Shifting the paradigm: physician-authorized, student-led efforts to provide harm reduction services amidst legislative opposition.

BACKGROUND: For over 30 years, syringe services programs (SSPs) have served as an efficacious intervention for the prevention of HIV and Hepatitis C transmission among persons who use drugs. Despite a strong body of evidence for the effectiveness of SSPs as a preventative public health measure, numerous local and state governments in the United States continue to resist the establishment of new SSPs and aggressively pursue the closure of those already in operation. COMMENTARY: In Orange County, California, local officials have repeatedly mobilized in opposition of the establishment of syringe access - thereby hindering access to healthcare for thousands of predominantly unhoused individuals. The county was previously served by the Orange County Needle Exchange Program from 2016 until 2018 when a civil suit brought by the Orange County Board of Supervisors resulted in the closure of the program. For more than 2 years, persons who inject drugs in Orange County lacked reliable access to clean syringes, placing them at increased risk for contracting HIV and Hepatitis C. Here, we comment on the ongoing effort to restore syringe access in Orange County. This collaborative physician-directed endeavor has brought together students and community volunteers to provide vital harm reduction services to a remarkably underserved population. Since the reestablishment of syringe access in Orange County by the Harm Reduction Institute, new legal barriers have arisen including the passage of new municipal legislation banning the operation of syringe exchanges. We are well-equipped to overcome these obstacles. This work serves as an affirmation of assertions made by previous authors regarding the unique qualifications of medical & graduate students as effective harm reductionists. CONCLUSION: Harm reduction services are vital to the health and well-being of people who use drugs. The provision of these services should not be impeded by legislative interference by municipal, county, or state governments.

Haunting of the phantom limb pain abolished by buprenorphine/naloxone.

Neuropathic opioid refractory phantom limb pain (PLP) following amputation can be a life long debilitating chronic pain syndrome capable of completely destroying a patient's life. The pain, its associated depression and sleep deprivation can make many patients suicidal. Ever changing and relentless, it is notoriously unresponsive to traditional cocktails of strong opioids, adjuvant pain medications, antidepressants, local anaesthetics, nerve stimulators, hypnotics and psychotropics. Drug effects are seldom more effective than placebo. We describe a successful sustained rescue of a difficult 2-year-long PLP case with sublingual buprenorphine/naloxone using the drug's potent multimodal mechanisms of action: potent long-acting mu agonist/antagonist, kapa receptor antagonist, delta receptor antagonist and novel opioid receptor-like 1 (OR-L1) agonist effects. Traditional escalating pure mu-opioid receptor agonists and adjuvant neuropathic pain cocktails often have disappointing efficacy in the treatment of resistant PLP. We suggest introducing buprenorphine/naloxone as an early effective opioid choice in PLP management.

Computerized alcohol screening identified more at-risk drinkers in a level 2 than a level 1 trauma center.

BACKGROUND: Alcohol abuse is recognized as a significant contributor to injury. It is therefore essential that trauma centers implement screening and brief intervention (SBI) to identify patients who are problem drinkers. Although, the utility of SBI in identifying at-risk drinkers have been widely studied in level 1 trauma centers, few studies have been done in level 2 centers. This study evaluates the usefulness of SBI in identifying at-risk drinkers and to investigate the pattern of alcohol drinking among level 2 trauma patients. METHODS: This is a retrospective study of a convenience sample of trauma patients participating in computerized alcohol screening, brief intervention, and referral to treatment (CASI) in an academic level 1 trauma center and a nearby suburban community hospital level 2 trauma center. CASI utilized Alcohol Use Disorders Identification Test (AUDIT) to screen patients. We compared the pattern of alcohol drinking, demographic factors, and readiness-to-change scores between those screened in a level 2 and 1 trauma center. RESULTS: A total of 3,850 and 1,933 admitted trauma patients were screened in level 1 and 2 trauma centers respectively. There was no difference in mean age, gender, and language between the two centers. Of those screened, 10.2% of the level 1 and 14.4% of the level 2 trauma patients scored at-risk (AUDIT 8-19) (p < 0.005). Overall, 3.7% of the level 1 and 7.2% of the level 2 trauma patients had an AUDIT score consistent with dependency (AUDIT > =20) (p < 0.005). After adjusting for age, sex, education, and language, the odds of being a drinker at the level 2 center was two times of those at the level 1 center (p < 0.005). The odds of being an at-risk or dependent drinker at level 2 trauma center were 1.72 times of those at the level 1 center (p < 0.005). CONCLUSIONS: Findings suggest that SBI is effective in identifying at-risk drinkers in level 2 trauma center. SBI was able to identify all drinkers, including at-risk and dependent drinkers at higher rates in level 2 versus level 1 trauma centers. Further studies to evaluate the effectiveness of SBI in altering drinking patterns among level 2 trauma patients are warranted.

