Overview of best practices for buprenorphine initiation in the emergency department.

In recent decades, opioid overdoses have increased dramatically in the United States and peer countries. Given this, emergency medicine physicians have become adept in reversing and managing complications of acute overdose. However, many remain unfamiliar with initiating medication for opioid use disorder such as buprenorphine, a high-affinity partial opioid agonist. Emergency department-based buprenorphine initiation is supported by a significant body of literature demonstrating a marked reduction in mortality in addition to increased engagement in care. Buprenorphine initiation is also safe, given both the pharmacologic properties of buprenorphine that reduce the risk of diversion or recreational use, and previously published literature demonstrating low rates of respiratory depression, sedation, and precipitated withdrawal. Further, barriers to emergency department-based initiation have been reduced in recent years, with publicly available dosing and up-titration schedules, numerous publications overviewing best practices for managing precipitated withdrawal, and removal of USA policies previously restricting patient access and provider prescribing, with the removal of the X-waiver via the Medication Access and Training Expansion Act. Despite reductions in barriers, buprenorphine initiation in the emergency room remains underutilized. Poor uptake has been attributed to numerous individual and systemic barriers, including inadequate education, provider stigma, and insufficient access to outpatient follow-up care. The following practice innovation aims to summarize previously published evidence-based best practices and provide an accessible, user-friendly initiation guide to increase emergency physician comfortability with buprenorphine initiation going forward.

Medical Student-Driven Efforts to Incorporate Segregated Care Education Into Their Curriculum.

US health care is segregated by insurance status and de facto by race; however, traditional models of medical education do not teach students about segregated care, and the authors know of no examples in the literature problematizing segregated care in medical education. To fill this gap, this article describes a student-led effort to disseminate peer-to-peer segregated care education at a single-site, large academic health system in New York City. It also provides educational resources that other student-advocates can adopt to drive curricular inclusion efforts at their own institutions. This article concludes that the primary goal of advocacy to teach segregated care is always desegregation, so curricular inclusion efforts are needed to educate students about the inequitable systems they are entering and to provide them with tools to advocate against such systems.

A medical student-led model for telephone-based opioid overdose education and naloxone distribution during the COVID-19 pandemic.

Background: The co-occurrence of the COVID-19 pandemic and opioid epidemic has increased the risk of overdose and death for patients with opioid use disorder (OUD). COVID-19 has also exacerbated already limited access to opioid overdose education and naloxone distribution (OEND). In this context, we aim to increase access to OEND for patients at risk for opioid overdose. Methods: Medical student volunteers were trained to conduct telephone-based OEND, and subsequently contacted all patients at a NYC primary care clinic for people who use drugs as well as those presenting to the hospital with OUD or a history of opioid overdose. Interested patients who completed the training received naloxone kits via mail or at hospital discharge. Results: OEND provision was converted to a remote-only model from May to June 2020. During this time, eight pre-clinical medical students called a total of 503 high-risk patients. Of these patients, 165 were reached, with 90 (55%) accepting telephone-based OEND. Comparing across populations, 51% of primary care patients versus 76% of ED/hospitalized patients accepted opioid overdose education. Eighty-four total patients received naloxone. Conclusions: We have outlined a scalable, adaptable model by which clinics and hospitals with affiliated medical schools can provide OEND by telephone. Medical student-driven, telephone-based OEND efforts can effectively reach at-risk patients and increase naloxone access.

Community Case Study of Naloxone Distribution by Hospital-Based Harm Reduction Program for People Who Use Drugs in New York City.

