Fentanyl-positive urine drug screens in the emergency department: Association with intentional opioid misuse and racial disparities.

Background: An increase in opioid-related overdoses, notably from potent synthetic opioids like fentanyl, prompted this consideration of characteristics of emergency department (ED) patients with evidence for illicit fentanyl use or exposure, the correlation with intentional opioid misuse, and subsequent ED management. Methods: A retrospective review was performed of patients presenting to an urban academic medical center ED with evidence for illicit fentanyl use, determined by positive urine drug screens (UDS), from 6/2021 through 11/2021. Participant demographics, comorbidities, ED chief complaint and disposition, and evidence of intentional opioid misuse were considered. Secondary outcomes included provision of buprenorphine/naloxone and/or naloxone kits at discharge, ED recidivism, and six-month mortality. Bivariate comparisons and logistic regression models were performed. Results: Among 409 unique patients, most were white and male with a mean age of 39.4. Approximately half presented with opioid-related complaints. Evidence of intentional opioid misuse was identified in 72.6 % of patients. Black patients had 79 % lower odds of intentional opioid misuse compared to white patients. Regarding ED management, 28.8 % were discharged with buprenorphine/naloxone and 14.0 % with a naloxone kit. Black patients had 63 % lower odds of receiving buprenorphine/naloxone compared to white patients after controlling for covariates. Nearly 6 % of the study population died within six months of the initial ED visit. Conclusion: This fentanyl-focused review describes patient characteristics which largely mirror the epidemiology of the current opioid epidemic; however, despite evidence of objective exposure, it also suggests that Black patients may be less likely to use fentanyl intentionally. It also highlights potential disparities related to ED-based opioid misuse patient management.

Does QBank participation impact in-training examination performance?

BACKGROUND: Performance on the annual in-training examination (ITE) for emergency medicine (EM) residents has been shown to correlate with performance on the American Board of Emergency Medicine (ABEM) qualifying examination. As such, significant planning is often committed to ITE preparation, from an individual resident and a residency program perspective. Online specialty-specific question banks (QBanks) represent a popular medium for ITE preparation; however, the impact of QBanks on ITE performance is unclear. We sought to assess the impact of QBank participation on EM resident ITE performance. METHODS: ITE and QBank performance results were collated over 2 academic years, 2019 and 2020, from a 3-year EM residency program. The QBank was provided as a self-study option in 2019 and incorporated as a mandatory component of the curriculum in 2020. ITE raw scores and percentile rank for training level scores were compared with performance on the QBank, including QBank average performance score as well as number of QBank questions completed. The Pearson correlation coefficient was used to measure association between ITE performance and QBank correlates. Additional descriptive demographics, to include gender, PGY level, and USMLE step 1 and 2 scores were also considered. RESULTS: Sixty-two sets (30 residents in 2019, 32 residents in 2020) of ITE performance data and QBank correlates were included. Overall, raw ITE scores and number of QBank questions completed were found to have a significant, positive correlation, (r(60) = 0.34, p < 0.05); correlation was stronger for 2019 (r[28] = 0.39, p < 0.05) compared to 2020 (r[30] =0.25, p = 0.16). Overall, ITE percentile rank for training level scores were also found to have a significant, positive correlation with number of QBank questions completed (r(60) = 0.35, p < 0.05); correlation was again stronger for 2019 (r(28) = 0.42, p < 0.05) compared to 2020 (r(30) = 0.29, p = 0.12). Finally, ITE percentile rank for training level correlated positively with QBank average performance (as a percentage), albeit weakly, and was not found to be significant overall (r[60] = 0.20, p = 0.16); in this instance, 2019 did not show a correlation (r[28] =0.12, p = 0.54); however, 2020 did (r[30] =0.55, p < 0.05). Academic year 2020 raw ITE scores also demonstrated a significant correlation with QBank average performance (r[30] = 0.66, p < 0.0001) while 2019 did not (r[28] = 0.08, p = 0.68). CONCLUSION: Participation and engagement in a QBank are associated with improved EM resident performance on the ABEM ITE. Utilization of a QBank may be an effective mode of ITE preparation for EM residents.

Training in the Management of Psychobehavioral Conditions: A Needs Assessment Survey of Emergency Medicine Residents.

