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The Joint Commission, other medical governing agencies, and various hospital policies mandate that certain screening questions be asked of all patients who come through the emergency department for evaluation. Before a patient has even seen a physician, they have likely been asked dozens of screening questions as part of the triage or nursing assessment. Screening questions are often implemented with good intentions and some questions serve as public health screening where the ED acts as a safety net.The downstream consequences of adding on numerous questions to the ED stay are often not considered. There is the potential for a significant amount of nursing time to be used administering assessments. Additionally, the purpose of triage is to identify and prioritize patients who require immediate treatment over those who do not. The required screening questions often have an unclear benefit on determining triage acuity and on the care that the patient receives in the ED. In many instances the addition of screening questions is based on rudimentary studies that do not examine clinical outcomes or costs.Screening questions can add time to the triage process and ED wait time, and take nurses away from performing more direct patient care. While any individual question may not take long to ask, when you multiply it by the tens of thousands of patients who pass through the ED and the expanding number of screening questions, it quickly adds up to a significant amount of time. Our objective was to analyze the time nursing spent conducting standardized nursing screens and calculate the corresponding time cost.This is a cursory look at the potential monetary and time costs of standardized screening questions in the ED. The calculated values directly affect time and cost efficiency in the ED process and could potentially be redirected to more direct patient care. For just the five observed triage questions alone,microgreen grow rack we estimated the nursing time cost to our institution to be $20,675.50. This time cost would be significantly increased if we examined additional triage and nurse screening questions. Furthermore, this is just the time spent in a single ED.

If all 136.9 million adult ED visits in the U.S. included the five studied questions the screening would take 964,354 hours to complete.This equates to $33.8 million in nursing costs annually. The required screening questions are often unrelated to the patient’s chief complaint and have a debatable impact on the medical management in the ED. Questions that may impact care, such as medication allergies, are typically asked by multiple medical providers during the ED visit, and redundancy leads to additional wasted time and cost. It is unclear whether the standardized questions are suitable for triage where the goal is to identify and prioritize patients who require immediate treatment over those who do not. Previous work has shown that triage assessments can have poor interrater and intra-rater agreement.Additional research could evaluate whether the additional screening questions distract the triage nurse from his or her primary goal of assessing acuity and contribute to inconsistency in triage assessments. If nurses were liberated from the mandated questions, they could potentially have more time for one-on-one patient care and other aspects of patient care, such as medication administration and lab draws. Although we suspect that reducing the number of required questions would free nurses to spend more time on direct patient care and improve efficiency of ED throughput, additional research will be required to study this hypothesis. Studies evaluating ED screening questions often praise their ability to detect at-risk groups without looking at patient oriented outcomes or cost. Cost-benefit analyses should be considered prior to mandating additional nurse screening questions as even a few seconds spent on a question adds up to a significant amount of time. A better research agenda is needed to assess the impact of triage questions on patient care.There is significant potential for future research related to this topic. Further studies are needed to determine cost effectiveness of required ED screenings, including questions included as public health screens. Other potential time saving measures, such as self-completed triage questionnaires on kiosks, could be researched as well. Dr. Roberts has delivered an excellent review of many medical aspects of cannabis use and the effect of cannabis legalization on emergency medicine in Colorado.As emergency physician researchers in Colorado, we echo many of his concerns.