Background: In 2017, The Respectful and Equitable Access to Comprehensive Healthcare (REACH) Program at Mount Sinai Hospital became a registered Opioid Overdose Prevention Program (OOPP) and received funding from the New York City Department of Health and Mental Hygiene to develop a program to provide overdose education and naloxone distribution (OEND) training to at risk population and bystanders. We report on the programmatic quality improvement initiatives conducted. Methods: From April 2017 to December 2020, the REACH OOPP conducted 290 opioid overdose reversal trainings, throughout the Mount Sinai Health System and in multiple other community settings. OEND training was at times offered alone and in other settings alongside Hepatitis C Virus point of care testing. Additionally, a "train the trainer" model was implemented whereby medical students and nurses at outpatient clinics were trained to train others. Results: There were 4235 naloxone kits distributed to 3,906 participants. The training venues included hospital settings (patients and medical staff), public events, substance use programs, educational facilities, homeless prevention programs, faith-based organizations, alternative to incarceration programs, and community-based organizations. We implemented two types of training. During outreach sessions, we utilized one-on-one personalized sessions to train bystanders. When training clinic staff in the "train the trainer" model we utilized a standardized didactic presentation with slides. The two top reasons participants reported for being trained were "Just in case I see someone overdose" (59.3%) and "I'm worried that someone I know will overdose OR that I will overdose" (20.2%). Conclusion: The REACH program at Mount Sinai Hospital developed an effective model to train community bystanders and health care staff by leveraging administrative support and building on broader programmatic initiatives to promote drug user health and stigma-free care for people who use drugs. Hospitals do not currently mandate staff training or keeping naloxone stocked at inpatient units or outpatients clinics posing a challenge when implementing an OEND program in this setting. A recommended policy change needed to decrease overdose deaths is for hospitals to be required to implement systematic naloxone education and access for all health care personal and at risk patients.

Forecasting essential childhood cancer drug need: An innovative model-based approach.

BACKGROUND: Childhood cancer outcomes in low-income and middle-income countries have not kept pace with advances in care and survival in high-income countries. A contributing factor to this survival gap is unreliable access to essential drugs. METHODS: The authors created a tool (FORx ECAST) capable of predicting drug quantity and cost for 18 pediatric cancers. FORx ECAST enables users to estimate the quantity and cost of each drug based on local incidence, stage breakdown, treatment regimen, and price. Two country-specific examples are used to illustrate the capabilities of FORx ECAST to predict drug quantities. RESULTS: On the basis of domestic public-sector price data, the projected annual cost of drugs to treat childhood cancer cases is 0.8 million US dollars in Kenya and 3.0 million US dollars in China, with average median price ratios of 0.9 and 0.1, respectively, compared with costs sourced from the Management Sciences for Health (MSH) International Medical Products Price Guide. According to the cumulative chemotherapy cost, the most expensive disease to treat is acute lymphoblastic lymphoma in Kenya, but a higher relative unit cost of methotrexate makes osteosarcoma the most expensive diagnosis to treat in China. CONCLUSIONS: FORx ECAST enables needs-based estimates of childhood cancer drug volumes to inform health system planning in a wide range of contexts. It is broadly adaptable, allowing decision makers to generate results specific to their needs. The resultant estimates of drug need can help equip policymakers and health governance institutions with evidence-informed data to advance innovative procurement strategies that drive global improvements in childhood cancer drug access.

A Novel Variant in the Calcium-Sensing Receptor Associated with Familial Hypocalciuric Hypercalcemia and Low-to-Normal PTH.

Familial hypocalciuric hypercalcemia (FHH) is considered a relatively benign condition characterized by mild elevations in serum calcium and relatively low urinary calcium excretion. It results from an elevated set point in serum calcium arising from variants in the calcium-sensing receptor (CaSR) gene but also AP2S1 and GNA11 genes, which encode for adaptor-related protein complex 2 and G11 proteins, respectively. The manifestations of FHH can vary and sometimes overlap with primary hyperparathyroidism making the diagnosis challenging. Case Presentations. We report a mother and daughter with a novel heterozygous variant in the CaSR gene resulting in a serine to leucine substitution at position 147 (S147L) of the CaSR. Both patients had mild hypercalcemia, relatively low urinary calcium excretion, elevated calcitriol, and low-to-normal intact PTH. The proband (daughter) presented with symptoms associated with hypercalcemia and was incidentally found to have a bony lesion suspicious for osteitis fibrosa cystica, and she was also diagnosed with sarcoidosis. Subtotal parathyroidectomy revealed normal-weight parathyroid glands comprised of 50-80% parathyroid epithelial cells, which has been documented as within the spectrum of normal. Her mother had no symptoms, and no intervention was pursued. Conclusion. We report a novel variant in the CaSR associated with FHH in two patients with similar biochemical features yet differing clinical manifestations. While the relationship of the bony findings and parathyroid histology with this variant remains unclear, these cases enrich our knowledge of CaSR physiology and provide further examples of how varied the manifestations of FHH can be.

