Exploring Bias in Restraint Use: Four Strategies to Mitigate Bias in Care of the Agitated Patient in the Emergency Department.

Agitation is a routine and increasingly common presentation to the emergency department (ED). In the wake of a national examination into racism and police use of force, this article aims to extend that reflection into emergency medicine in the management of patients presenting with acute agitation. Through an overview of ethicolegal considerations in restraint use and current literature on implicit bias in medicine, this article provides a discussion on how bias may impact care of the agitated patient. Concrete strategies are offered at an individual, institutional, and health system level to help mitigate bias and improve care. Reprinted from Acad Emerg Med 2021; 28:1061-1066, with permission from John Wiley & Sons. Copyright © 2021.

Exploring bias in restraint use: Four strategies to mitigate bias in care of the agitated patient in the emergency department.

Agitation is a routine and increasingly common presentation to the emergency department (ED). In the wake of a national examination into racism and police use of force, this article aims to extend that reflection into emergency medicine in the management of patients presenting with acute agitation. Through an overview of ethicolegal considerations in restraint use and current literature on implicit bias in medicine, this article provides a discussion on how bias may impact care of the agitated patient. Concrete strategies are offered at an individual, institutional, and health system level to help mitigate bias and improve care.

Mortality in Rohingya refugee camps in Bangladesh: historical, social, and political context.

Fifty-two maternal deaths occurred between September 2017 and August 2018 in the Rohingya refugee camps in Ukhia and Teknaf Upazilas, Cox's Bazar District, Bangladesh. Behind every one of these lives lost is a complex narrative of historical, social, and political forces, which provide an important context for reproductive health programming in Rohingya camps. Rohingya women and girls have experienced human rights violations in Myanmar for decades, including government-sponsored sexual violence and population control efforts. An extension of nationalist, anti-Rohingya policies, the attacks of 2017 resulted in the rape and murder of an unknown number of women. The socio-cultural context among Rohingya and Bangladeshi host communities limits provision of reproductive health services in the refugee camps, as does a lack of legal status and continued restrictions on movement. In this review, the historical, political, and social contexts have been overlaid below on the Three Delays Model, a conceptual framework used to understand the determinants of maternal mortality. Attempts to improve maternal mortality among Rohingya women and girls in the refugee camps in Bangladesh should take into account these complex historical, social and political factors in order to reduce maternal mortality.

Interaction of a Cationic Porphyrin and Its Metal Derivatives with G-Quadruplex DNA.

G-quadruplex (GQ) structures formed from guanine-rich sequences are found throughout the genome and are overrepresented in the promoter regions of some oncogenes, at the telomeric ends of eukaryotic chromosomes, and at the 5'-untranslated regions of mRNA. Interaction of small molecule ligands with GQ DNA is an area of great research interest to develop novel anticancer therapeutics and GQ sensors. In this paper we examine the interactions of TMPyP4, its isomer TMPyP2 (containing N-methyl-2-pyridyl substituents, N-Me-2Py) as well as two metal derivatives ZnTMPyP4 and CuTMPyP4 with GQs formed by dT4G4 and dT4G4T in 100 mM K+ or Na+ conditions. The DNA sequences were chosen to elucidate the effect of the 3'-T on the stabilization effect of porphyrins, binding modes, affinities, and stoichiometries determined via circular dichroism melting studies, UV-vis titrations, continuous variation analysis, and fluorescence studies. Our findings demonstrate that the stabilizing abilities of porphyrins are stronger toward (dT4G4)4 as compared to (dT4G4T)4 (ΔTm is 4.4 vs -6.4 for TMPyP4; 12.7 vs 5.7 for TMPyP2; 16.4 vs 12.1 for ZnTMPyP4; and 1.9 vs -8.4 °C for CuTMPyP4) suggesting that the 3'G-tetrad presents at least one of the binding sites. The binding affinity was determined to be moderate (Ka ∼ 106-107 µM-1) with a typical binding stoichiometry of 1:1 or 2:1 porphyrin-to-GQ. In all studies, ZnTMPyP4 emerged as a ligand superior to TMPyP4. Overall, our work contributes to clearer understanding of interactions between porphyrins and GQ DNA.