As he notes, since legalization, we have identified an increase in accidental pediatric exposures, an increase in emergency department visits for hyperemesis ,an increased number of visits attributable to cannabis edibles,a disproportionate increase in adult and adolescent mental health visits related to cannabis, and an increased number of visits for cannabis toxicity.These effects are measurable, and while the direct attribution of these changes to cannabis legalization are limited to observational data that is subject to temporal trends, selection bias, and confounding, we believe the links between these changes and cannabis legalization are plausible, consistent and relevant. While much of the focus in Colorado has been on recreational cannabis, it is important to note that many of the issues identified began before recreational cannabis was available in 2014. In Colorado, medical cannabis was legalized in 2000 and has been widely available since 2009. In Colorado, the qualifying medical conditions for cannabis use include the following: cancer, glaucoma HIV, severe pain, seizures, nausea, muscle spasm, post-traumatic stress disorder , autism spectrum disorder, and cachexia.As of June 2019, almost 84,000 patients have an active medical marijuana registration, 337 less than 18 years of age.As with any therapy, the adverse effects we have identified must be balanced against the potential benefits to patients and society. However, there are few high-quality evidenced based studies to support these recommendations. Without clinical trials the measurement of the positive effects of cannabis remain largely anecdotal.The United States Food and Drug Administration has issued numerous warning letters to various cannabidiol manufacturers for false claims in relation to disease diagnosis and treatment.The medical utility of cannabis is further limited by insufficient training provided to medical professionals and trainees, in addition to the reliance of many users on non-medical providers to guide therapeutic choices. For example, many dispensaries will recommend cannabis to pregnant women despite various national guidelines cautioning against this practice.The medical benefits of cannabis should have been evaluated using accepted clinical standards prior to providing legal status as medical treatments.

Recreational use has no demonstrated inherent health benefit. While some have suggested that it may increase relaxation and reduce stress, there are no clinical studies to support those claims. One plausible health benefit is the substitution of cannabis for other more dangerous recreational drugs; however, ebb and flow flood table this is also not studied. Unfortunately, in Colorado we see that cannabis is also often combined with alcohol and other drugs and the relative increase in adverse effects may outweigh this potential benefit. Despite the observed increase in cannabis related driving fatalities in Colorado, 55% of cannabis users believed it was safe to drive under the influence of cannabis.There have been mixed results on how marijuana legalization has affected medical and non-medical opioid use and prescribing.The discussion around the impact of cannabis on the healthcare system is not absolute. When we speak to cannabis supporters we often hear the justification that it is safer than alternatives, and there are no real adverse effects. We believe our work has clearly demonstrated that cannabis legalization has measurably impacted the delivery of emergency care in Colorado. However, it is important to put the magnitude of this impact in perspective. Since 2006, more than 2000 Coloradans have died from opioid overdose, and tobacco use-associated healthcare costs in Colorado are almost 2 billion dollars per year. While it is disingenuous to say that cannabis legalization has not impacted emergency medicine in Colorado, it is important to recognize that there are many greater threats to public health and to provide appropriate focus to each of these conditions. A legitimate discussion around the health effects of cannabis in Colorado requires a fair assessment of the risks and benefits by advocates and critics alike. Continued surveillance on both the positive and negative effects on marijuana legalization, and evidence based research is needed as more states continue to pass medical and recreational marijuana. The long-term effects of increased availability of high-THC-cannabis are still to be determined. It is critical for public health officials, healthcare providers and legislators, in conjunction with advocates and industry representatives, to work toward regulations aimed at minimizing the public health impact of cannabis legalization on society. Musculoskeletal injuries are a major cause of morbidity and mortality across the world that disproportionately affect those in low- and middle-income countries , which often lack trained healthcare providers who can properly treat such conditions.Approximately 90% of the five million annual deaths across the world due to injuries occur in LMICs such as Rwanda.The literature lacks an updated fund of knowledge regarding the prevalence, etiology, and treatment for MSIs in Rwanda to supplement previous studies. The growing number of Rwandan healthcare providers may incorporate this knowledge into educational programs when approaching MSI.Injuries in Rwanda are associated with significant morbidity and mortality.Past studies in Rwanda have shown that most trauma victims are young men.Road traffic accidents , especially those involving motorcycles, were the most common mechanism for adults, while children were frequently injured as