Asymptomatic chyluria presenting with fat-fluid level after renal microwave ablation.

We present a case of asymptomatic chyluria in a 70-year-old man detected two years after microwave ablation of renal cell carcinoma. Chyluria is a rare complication of partial nephrectomy, but has not been previously reported after renal microwave ablation therapy. Recently, percutaneous thermal ablation techniques for T1a renal cancers are in surge due to comparable treatment efficacy, less invasive nature and lower complications. It is imperative to be aware of the post-ablation imaging findings and complications for correct diagnosis. Most patients with chyluria are clinically asymptomatic; therefore, serendipitous diagnosis on imaging detecting fat-fluid level may not be unusual.

Qualitative analysis of social network influences on quitting smoking among individuals with serious mental illness.

Objective: The prevalence of cigarette smoking among adults with serious mental illness (SMI) remains high in the United States despite the availability of effective smoking cessation treatment. Identifying social influences on smoking and smoking cessation may help enhance intervention strategies to help smokers with SMI quit. The objective of this qualitative study was to explore social network influences on efforts to quit smoking among adults with SMI enrolled in a cessation treatment program. Methods: Participants were 41 individuals with SMI enrolled in a Medicaid Demonstration Project of smoking cessation at community mental health centers. A convenience sampling strategy was used to recruit participants for social network interviews exploring the influence of family, friends, peers, and significant others on quitting smoking. A team-based analysis of qualitative data involved descriptive coding, grouping coded data into categories, and identifying themes across the data. Results: Social barriers to quitting smoking included pro-smoking social norms, attitudes, and behaviors of social network members, and negative interactions with network members, either specific to smoking or that triggered smoking. Social facilitators to quitting included quitting with network members, having cessation role models, and social support for quitting from network members. Conclusions: Similar to the general population, social factors appear to influence efforts to quit smoking among individuals with SMI enrolled in cessation treatment. Interventions that leverage positive social influences on smoking cessation have the potential to enhance strategies to help individuals with SMI quit smoking.

Image-guided percutaneous ablation of lung malignancies: A minimally invasive alternative for nonsurgical patients or unresectable tumors.

Lung cancer remains the malignancy with the highest mortality and second highest incidence in both men and women within the United States. Image-guided ablative therapies are safe and effective for localized control of unresectable liver, renal, bone, and lung tumors. Local ablative therapies have been shown to slow disease progression and prolong disease-free survival in patients who are not surgical candidates, either due to local extent of disease or medical comorbidities. Commonly encountered complications of percutaneous ablation of lung tumors include pneumothorax, pleural inflammation, pleural effusions, and pneumonia, which are usually easily managed. This review will discuss the merits of image-guided ablation in the treatment of lung tumors and the underlying mechanism, procedural techniques, clinical utility, toxicity, imaging of tumor response, and future developments, with a focus on radiofrequency ablation.

Complicated penetrating ulcer of the ascending aorta: similar to dissection, yet different.

