Effect of an Emergency Department Process Improvement Package on Suicide Prevention: The ED-SAFE 2 Cluster Randomized Clinical Trial.

Importance: Suicide is a leading cause of deaths in the US. Although the emergency department (ED) is an opportune setting, ED-initiated interventions remain underdeveloped and understudied. Objective: To determine if an ED process improvement package, with a subfocus on improving the implementation of collaborative safety planning, reduces subsequent suicide-related behaviors. Design, Setting, and Participants: The Emergency Department Safety Assessment and Follow-up Evaluation 2 (ED-SAFE 2) trial, a stepped-wedge cluster randomized clinical trial conducted in 8 EDs across the US, used an interrupted time series design with three 12-month sequential phases: baseline, implementation, and maintenance. A random sample of 25 patients per month per site 18 years and older who screened positive on the Patient Safety Screener, a validated suicide risk screener, were included. The primary analyses focused on those who were discharged from the ED, while secondary analyses focused on all patients who screened positive, regardless of disposition. Data were collected on patients who presented for care from January 2014 to April 2018, and data were analyzed from April to December 2022. Interventions: Each site received lean training and built a continuous quality improvement (CQI) team to evaluate the current suicide-related workflow in the ED, identify areas of improvement, and implement efforts to improve. Each site was expected to increase their universal suicide risk screening and implement collaborative safety planning for patients at risk of suicide who were discharged home from the ED. Site teams were centrally coached by engineers experienced in lean CQI and suicide prevention specialists. Main Outcomes and Measures: The primary outcome was a composite comprising death by suicide or suicide-related acute health care visits, measured over a 6-month follow-up window. Results: Across 3 phases, 2761 patient encounters were included in the analyses. Of these, 1391 (50.4%) were male, and the mean (SD) age was 37.4 (14.5) years. A total of 546 patients (19.8%) exhibited the suicide composite during the 6-month follow-up (9 [0.3%] died by suicide and 538 [19.5%] of a suicide-related acute health care visit). A significant difference was observed for the suicide composite outcome between the 3 phases (baseline, 216 of 1030 [21%]; implementation, 213 of 967 [22%]; maintenance, 117 of 764 [15.3%]; P = .001). The adjusted odds ratios of risk of the suicide composite during the maintenance phase was 0.57 (95% CI, 0.43-0.74) compared with baseline and 0.61 (0.46-0.79) compared with the implementation phase, which reflect a 43% and 39% reduction, respectively. Conclusions and Relevance: In this multisite randomized clinical trial, using CQI methods to implement a department-wide change in suicide-related practices, including the implementation of a safety plan intervention, yielded a significant decrease in suicide behaviors in the maintenance period of the study. Trial Registration: ClinicalTrials.gov Identifier: NCT02453243.

Metal-Free Arylation of Benzothiophenes at C4 by Activation as their Benzothiophene S-Oxides.

Benzothiophenes, activated by oxidation to the corresponding S-oxides, undergo C-H/C-H-type coupling with phenols to give C4 arylation products. While an electron-withdrawing group at C3 of the benzothiophene is important, the process operates without a directing group and a metal catalyst, thus rendering it compatible with sensitive functionalities-e.g. halides and formyl groups. Quantum chemical calculations suggest a formal stepwise mechanism involving heterolytic cleavage of an aryloxysulfur species to give a π-complex of the corresponding benzothiophene and a phenoxonium cation. Subsequent addition of the phenoxonium cation to the C4 position of the benzothiophene is favored over the addition to C3; Fukui functions predict that the major regioisomer is formed at the more electron-rich position between C3 and C4. Varied selective manipulation of the benzothiophene products showcase the synthetic utility of the metal-free arylation process.

Development and pilot study of simple suicide risk rulers for use in the emergency department.

BACKGROUND: Many patients treated in the emergency department (ED) for non-psychiatric complaints have elevated suicide risk. Universal screening can detect occult suicide risk, but gold standard risk measurement tools, such as the Beck Scale for Suicidal Ideation (BSS), are too long and cumbersome for ED use. OBJECTIVE: To test the performance of seven novel 0- to 10-point suicide risk "rulers" against the BSS. METHOD: 399 patients from three EDs completed seven novel risk rulers, traditional binary screening items, and the BSS. Using BSS criterion references, we tested the diagnostic performance of each risk ruler and examined correlations between the rulers and BSS scores. RESULTS: By varying thresholds on the risk rulers, high levels of sensitivity and specificity were obtained. A threshold of 3 on the "sadness" ruler gave 89% sensitivity for the BSS criterion reference, and a threshold of 1 on the "wish to be dead" ruler provided 94-97% specificity. CONCLUSION: Our novel risk rulers may be an efficient way to detect risk and triage potentially suicidal patients, showing good concurrent validity with the BSS. Clinicians can obtain high sensitivity and high specificity using just two rulers. Further research should examine the rulers' ability to predict independent clinician risk ratings and prospective suicidal behavior.