pedestrians.Approximately one-quarter of injured patients suffered a fracture.The overall mortality prevalence was 5.5% with approximately half of the hospital deaths occurring in the emergency department.Yet, these mortality figures do not paint a comprehensive picture of the burdens posed by MSIs and fractures in particular. MSIs resulting from trauma are frequently undertreated, causing difficulty for patients to resume normal work and life activities.This is related both to cost and a shortage of technology and supplies.In addition to a dearth of supplies, achieving health outcome targets without securing the appropriate human resources is difficult.One team in Namibia found that three out of the eight Millennium Development Goals concerning healthcare required appropriate human resources for success.A recent interrupted time-series study found that building Rwanda’s emergency medicine training program resulted in an absolute reduction of overall facilities-based mortality by 4% overall, which was twice as great a decline as the national trend.Such investments are vital to improving health in this region. While Africa contains approximately one-quarter of the world’s burden of diseases, it possesses 4% of its health staff.A recent systematic review found that of 59 LMIC emergency care programs, very few incorporated specialist emergency care training.The largest share of facilities was staffed either by physicians-in-training or by physicians whose level of training was unspecified. Data showed high patient loads and mortality, specifically in Africa where a substantial proportion of total deaths occurred in EDs.Compared to other LMIC regions, ED mortality is highest in Africa, with a median mortality rate of 3.4% compared to the average of 1.8% across all studied LMICs.A minority of LMIC EDs incorporate specialty-trained emergency physicians into the staffing paradigm, but availability is limited.The high volume and urgency of treatment make emergency care an important area of focus for interventions aimed at reducing mortality in these settings. Within a short period of time, Rwanda has made significant improvements to its healthcare system. Rwanda’s transformation of its health sector since the 1990s has helped to raise life expectancy from 27 years to 63 years of age, and nearly all Rwandans have health insurance.Although there have been significant improvements, Rwanda has just 0.84 health providers per 1000 population, the majority of whom are generalists. This number falls below the minimum 2.3 providers per 1000 population set forth by the World Health Organization.In 2011, the Rwandan Ministry of Health began a seven-year partnership with a U.S. academic consortium to train Rwandan providers to become future educators through medical residencies, creating the Human Resources for Health Program. Among the new medical residencies is the first EMTP in Rwanda.These trainees have introduced new emergency skills, such as triage and resuscitation, along with improvements to local protocols and systems.The training curriculum was in line with the American Board of Emergency Medicine 2013 Model of the Clinical Practice of Emergency Medicine.International faculty practicing EM were hired to implement EM training through the HRH program, a collaboration between academic medical centers in the U.S. and the Rwandan Ministry of Health.

This study examined longitudinal patterns of healthcare utilization among SUD patients and their relationships to key aspects of ACA benefit plans, including enrollment mechanisms and deductible levels. We anticipated that the increase in coverage opportunities that the ACA provided would bring high-utilizing patients into health systems, driving up overall use of healthcare. Consistent with prior studies of SUD treatment samples that have found elevated levels of healthcare utilization either immediately before or after starting SUD treatment , results of our longitudinal analysis showed that utilization among people with SUDs was highest immediately after initial SUD diagnosis at KPNC, and declined to a stable level in subsequent years. This suggests that the initial high utilization may be temporary. Our sensitivity analysis suggested that this result was not due to high utilizers leaving the KPNC healthcare system. This overall trend in utilization is a welcome finding, and consistent with the intent of the ACA to increase access to care; however, the subsequent decrease in utilization could also signify that patients are disengaging from treatment. Although we cannot specifically attribute the initial levels of utilization to lack of prior insurance coverage, as we did not have data on prior coverage, we found that individuals with fewer than 6 months of membership before receiving an SUD diagnosis were more likely to utilize primary care and specialty SUD treatment than those who had 6–12 months of membership. This suggests that future healthcare reforms that expand insurance coverage for people with SUDs might also lead to short-term increases in utilization for a range of health services. Deductibles are a key area of health policy interest given the growing number of people enrolling in deductible plans post-ACA. As anticipated, higher deductibles had a generally negative association with utilizing healthcare in this population. We found that patients with high deductibles had lower odds of using primary care, psychiatry, inpatient, and ED services than those without deductibles. Additionally,flood tray we found the associations between high deductibles and likelihood of utilizing primary care and psychiatry were strongly negative among ACA Exchange enrollees.

