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Incidence of mortality due to rebound toxicity after ‘treat and release’ practices in prehospital opioid overdose care: a systematic review
IntroductionDeath due to opioid overdose was declared a public health crisis in Canada in 2015. Traditionally, patients who have overdosed on opioids that are managed by emergency medical services (EMS) are treated with the opioid antagonist naloxone, provided ventilatory support and subsequently transported to hospital. However, certain EMS agencies have permitted patients who have been reversed from opioid overdose to refuse transport, if the patient exhibits capacity to do so. Evidence on the safety of this practice is limited. Therefore, our intent was to examine the available literature to determine mortality and serious adverse events within 48 hours of EMS treat and release due to suspected rebound opioid toxicity after naloxone administration.MethodsA systematic search was performed on 11 May 2017 in PubMed, Cochrane Central, Embase and CINHAL. Studies that reported on the outcome of patients treated with prehospital naloxone and released at the scene were included. Analyses for incidence of mortality and adverse events at the scene were conducted. Risk of bias and assessment of publication bias was also done.Results1401 records were screened after duplicate removal. Eighteen full-text studies were reviewed with seven selected for inclusion. None were found to be high risk of bias. In most studies, heroin was the source of the overdose. Mortality within 48 hours was infrequent with only four deaths among 4912 patients ﴾0.081%﴿ in the seven studies. Only one study reported on adverse events and found no incidence of adverse events from their sample of 71 released patients.ConclusionMortality or serious adverse events due to suspected rebound toxicity in patients released on scene post-EMS treatment with naloxone were rare. However, studies involving longer-acting opioids were rare and no study involved fentanyl.
Journal Article
Managing your mind : the mental fitness guide
\"Managing Your Mind is a book for building resilience, overcoming emotional difficulties and enabling self-development. It is for any of us who wish to understand ourselves better, to be more effective in day-to-day life, to overcome current problems; or who want to support others in these tasks. The authors have between them almost 100 years of experience helping people respond skillfully to life's challenges. Drawing on this experience as well as on cutting-edge scientific research, Managing Your Mind distills effective techniques and ideas, enabling readers to select those that suit their preferences and needs. Part One of the book helps us gain a better understanding of ourselves and provides tools for clarifying what we value most in life. It highlights the benefits of the practice of acceptance and kindness, and shows how to build self-esteem and self-confidence. Part Two presents practical tools and methods, relevant to everyone, for making our way in the world. This includes the importance of perspective and how we can best use our thinking skills. It also covers everyday topics such as the value of useful habits, time management, looking after our physical health, increasing happiness, well-being and creativity, and developing and maintaining good relationships. The third part of the book provides scientifically-tested approaches to overcoming specific emotional difficulties, such as worry, panic, low mood, anger, addictions, and coping with trauma, loss and chronic ill health. With well over 150,000 copies in print, Managing Your Mind remains the definitive self-help guide for anyone seeking to lead a more fulfilling and productive life.\"-- Provided by publisher.
BOOK
An integrative look at SARS-CoV-2 (Review)
SARS-CoV-2 is a newly discovered member of the betacoronaviruses and the etiological agent of the disease COVID-19. SARS-CoV-2 is responsible for the worldwide pandemic which has been taking place in 2020, and is causing a markedly higher number of infections and deaths compared to previous coronaviruses, such as SARS-CoV or MERS-CoV. Based on updated scientific literature, the present review compiles the most relevant knowledge of SARS-CoV-2, COVID-19 and the clinical and typical responses that patients have exhibited against this virus, discussing current and future therapies, and proposing strategies with which to combat the disease and prevent a further global threat. The aggressiveness of SARS-CoV-2 arises from its capacity to infect, and spread easily and rapidly through its tight interaction with the human angiotensin-converting enzyme 2 (ACE-2) receptor. While not all patients respond in a similar manner and may even be asymptomatic, a wide range of manifestations associated with COVID-19 have been described, particularly in vulnerable population groups, such as the elderly or individuals with other underlying conditions. The proper function of the immune system plays a key role in an individual's favorable response to SARS-CoV-2 infection. A hyperactivated response, on the contrary, could account for the more severe cases of COVID-19, and this may finally lead to respiratory insufficiency and other complications, such as thrombotic or thromboembolic events. The development of novel therapies and vaccines designed to control and regulate a proper immune system response will be key to clinical management, prevention measures and effective population screening to attenuate the transmission of this novel RNA virus.
Journal Article
Impact of Real‐Time, On‐Demand Influenza and Respiratory Syncytial Virus Testing at Point‐of‐Care on Antibiotic Prescribing and Clinical Outcome in Pediatric Outpatients With Acute Respiratory Illness: A Prospective, Quasi‐Randomized, Controlled Study
Background Rapid and accurate detection and identification of viral pathogens have an impact on physician decision‐making for patients with acute respiratory illness (ARI). We aimed to evaluate the Xpert Xpress Flu/RSV test for the management of antibiotic prescribing in pediatric outpatients with ARI. Methods We performed a prospective, quasi‐randomized, controlled study in Beijing Children's Hospital between December 1, 2021 and April 28, 2022. Outpatients with ARI aged 28 days to 18 years were enrolled and randomly assigned to the Xpert Xpress Flu/RSV test (Xpert) group or the influenza (Flu) antigen test (control) group. Both tests were performed on site. Results A total of 771 patients were enrolled and assigned randomly to the Xpert (n = 398) and the control (n = 373) groups. There was no statistically significant difference in antibiotic prescriptions between the two groups, whereas a significant difference was observed for the prescriptions of oseltamivir (p < 0.001). In Flu B‐positive patients, a statistically significant decrease in antibiotic use and increase in antiviral use were observed in both Xpert and control groups. Cephalosporin use was significantly decreased in respiratory syncytial virus (RSV)‐positive patients in the Xpert group before (n = 8, 17.4%) and after (n = 1, 2.2%)visit (p = 0.035). Among clinical and laboratory parameters, shorter fever length (OR = 0.366) and positive Flu B or RSV (OR = 3.99) were two independent factors for antibiotic withdrawal by logistic regression analysis. There was no significant difference in duration of fever, clinical outcomes, and expenditure between the two groups at the 7‐day and 30‐day follow‐up. Conclusions Use of Xpert Xpress Flu/RSV at point‐of‐care in pediatric outpatients with ARI reduced antibiotic prescription, which has the potential to improve antibiotic stewardship.