Long-Term Safety of Using Local Anesthetic Injections in Professional Rugby League for Modified Indications.

OBJECTIVE: To assess and evaluate the long-term safety of local anesthetic injections before or during games in professional rugby league players. DESIGN: Retrospective case series. SETTING: Professional rugby league team. PARTICIPANTS: Sydney Roosters players over a 6-year period (2008-2013), who had been administered a local anesthetic injection for an injury before or during a match to aid return to play. INTERVENTIONS: Follow-up survey (no active intervention). MAIN OUTCOME MEASURES: Player self-reported satisfaction. Survey results were compared with a previous cohort who had received local anesthetic injection from 1998 to 2007. RESULTS: Thirty-two players who had been injected with local anesthetic on 249 occasions for 81 injuries completed the current survey at an average of 5.64 years postinjection. In the cohort of 2008 to 2013, fewer injections were performed to areas deemed higher risk compared with the 1998 to 2007 cohort (P < 0.00002). The vast majority of players (80/81 cases) would repeat the injection in the same circumstances and reported that ongoing side effects were uncommon. There were 6 cases (8%) in which players reported significant ongoing pain in the area of injection at long-term follow-up. CONCLUSIONS: This study affirmed the long-term safety of injections in most cases. LEVEL OF EVIDENCE: IV.

Long-term safety of using local anesthetic injections in professional rugby league.

BACKGROUND: Local anesthetic pain-killing injections are commonly used by some professional football teams to allow continued play for certain injuries; however, the long-term safety of this practice has not been studied. HYPOTHESIS: The majority of local anesthetic injections administered in professional football are helpful and safe, not leading to long-term sequelae. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective survey was conducted of 100 players over 10 seasons who had been injected with local anesthetic on 1023 occasions for 307 injuries (81% follow-up; average follow-up, 5 years; minimum, 1 year). A comparison of match performance statistics was made from 3 seasons between players using and not using local anesthetic. RESULTS: The majority (98%) of players would repeat the procedure if they had their injury again, although 32% felt that there were side effects associated with the procedure (including 22% who thought that the recovery of the primary injury was delayed and 6% who thought that the injury was worsened by playing with local anesthetic). On long-term follow-up, only 6% of players had significant residual pain in the body part injected. The satisfaction rates for acromioclavicular injuries, finger injuries, rib injuries, and iliac contusions were higher than for sternum injuries, wrist injuries, and ankle injuries. Player performance between those players injected and not injected with local anesthetic was not substantially different and mainly reflected a positional bias for the players who used local anesthetic. CONCLUSION: The most commonly injected injuries-acromioclavicular joint sprains, finger and rib injuries, and iliac crest contusions-appear to be quite safe (in the context of professional sport) to inject at long-term follow-up. Conversely, ankle, wrist, and sternum injections appear to be less safe. A few injuries may have been substantially worsened by playing after an injection.

Simplified gene synthesis: a one-step approach to PCR-based gene construction.

PCR-based gene synthesis conventionally requires two steps: first, all overlapping oligonucleotides are assembled by self-priming; then an additional pair of primers is used to amplify the full-length gene product. Here we propose a simplified method of gene synthesis which combines these two steps into one. We have found that the efficiency of this one-step method, which we term "Simplified Gene Synthesis", is affected by multiple parameters of the PCR reactions. In particular, the choice of polymerase is critical for successful one-step assembly. Other important factors include the concentration of assembly oligonucleotides and amplification primers. Moreover, we offer a general method to estimate, given a known mutation rate, how many clones should be sequenced in order to be confident of obtaining at least one correct gene product. Having determined the accuracy of gene products synthesized under optimal conditions with Simplified Gene Synthesis, we show that our estimation works well. Overall, the simplified gene synthesis provides an easier and more efficient approach to gene synthesis, providing a further step towards the future goal of generalized automation for this process.