: Searches were conducted in seven electronic databases and common sources of grey literature. Studies reporting disposition for adults after ED presentation were included. Admission proportions and factors associated with hospitalization that remained statistically significant in multivariable analyses (p < 0.05) were reported. RESULTS: Out of an initial 5865 identified articles, 15 articles met full inclusion criteria and 11 were included in the analyses. Female sex (n = 2) and older age (n = 2) were individual factors associated with admission. Patient vital signs and severity followed by patient attributes were the two most frequent domains associated with admission. Admission proportions were analyzed in 10 studies at an median of ∼20% with no clear change between 1996 and 2012. CONCLUSIONS: Factors such as patient demographics (e.g., female sex, older age), patient vital signs/severity, and history are associated with admission following ED presentation for acute asthma. These can be employed by ED clinicians to effectively discern patients at high risk for admission and lead to more evidence-based decision-making.

Factors associated with relapse in adult patients discharged from the emergency department following acute asthma: a systematic review.

A significant proportion of patients discharged from the emergency department (ED) with asthma exacerbations will relapse within 4 weeks. This systematic review summarises the evidence regarding relapses and factors associated with relapse in adult patients discharged from EDs after being treated for acute asthma. Following a registered protocol, comprehensive literature searches were conducted. Studies tracking outcomes for adults after ED management and discharge were included if they involved adjusted analyses. Methodological quality was assessed using the Newcastle-Ottawa Scale (NOS) and the Risk of Bias (RoB) Tool. Results were summarised using medians and IQRs or mean and SD, as appropriate. 178 articles underwent full-text review and 10 studies, of various methodologies, involving 32 923 patients were included. The majority of the studies were of high quality according to NOS and RoB Tool. Relapse proportions were 8±3%, 12±4% and 14±6% at 1, 2 and 4 weeks, respectively. Female sex was the most commonly reported and statistically significant factor associated with an increased risk of relapse within 4 weeks of ED discharge for acute asthma. Other factors significantly associated with relapse were past healthcare usage and previous inhaled corticosteroids (ICS) usage. A median of 17% of patients who are discharged from the ED will relapse within the first 4 weeks. Factors such as female sex, past healthcare usage and ICS use at presentation were commonly and significantly associated with relapse occurrence. Identifying patients with these features could provide clinicians with guidance during their ED discharge decision-making.

Urban Compost Attracts Coyotes, Contains Toxins, and may Promote Disease in Urban-Adapted Wildlife.

Anthropogenic food is often concentrated in cities where it can attract wildlife, promote conflict with people, and potentially spread disease. Although these associations are well-documented for conventional garbage, they are unexplored for many seemingly innocuous and even environmentally friendly attractants such as piles of compost. In this study, we tested the hypothesis that municipal piles of compost are underappreciated and potentially important contributors to a recent rise in encounters with urban-adapted wildlife by attracting wildlife and promoting the spread of wildlife disease. We used remote cameras to compare visitation rates to compost piles and urban natural areas by coyotes (Canis latrans). For each site type, we assessed photographs for evidence of ectoparasites, screened scats for endoparasites, and sampled compost for harmful mycotoxins. At compost piles, visitation rates were eight times more frequent, coyotes with visible parasitic infections were 4.5 times more common, scats were 10 times more likely to contain tapeworm eggs, and mycotoxins were detected in 86% of piles and often at concentrations higher than legal limits for animal feed. Greater securement of compost waste in cities may reduce encounters with animals, susceptibility to and spread of disease, and rates of human-wildlife conflict for coyotes and other urban-adapted species.

Does location of prostate cancer by sextant biopsies predict for relapse after (125)I seed implant brachytherapy?

PURPOSE: To report on the importance of cancer location from diagnostic prostate biopsies in predicting biochemical relapse for patients treated with (125)I seed implant brachytherapy as monotherapy for favorable risk disease; specifically, to assess the clinical significance of potentially underdosing the base region of the prostate gland. METHODS AND MATERIALS: Of 1145 consecutive patients, 846 had pretreatment biopsies allowing for sextant analysis and consequent evaluation of biochemical failure tendencies. Biochemical failure was defined as a posttreatment rise in the nadir prostate-specific antigen (PSA) by at least 2 ng/mL. Patient and tumor characteristics, dosimetry, the use of hormone therapy, source strength, and postimplant PSA kinetics were analyzed between sextant subgroups. RESULTS: Sixty-two patients (7.3%) with sextant pathology had biochemical failure. There was no significant difference between the failure locations. There were 528 patients (62.4%) with some element of base involvement (BI), and 318 patients (37.6%) with no evidence of BI. Of the 62 patients with biochemical failure, 42 (67.7%) showed BI on biopsy and 20 (32.3%) had no BI. The 10-year relapse-free survival rate is 88.2% (95% confidence interval: 84.3%, 92.2%) and 92.0% (95% confidence interval: 88.4%, 95.8%) for the BI and no BI groups, respectively (p = 0.17). The mean D90 delivered to the base, midgland, and apex was 140.8 (±21.8) Gy, 170.8 (±22.5) Gy, and 177.9 (±29.5) Gy, respectively, for all patients. CONCLUSIONS: There are no significantly worse outcomes for patients treated with an (125)I seed implant for favorable risk prostate cancer with some element of BI, despite lower doses of radiation delivered to the base region.