Life-threatening acute aortic syndrome includes aortic dissection, intramural hematoma (IMH) and penetrating atherosclerotic ulcer (PAU). PAU and IMH carry a greater risk for aortic rupture. They most commonly occur in the descending thoracic aorta and are rare in the ascending aorta. Early diagnosis and intervention is crucial. We present the case of a 72-year-old female with a PAU of the ascending aorta complicated by hemopericardium with tamponade as well as IMH, successfully treated after rapid diagnosis and intervention, followed by a brief literature review.

Celiac artery stenting to facilitate hepatic yttrium-90 radioembolization therapy.

Radioembolization offers a novel way to treat the nonresectable, liver predominant hepatic malignancies with better tumor response and overall progression-free survival rates. Transarterial catheter-based radioembolization procedure involves the hepatic arterial administration of glass- or resin-based beta emitting Yttirum-90 microspheres. Safe delivery of the tumoricidal radiation dose requires careful angiogram planning and coil embolization to quantify lung shunting and prevent systemic toxicity, respectively. Diagnostic pretreatment angiogram also serves to identify the hepatic arterial variant anatomy and other coexisting pathologies that might require a different or alternative approach. We describe a complex case of celiac artery stenosis with tortuous pancreaticoduodenal arterial arcade precluding access to the right hepatic artery for performing radioembolization. Celiac artery stenting of the stenosis was performed to facilitate subsequent safe and successful Yttrium-90 microsphere radioembolization.

Human activity selectively impacts the ecosystem roles of parrotfishes on coral reefs.

Around the globe, coral reefs and other marine ecosystems are increasingly overfished. Conventionally, studies of fishing impacts have focused on the population size and dynamics of targeted stocks rather than the broader ecosystem-wide effects of harvesting. Using parrotfishes as an example, we show how coral reef fish populations respond to escalating fishing pressure across the Indian and Pacific Oceans. Based on these fish abundance data, we infer the potential impact on four key functional roles performed by parrotfishes. Rates of bioerosion and coral predation are highly sensitive to human activity, whereas grazing and sediment removal are resilient to fishing. Our results offer new insights into the vulnerability and resilience of coral reefs to the ever-growing human footprint. The depletion of fishes causes differential decline of key ecosystem functions, radically changing the dynamics of coral reefs and setting the stage for future ecological surprises.

Spatial variance in abundance and occupancy of corals across broad geographic scales.

Species assemblages vary in structure due to a wide variety of processes operating at ecological and much broader biogeographical scales. Cross-scale studies of assemblage structure are necessary to fully understand this variability. Here, we evaluate the abundance and occupancy patterns of hierarchically sampled coral assemblages in three habitats (reef flat, crest, and slope) and five regions (Indonesia, Papua New Guinea, the Solomon Islands, American Samoa, and the Society Islands) across the west-central Pacific Ocean. Specifically, we compare two alternative models that unify spatial variance and occupancy via the negative binomial distribution. The first assumes a power-law scaling between the mean and variance of abundance; the second assumes a quadratic variance-mean relationship and a constant abundance-invariant aggregation parameter. Surprisingly, the well-established power-law model performs worse than the model assuming abundance-invariant aggregation, for both variance-mean and occupancy-abundance relationships. We also find strong evidence for regional and habitat variation in these relationships and in the levels of aggregation estimated by the abundance-invariant aggregation model. Among habitats, corals on reef flats exhibited lower occupancy and higher levels of aggregation compared to reef crests and slopes. Among regions, low occupancy and high aggregation were most pronounced across all habitats in American Samoa. These patterns may be related to habitat and regional differences in disturbance and recovery processes. Our results suggest that the spatial scaling of abundance and occupancy is sensitive to processes operating among these habitats and at regional scales. However, the consistency of these relationships across species within assemblages suggests that a theoretical unification of spatial variance and occupancy patterns is indeed possible.

Short-term femoral vein catheterization rarely causes thrombosis or bacteremia.