OBJECTIVE: Mental health-related ED visits are increasing. Despite this trend, most emergency medicine (EM) residency programs devote little time to psychiatry education. This study aimed to identify EM residents' perceptions of training needs in emergency psychiatry and self-confidence in managing patients with psychobehavioral conditions. METHODS: A needs assessment survey was distributed to residents at 15 Accreditation Council for Graduate Medical Education-accredited EM programs spanning the U.S. Survey items addressed amount and type of training in psychiatry during residency, perceived training needs in psychiatry, and self-confidence performing various clinical skills related to emergency psychiatric care. Residents used a 5-point scale (1 = nothing; 5 = very large amount) to rate their learning needs in a variety of topic areas related to behavioral emergencies (e.g., medically clearing patients, substance use disorders). Using a scale from 0 to 100, residents rated their confidence in their ability to independently perform various clinical skills related to emergency psychiatric care (e.g., differentiating a psychiatric presentation from delirium). RESULTS: Of the 632 residents invited to participate, 396 (63%) responded. Twelve percent of respondents reported completing a psychiatry rotation during EM residency. One of the 15 participating programs had a required psychiatry rotation. Residents reported that their program used lectures (56%) and/or supervised training in the ED (35%) to teach residents about psychiatric emergencies. Most residents reported minimal involvement in the treatment of patients with psychiatric concerns. The majority of residents (59%) believed that their program should offer more education on managing psychiatric emergencies. Only 14% of residents felt "quite" or "extremely" prepared to treat psychiatric patients. Overall, residents reported the lowest levels of confidence and highest need for more training related to counseling suicidal patients and treating psychiatric issues in special populations (e.g., pregnant women, elderly, and children). CONCLUSIONS: Most EM residents desire more training in managing psychiatric emergencies than is currently provided.

Potential contribution of natural enemies to patterns of local adaptation in plants.

Genetic differentiation among plant populations and adaptation to local environmental conditions are well documented. However, few studies have examined the potential contribution of plant antagonists, such as insect herbivores and pathogens, to the pattern of local adaptation. Here, a reciprocal transplant experiment was set up at three sites across Europe using two common plant species, Holcus lanatus and Plantago lanceolata. The amount of damage by the main above-ground plant antagonists was measured: a rust fungus infecting Holcus and a specialist beetle feeding on Plantago, both in low-density monoculture plots and in competition with interspecific neighbours. Strong genetic differentiation among provenances in the amount of damage by antagonists in both species was found. Local provenances of Holcus had significantly higher amounts of rust infection than foreign provenances, whereas local provenances of Plantago were significantly less damaged by the specialist beetle than the foreign provenances. The presence of surrounding vegetation affected the amount of damage but had little influence on the ranking of plant provenances. The opposite pattern of population differentiation in resistance to local antagonists in the two species suggests that it will be difficult to predict the consequences of plant translocations for interactions with organisms of higher trophic levels.

Climate vs. soil factors in local adaptation of two common plant species.

Evolutionary theory suggests that divergent natural selection in heterogeneous environments can result in locally adapted plant genotypes. To understand local adaptation it is important to study the ecological factors responsible for divergent selection. At a continental scale, variation in climate can be important while at a local scale soil properties could also play a role. We designed an experiment aimed to disentangle the role of climate and (abiotic and biotic) soil properties in local adaptation of two common plant species. A grass (Holcus lanatus) and a legume (Lotus corniculatus), as well as their local soils, were reciprocally transplanted between three sites across an Atlantic-Continental gradient in Europe and grown in common gardens in either their home soil or foreign soils. Growth and reproductive traits were measured over two growing seasons. In both species, we found significant environmental and genetic effects on most of the growth and reproductive traits and a significant interaction between the two environmental effects of soil and climate. The grass species showed significant home site advantage in most of the fitness components, which indicated adaptation to climate. We found no indication that the grass was adapted to local soil conditions. The legume showed a significant home soil advantage for number of fruits only and thus a weak indication of adaptation to soil and no adaptation to climate. Our results show that the importance of climate and soil factors as drivers of local adaptation is species-dependent. This could be related to differences in interactions between plant species and soil biota.