Thrombosis of Inferior Vena Cava Diagnosed Using Point-of-Care Ultrasound After Pediatric Near-Syncope.

BACKGROUND: Venous thromboembolism (VTE) is extremely rare but under recognized in the pediatric population. Although the literature on the use of ultrasound to detect VTEs in adults is plentiful, little has been documented on its use in the pediatric population. CASE REPORT: We present a case of a healthy 16-year-old female who presented to our emergency department with 3 months of dyspnea on exertion and one episode of near-syncope. Point-of-care cardiac ultrasound identified an inferior vena cava thrombosis. Subsequent computed tomography angiography diagnosed concurrent bilateral pulmonary emboli (PE). The patient's identical twin sister presented with similar symptoms shortly thereafter and was also diagnosed with VTE and bilateral PE. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case demonstrates an instance of VTE and pulmonary embolism in twin adolescent girls. Physical examination findings, electrocardiogram, chest x-ray study, and several previous evaluations did not reveal the diagnosis. Point of care ultrasound was used to correctly diagnosis VTE and for heightened concern for a pulmonary embolism.

Approaches to describing inter-rater reliability of the overall clinical appearance of febrile infants and toddlers in the emergency department.

Objectives. To measure inter-rater agreement of overall clinical appearance of febrile children aged less than 24 months and to compare methods for doing so. Study Design and Setting. We performed an observational study of inter-rater reliability of the assessment of febrile children in a county hospital emergency department serving a mixed urban and rural population. Two emergency medicine healthcare providers independently evaluated the overall clinical appearance of children less than 24 months of age who had presented for fever. They recorded the initial 'gestalt' assessment of whether or not the child was ill appearing or if they were unsure. They then repeated this assessment after examining the child. Each rater was blinded to the other's assessment. Our primary analysis was graphical. We also calculated Cohen's κ, Gwet's agreement coefficient and other measures of agreement and weighted variants of these. We examined the effect of time between exams and patient and provider characteristics on inter-rater agreement. Results. We analyzed 159 of the 173 patients enrolled. Median age was 9.5 months (lower and upper quartiles 4.9-14.6), 99/159 (62%) were boys and 22/159 (14%) were admitted. Overall 118/159 (74%) and 119/159 (75%) were classified as well appearing on initial 'gestalt' impression by both examiners. Summary statistics varied from 0.223 for weighted κ to 0.635 for Gwet's AC2. Inter rater agreement was affected by the time interval between the evaluations and the age of the child but not by the experience levels of the rater pairs. Classifications of 'not ill appearing' were more reliable than others. Conclusion. The inter-rater reliability of emergency providers' assessment of overall clinical appearance was adequate when described graphically and by Gwet's AC. Different summary statistics yield different results for the same dataset.

Large-volume paracentesis: a fast, convenient, and safe technique.

BACKGROUND: Ascites is a common complication of liver cirrhosis, malignancy, cardiac failure, pancreatitis, and tuberculosis, with cirrhosis of the liver being the most common cause. Onset of ascites in cirrhosis of the liver is associated with worsened quality of life, increased risk of spontaneous bacterial peritonitis, and renal failure. Management of ascites caused by cirrhosis requires sodium restriction in diet, sodium excretion with diuretics and, in refractory cases, large volume paracentesis. TECHNIQUE: We describe a simple adjustment to the standard paracentesis technique that does not require additional equipment or manpower. CONCLUSION: Removing over 5 L of ascitic fluid can become a time-consuming and labor-intensive process. We describe a setup that makes this commonly performed procedure fast, convenient, and safe.

Predictors of mortality and management of patients with traumatic inferior vena cava injuries.

The aim of this study was to determine factors that predict mortality in patients with traumatic inferior vena cava (IVC) injuries and to review the current management of this lethal injury. A 7-year retrospective review of all trauma patients with IVC injuries was performed. Factors associated with mortality were assessed by univariate analysis. Significant variables were included in a multivariate regression analysis model to determine independent predictors of mortality. Statistical significance was determined at P < or = 0.05. A literature review of traumatic IVC injuries was performed and compared with our institutional experience. Thirty-six IVC injuries were identified (mortality, 56%; mechanisms of injury, 28% blunt and 72% penetrating). There was no difference in mortality based on mechanism of injury. Injuries with closer proximity to the heart were associated with increased mortality (P < 0.001). Univariate analysis demonstrated that nonsurvivors had a higher injury severity scale, a lower systolic blood pressure in the emergency department, a lower Glasgow coma score (GCS), and were more likely to have thoracotomies performed in the emergency department or operating room. Multivariate analysis revealed that only GCS (P = 0.03) was an independent predictor of mortality. Typical factors predicting mortality were identified in our cohort of patients, including GCS. The mechanism of injury is not associated with survival outcome, although mortality is higher with injuries more proximal to the heart. The form of management by IVC level is reviewed in our patient population and compared with the literature.