BACKGROUND: Experts and national regulatory bodies have deemed femoral vein catheterization (FVC) unsafe, and recommend avoiding it whenever possible. OBJECTIVE: To assess rates of catheter-related bloodstream infections (CRBI) and deep venous thrombosis (DVT) complicating FVC. DESIGN: Prospective observational cohort study. SETTING: Medical intensive care unit (MICU) of a 350-bed community teaching hospital. PATIENTS: Consecutive admissions to the MICU during 7 months. METHODS: Demographic, laboratory and Doppler ultrasound studies were collected on patients receiving large vein catheters (VC) in our MICU. Ultrasound examinations were systematically performed on the day of and 5 to 7 days after removal of FVC. RESULTS: VC were inserted in 238 (35% of) patients. Of that total, 217 catheters were in large veins (49% FVC, 38% internal jugular and 13% subclavian) for an average of 2.7 days for femoral, 5.7 days for internal jugular and 3.6 days for subclavian vein catheters. During 1200 catheter-days, no central VC CRBI was identified. Of 107 FVC, initial and follow-up Doppler studies were performed in 50 patients. A total of 97% of patients received routine thromboprophylaxis and none had a DVT. Of the 57 patients with initial but no Doppler follow-up at 5 to 7 days following removal, no patient developed clinically detected venous thromboembolism (VTE). CONCLUSION: Short-term FVC was used safely in our MICU in the setting of thromboprophylaxis. In light of its favorable safety profile for initial resuscitation of critically ill patients, it may be premature to strongly discourage FVC.

Testing species abundance models: a new bootstrap approach applied to Indo-Pacific coral reefs.

Patterns in the commonness and rarity of species are a fundamental characteristic of ecological assemblages; however, testing between alternative models for such patterns remains an important challenge. Conventional approaches to fitting or testing species abundance models often assume that species, not individuals, are the units that are sampled and that species' abundances are independent of one another. Here we test three different models (the Poisson lognormal, the negative binomial, and the neutral, "zero-sum multinomial" [ZSM]) against species abundance distributions of Indo-Pacific corals and reef fishes. We derive and apply several alternative bootstrap analyses of model fit, each of which makes different assumptions about how species abundance data are sampled, and we assess the extent to which tests of model fit are sensitive to such assumptions. For all models, goodness of fit is remarkably consistent, regardless of whether one assumes that species or individuals are the units that are sampled or whether or not one assumes that species' abundances are statistically independent of one another. However, goodness-of-fit estimates are approximately twice as precise and detect lack of model fit more frequently, when based on sampling of individuals, rather than species. Bootstrap analyses indicate that the Poisson lognormal distribution exhibits substantially better fit to species abundance patterns, consistent with model selection analyses. In particular, heterogeneity in species abundances (many rare and few highly abundant species) is too great to be captured by the ZSM model or the negative binomial model and is best explained by models that predict species abundance patterns that are much closer, but not identical, to the lognormal distribution. More broadly, our bootstrap analyses suggest that estimates of model fit are likely to be robust to assumptions about the statistical interdependence of species abundances, but that tests of model fit are more powerful when they assume sampling of individuals, rather than species. Such individual-based tests therefore may be able to identify lack of model fit where previous tests have been inconclusive.

Community-level density dependence: an example from a shallow coral assemblage.

While density dependence is a popular topic of research in population ecology, it has received much less attention at the community level. Using 27 years of data from Heron Island, on Australia's Great Barrier Reef, we develop a matrix model of coral community dynamics that shows that community-level density dependence does occur and that it is fairly common, being found in 38% of the model parameters for which it was tested. In particular, colonization of free space (through either recruitment or growth of existing colonies) was nearly always density dependent. There were no consistent patterns in the results for mortality, persistence, or species interactions. Most transitions were found to be dependent on the cover of the incoming species group, with only a few dependent on that of the outgoing species group. In addition, few of the transitions representing species interactions were dependent on the amount of free space present, suggesting that the cover of other species does not influence encounters. When these results were combined into a model of community dynamics, it was found that density dependence resulted in a moderate increase in coral cover, which was spread over most species groups. The dynamics of the density-dependent assemblage were also a lot noisier than those of an assemblage without density dependence. Sensitivity analysis indicated that it was density dependence in the colonization probabilities, particularly of encrusting acroporids, bushy Acropora and staghorn Acropora, which had the main influence on the model, although persistence of free space was also important. Transitions representing mortality were only of minor importance, and those representing species interactions were of no importance.