Measurement of segmental lumbar spine flexion and extension using ultrasound imaging.

STUDY DESIGN: Clinical measurement, technical note. OBJECTIVES: To describe a technique to measure interspinous process distance using ultrasound (US) imaging, to assess the reliability of the technique, and to compare the US imaging measurements to magnetic resonance imaging (MRI) measurements in 3 different positions of the lumbar spine. BACKGROUND: Segmental spinal motion has been assessed using various imaging techniques, as well as surgically inserted pins. However, some imaging techniques are costly (MRI) and some require ionizing radiation (radiographs and fluoroscopy), and surgical procedures have limited use because of the invasive nature of the technique. Therefore, it is important to have an easily accessible and inexpensive technique for measuring lumbar segmental motion to more fully understand spine motion in vivo, to evaluate the changes that occur with various interventions, and to be able to accurately relate the changes in symptoms to changes in motion of individual vertebral segments. METHODS: Six asymptomatic subjects participated. The distance between spinous processes at each lumbar segment (L1-2, L2-3, L3-4, L4-5) was measured digitally using MRI and US imaging. The interspinous distance was measured with subjects supine and the lumbar spine in 3 different positions (resting, lumbar flexion, and lumbar extension) for both MRI and US imaging. The differences in distance from neutral to extension, neutral to flexion, and extension to flexion were calculated. RESULTS: The measurement methods had excellent reliability for US imaging (intraclass correlation coefficient [ICC3,3] = 0.94; 95% confidence interval: 0.85, 0.97) and MRI (ICC3,3 = 0.98; 95% confidence interval: 0.95, 0.99). The distance measured was similar between US imaging and MRI (P>.05), except at L3-4 flexion-extension (P = .003). On average, the MRI measurements were 1.3 mm greater than the US imaging measurements. CONCLUSION: This study describes a new method for the measurement of lumbar spine segmental flexion and extension motion using US imaging. The US method may offer an alternative to other imaging techniques to monitor clinical outcomes because of its ease of use and the consistency of measurements compared to MRI.

Evaluation of open globe injuries of children in the last 12 years.

PURPOSE: To determine whether advances in vitreoretinal surgical techniques developed over the last decade have translated into improved anatomic and visual outcomes. METHODS: Retrospective review of children under the age of 18 who were treated for open globe injuries at a children's hospital between January 1990 and December 2002. RESULTS: The authors identified 59 open globe injuries seen at a single center in the past 12 years. Thirty eyes (51%) required secondary surgery after primary closure. Twelve patients underwent pars plana vitrectomy (PPV), and all presented with an initial visual acuity of count fingers or worse. Seven (58%) had an improvement in vision to 20/200 or better, and 6 (50%) of these patients achieved a visual acuity of 20/50 or better. CONCLUSION: Improvements in outcome compared to previous studies may signify refinement in technique and an increased utility of PPV over the last 10 years.

Alphav-integrin utilization in human beta-cell adhesion, spreading, and motility.

The role of individual integrins in human beta-cell development and function is largely unknown. This study describes the contribution of alpha(v)-integrins to human beta-cell adhesion, spreading, and motility. Developmental differences in alpha(v)-integrin utilization are addressed by comparing the responses of adult and fetal beta-cells, and vitronectin is used as a substrate based on its unique pattern of expression in the developing pancreas. Fetal and adult beta-cells attached equally to vitronectin and integrin alpha(v)beta(5) was found to support the adhesion of both mature and immature beta-cell populations. Fetal beta-cells were also observed to spread and migrate on vitronectin, and integrin alpha(v)beta(1) was found to be essential for these responses. In contrast to their fetal counterparts, adult beta-cells failed to either spread or migrate and this deficit was associated with a marked down-regulation of alpha(v)beta(1) expression in adult islet preparations. The integrin alpha(v)beta(3) was not found to support significant beta-cell attachment or migration. Based on our findings, we conclude that integrins alpha(v)beta(5) and alpha(v)beta(1) are important mediators of human beta-cell adhesion and motility, respectively. By supporting fetal beta-cell migration, alpha(v)beta(1) could play an important role in early motile processes required for islet neogenesis.