Although it is somewhat difficult to gauge the clinical significance of these specific results, the strength of the odds ratios for primary care and psychiatry access gives some indication of the potential impact. The associations of high deductibles with primary care and psychiatry access is worrying given the extent of medical and psychiatric comorbidities among people with SUDs . Although we found more consistent associations for higher deductibles and less healthcare initiation, it is possible that even a modest deductible could deter patients from seeking treatment . From a public policy and health system perspective, the possibility that deductibles could prevent people with SUDs from accessing any needed medical care is a cause for concern. Consistent with prior findings , our results suggest that high deductibles have the potential to dissuade SUD patients from accessing needed health services, and that those who enroll via the ACA exchange may be more sensitive to them. This could be attributable to greater awareness of coverage terms due to the mandate that exchange websites offer clear, plain-language explanations to compare insurance options . In contrast, high deductibles were associated with a greater relative likelihood of SUD treatment utilization. However, this association existed only among patients who enrolled via mechanisms other than the ACA Exchange. It is possible that individuals with emerging or unrecognized substance use problems may have selected higher deductible plans at enrollment due to either not anticipating use of SUD treatment, which is often more price-sensitive relative to other medical care , or not being aware of the implications of deductibles. However, once engaged in treatment, individuals with high deductibles may have been motivated to remain there. A contributing factor could also be that such patients were required to remain in treatment either by employer or court mandates, which are common and are associated with retention . The varying associations between deductibles and different types of health service utilization by enrollment mechanisms highlight the need for future research in this area. Insurance exchanges provide access to tax credits, a broader range of coverage levels, and information to assist in healthcare planning that might be less easily accessible through other sources of coverage, e.g., through employers .

In our sample, Exchange enrollment was associated with greater likelihood of remaining a member of KPNC, did not demonstrate an adverse association with routine care, and was associated with lower ED use. However, primary care and psychiatric services use were similar across enrollment types, even within low and high deductible limits. Prior studies have found that health plans offered through the ACA Exchange are more likely to have narrow behavioral health networks compared to other non-Exchange plans and primary care networks , which raises concerns about treatment access. For this health system, that concern appears unfounded. Psychiatric comorbidity was associated with greater service use of all types. Several prior studies have also found that patients with psychiatric comorbidity use more health services than those with SUD alone . Similar to our results, a recent study based in California found that after controlling for patient-level characteristics, the strongest predictors of frequent ED use post-ACA included having a diagnosis of a psychiatric disorder or an SUD . While the ACA was not expected to alter this general pattern, the inclusion of mental health treatment as an essential benefit was intended to improve availability of care and to contribute to efforts to reduce unnecessary service utilization. Our investigation confirms the ongoing importance post-ACA of psychiatric comorbidity and suggests that future efforts in behavioral health reform must anticipate high demand for healthcare in this vulnerable clinical population.Race/ethnic disparities in access to care are a longstanding concern in the addiction field . Some expected these disparities to be mitigated postACA . Findings on race/ethnic differences are similar to what has been observed in other health systems ; although, few studies have examined associations post-ACA. One prior study among young adults with SUD and psychiatric conditions post-ACA found modest ethnic disparities in lack of coverage between whites and other ethnic groups ; although, another study of young people more broadly found larger gains in coverage among Hispanics and Blacks relative to whites . The race/ethnic disparities in SUD and psychiatry treatment initiation in this cohort, in which overall insurance coverage was not a barrier but specific mechanisms could be, highlight the importance of addressing this complicated challenge to health equity. This study used a large SUD patient cohort enrolled in health coverage post-ACA and included comprehensive data on diagnoses,grow table insurance coverage, and use of care over three years. KPNC data are well suited to examine ACA-related changes in health service utilization given the size and diversity of its membership. KPNC’s integrated model is becoming more common as other health plans and federally qualified health centers move toward providing integrated SUD treatment services and using EHRs . However, we should note that is an observational study based on EHR data.