Cortisol/DHEA ratio and hippocampal volume: A pilot study in major depression and healthy controls.

Structural imaging studies investigating the relationship between hippocampal volume (HCV) and peripheral measures of glucocorticoids (GCs) have produced conflicting results in both normal populations and in individuals with MDD, raising the possibility of other modulating factors. In preclinical studies, dehydroepiandrosterone (DHEA) and its sulfate ester (DHEAS; together abbreviated, DHEA(S)) have been shown to antagonize the actions of GCs on the central nervous system. Therefore, considering the relationship of HCV to both of these hormones simultaneously may be important, although it has rarely been done in human populations. Using high-resolution magnetic resonance imaging (MRI), the present pilot study examined the relationship between morning serum cortisol, DHEA(S), and HCV in nineteen normal controls and eighteen unmedicated subjects with Major Depressive Disorder (MDD). Serum cortisol and DHEA(S) were not significantly correlated with HCV across all subjects (cortisol: r=-0.165, p=0.33; DHEA: r=0.164, p=0.35; DHEAS: r=0.211, p=0.22, respectively). However, the ratios of cortisol/DHEA(S) were significantly negatively correlated with HCV in combined group (Cortisol/DHEA: r=-0.461, p=0.005; Cortisol/DHEAS: r=-0.363, p=0.03). Significant or near-significant correlations were found between some hormonal measurements and HCV in the MDDs alone (DHEA: r=0.482, p=0.059; DHEAS: r=0.507, p=0.045; cort/DHEA: r=-0.589, p=0.02; cort/DHEAS: r=-0.424p=0.10), but not in the controls alone (DHEA: r=0.070, p=0.79; DHEAS: r=0.077, p=0.77; cort/DHEA: r=-0.427, p=0.09; cort/DHEAS: r=-0.331, p=0.19). However, Group (MDDs vs controls) did not have a significant effect on the relationship between cortisol, DHEA(S), and their ratios with HCV (p>0.475 in all analyses). Although the exact relationship between serum and central steroid concentrations as well as their effects on the human hippocampus remains not known, these preliminary results suggest that the ratio of cortisol to DHEA(S), compared to serum cortisol alone, may convey additional information about "net steroid activity" with relation to HCV.

Juvenile stress enhances anxiety and alters corticosteroid receptor expression in adulthood.

BACKGROUND: Exposure to stress in early life is correlated with the development of anxiety disorders in adulthood. The underlying mechanisms are not fully understood, but an imbalance in corticosteroid receptor (CR) expression in the limbic system, particularly the hippocampus, has been implicated in the etiology of anxiety disorders. However, little is known about how prepubertal stress in the so called "juvenile" period might alter the expression of these receptors. AIMS: Therefore, the aim of this study was to investigate how stress experienced in the juvenile phase of life altered hippocampal expression of CRs and anxiety behaviors in adulthood. MATERIALS AND METHODS: We used a rodent model to assess the effects of juvenile stress on hippocampal CR expression, and performance in three behavioral tests of anxiety in adulthood. RESULTS: Juvenile stress (JS) increased anxiety-like behavior on the elevated plus maze, increased mineralocorticoid receptor (MR) expression, and decreased the ratio of glucocorticoid receptor (GR) to MR expression in the hippocampus of adult animals. Females demonstrated lower levels of anxiety-type behavior and increased activity in three behavioral tests, and had greater expression of GR and GR:MR ratio than males, regardless of treatment. DISCUSSION AND CONCLUSION: These results demonstrate that JS can alter the expression and balance of CRs, providing a potential mechanism for the corresponding increase in anxiety behavior observed in adulthood. Further evidence for the role of CR expression in anxiety is provided by sex differences in anxiety behavior and corresponding alterations in CR expression.