Journal Article
Care-pathways for patients presenting to emergency ambulance services with self-harm: national survey
BackgroundSelf-harm is among the top five causes of acute hospital admissions and ambulance clinicians are often the first point of contact. However, the Emergency Department (ED) may not be the most appropriate place of care and little is known about the existence or nature of alternative pathways available to UK ambulance services. This survey describes the current management pathways used by ambulance services for patients who have self-harmed.MethodsA structured questionnaire was sent to all UK ambulance services by email and followed up by telephone in 2018. Three independent researchers (two clinical) coded responses which were analysed thematically.ResultsAll 13 UK ambulance services responded to the survey: nine by email and four by telephone interview. Two services reported a service-wide protocol for managing people presenting with self-harm, with referral to mental health crisis team available as an alternative to conveyance to ED, following on-scene psychosocial assessment. Four services reported local pathways for managing mental health patients which included care of patients who had self-harmed. Four services reported being in the process of developing pathways for managing mental health patients. Six services reported no service-wide nor local pathways for managing self-harm patients. No robust evaluation of new care models was reported.ConclusionPractice in ambulance services in the UK is variable, with a minority having a specific clinical pathway for managing self-harm, with an option to avoid ED. New pathways for patients who have self-harmed must be evaluated in terms of safety, clinical and cost-effectiveness.
Journal Article
Confirmed cardiac output on emergency medical services arrival as confounding by indication: an observational study of prehospital airway management in patients with out-of-hospital cardiac arrest
ObjectivesMany registry studies on patients with out-of-hospital cardiac arrest (OHCA) have reported that conventional bag-valve-mask (BVM) ventilation is independently associated with favourable outcomes. This study aimed to compare the data of patients with OCHA with confirmed cardiac output on emergency medical services (EMS) arrival and consider the confounding factors in prehospital airway management studies.MethodsThis was a cohort study using the registry data for survivors after out-of hospital cardiac arrest in the Kanto region at 2012 in Japan (SOS-KANTO 2012). Survivors who received advanced airway management (AAM) group and a BVM group were compared for confirmed cardiac output on EMS arrival and neurolgical outcome at 1 month. Favourable neurological outcome was defined as a score of one or two on the Cerebral Performance Categories Scale. Multivariable logistic regression was used to adjust the neurological outcome by age, gender, cardiac aetiology, witnessed arrest, shockable rhythm, cardiopulmonary resuscitation performed by a bystander, BVM at prehospital ventilation and presence of confirmed cardiac output on EMS arrival.ResultsA total of 16 452 patients were enrolled in the SOS-KANTO 2012 study, and of those data 12 867 were analysed; 5893 patients comprised the AAM group and 6974 comprised the BVM group. Of the study participants, 386 (2.9%) had confirmed cardiac output on EMS arrival; 340 (2.6%) of the entire study group had a favourable neurological outcome. The proportion of patients with confirmed cardiac output on EMS arrival was significantly higher in the BVM group (272: 3.9%) than in the AAM group (114: 1.9%) (95% CI: 1.65 to 2.25). The proportion of patients with favourable neurological outcomes was 30% (117/386) in those with cardiac output on EMS arrival compared with 1.8% (223/12481) in those without. The OR for a good neurological outcome with BVM decreased from 3.24 (2.49 to 4.20) to 2.60 (1.97 to 3.44) when confirmed cardiac output on EMS arrival was added to the multivariable model analysis.ConclusionConfirmed cardiac output on EMS arrival should be considered as confounding by indication in observational studies of prehospital airway management.
Journal Article
Neuronal injuries in cerebral infarction and ischemic stroke: From mechanisms to treatment (Review)
Stroke is the leading cause of disabilities and cognitive deficits, accounting for 5.2% of all mortalities worldwide. Transient or permanent occlusion of cerebral vessels leads to ischemic strokes, which constitutes the majority of strokes. Ischemic strokes induce brain infarcts, along with cerebral tissue death and focal neuronal damage. The infarct size and neurological severity after ischemic stroke episodes depends on the time period since occurrence, the severity of ischemia, systemic blood pressure, vein systems and location of infarcts, amongst others. Ischemic stroke is a complex disease, and neuronal injuries after ischemic strokes have been the focus of current studies. The present review will provide a basic pathological background of ischemic stroke and cerebral infarcts. Moreover, the major mechanisms underlying ischemic stroke and neuronal injuries are summarized. This review will also briefly summarize some representative clinical trials and up-to-date treatments that have been applied to stroke and brain infarcts.
Journal Article