Linking social and ecological systems to sustain coral reef fisheries.

The ecosystem goods and services provided by coral reefs are critical to the social and economic welfare of hundreds of millions of people, overwhelmingly in developing countries [1]. Widespread reef degradation is severely eroding these goods and services, but the socioeconomic factors shaping the ways that societies use coral reefs are poorly understood [2]. We examine relationships between human population density, a multidimensional index of socioeconomic development, reef complexity, and the condition of coral reef fish populations in five countries across the Indian Ocean. In fished sites, fish biomass was negatively related to human population density, but it was best explained by reef complexity and a U-shaped relationship with socioeconomic development. The biomass of reef fishes was four times lower at locations with intermediate levels of economic development than at locations with both low and high development. In contrast, average biomass inside fishery closures was three times higher than in fished sites and was not associated with socioeconomic development. Sustaining coral reef fisheries requires an integrated approach that uses tools such as protected areas to quickly build reef resources while also building capacities and capital in societies over longer time frames to address the complex underlying causes of reef degradation.

Adaptive management of the Great Barrier Reef and the Grand Canyon world heritage areas.

Conventional perceptions of the interactions between people and their environment are rapidly transforming. Old paradigms that view humans as separate from nature, natural resources as inexhaustible or endlessly substitutable, and the world as stable, predictable, and in balance are no longer tenable. New conceptual frameworks are rapidly emerging based on an adaptive approach that focuses on learning and flexible management in a dynamic social-ecological landscape. Using two iconic World Heritage Areas as case studies (the Great Barrier Reef and the Grand Canyon) we outline how an improved integration of the scientific and social aspects of natural resource management can guide the evolution of multiscale systems of governance that confront and cope with uncertainty, risk, and change in an increasingly human-dominated world.

Scale-dependent variation in coral community similarity across sites, islands, and island groups.

Community similarity is the proportion of species richness in a region that is shared on average among communities within that region. The slope of local richness (alpha diversity) regressed on regional richness (gamma diversity) can serve as an index of community similarity across regions with different regional richness. We examined community similarity in corals at three spatial scales (among transects at a site, sites on an island, and islands within an island group) across a 10 000-km longitudinal diversity gradient in the west-central Pacific Ocean. When alpha diversity was regressed on gamma diversity, the slopes, and thus community similarity, increased with scale (0.085, 0.261, and 0.407, respectively) because a greater proportion of gamma diversity was subsumed within alpha diversity as scale increased. Using standard randomization methods, we also examined how community similarity differed between observed and randomized assemblages and how this difference was affected by spatial separation of species within habitat types and specialization of species to three habitat types (reef flats, crests, and slopes). If spatial separation within habitat types and/or habitat specialization (i.e., underdispersion) occurs, fewer species are shared among assemblages than the random expectation. When the locations of individual coral colonies were randomized within and among habitat types, community similarity was 46-47% higher than that for observed assemblages at all three scales. We predicted that spatial separation of coral species within habitat types should increase with scale due to dispersal/extinction dynamics in this insular system, but that specialization of species to different habitat types should not change because habitat differences do not change with scale. However, neither habitat specialization nor spatial separation within habitat types differed among scales. At the two larger scales, each accounted for 22-24% of the difference in community similarity between observed and randomized assemblages. At the smallest scale (transect-site), neither spatial separation within habitat types nor habitat specialization had significant effects on community similarity, probably due to the small size of transect samples. The results suggest that coral species can disperse among islands in an island group as easily as they can among sites on an island over time scales that are relevant to their establishment and persistence on reefs.