As such, we cannot attribute causal relationships to our findings. However, we have conducted sensitivity analyses to examine the robustness of our findings in the absence of a randomized clinical trial. These analyses supported our initial findings; e.g., indicating that service use decrease over time was not due to high utilizers leaving KPNC. Medicaid expansion has the potential to improve access to SUD treatment , but we were also not able to examine its relationship to services in the current analysis due to collinearity with deductible limits . Our study was set in a single nonprofit healthcare delivery system in Northern California, which enabled us to characterize post-ACA patterns of service utilization in depth but did not allow us to compare populations or implementation across systems . Nevertheless, our findings can inform future work on health reform and policy efforts to improve access to healthcare for similar clinically complex patients in other health systems. E-cigarette use, or vaping, among adolescents has become a public health concern, with 26.7% of high school seniors reporting past-month vaping in 2018, and 900,000 middle and high school students reporting daily or near-daily use. Adolescents’ use of e-cigarettes is associated with an increased risk of subsequent cigarette initiation and frequent use, an increased risk of nicotine dependence, and exposure to potentially toxic chemicals. Despite harm reduction claims by e-cigarette companies, in cross-sectional studies, e-cigarette use among adolescent and young adult dual users is associated with smoking a greater number of cigarettes per day , more frequent smoking, and fewer attempts to quit smoking. Notably little is known about the stability of adolescents’ use of e-cigarettes over time, such as whether non-daily use progresses into daily use and whether daily use is sustained. The potential for harm from exposure to nicotine and toxicants is likely to be greater with sustained and frequent use over time. Study of longitudinal patterns of adolescent e-cigarette use is needed to model the potential for harm from these products. Furthermore, research is needed to articulate adolescent patterns of dual product use over time and the resulting levels of nicotine and toxicant exposure. It remains unclear, for example, whether dual users succeed in reducing and stopping their cigarette use or whether they continue to dual use over time. The stability in adolescents’ e-cigarette preferred type or brand also has not been examined. E-cigarette brands that are popular today among adolescents can deliver nicotine from a single compact pod that equals that of a pack of cigarettes, in attractive flavors, and with easy concealment for use in settings where cigarettes may be forbidden . These characteristics may facilitate the progression from intermittent to frequent use and nicotine dependence. Alternatively, low nicotine content and/or low device appeal may result in adolescents losing interest in e-cigarettes over time, with diminishing frequency and dependence risk. Among adults, research indicates that evolving from a simpler e-cigarette device to a more complex modifiable device is a common pattern and is associated with greater dependence on e-cigarettes. Despite rapid growth in the e-cigarette market in recent years, research has not yet examined whether or how adolescents’ preferred devices change over time, particularly with regard to nicotine delivery and exposure. Finally, minimal research has examined changes in adolescents’ reasons for initiating, continuing, and/or quitting e-cigarette use over time. In cross-sectional survey studies, adolescents’ top reasons for experimenting with e-cigarettes include curiosity, appealing flavors, friends’ use, and perceived benefits compared with cigarettes. However, reasons may shift over time, as adolescents move from experimentation to sustained use. The literature on youth initiation and transition to regular use of combustible cigarettes shows that media/marketing and social influences motivate initiation, whereas the drive for nicotine due to addiction motivates regular use. These nicotine product use patterns observed with combustible cigarettes warrant investigation with e-cigarettes. With e-cigarettes, adolescents who begin experimenting because of curiosity or appealing flavors may subsequently use to alleviate withdrawal symptoms. The present study followed a cohort of adolescent e-cigarette users over 12 months’ time to examine patterns of e-cigarette use frequency, nicotine exposure, and dependence, product use and flavor preference, and motivators to use and cease use. The primary objectives were to determine persistence in e-cigarette and dual use and the stability in frequency and dependence measures of e-cigarette use. We also examined changes in device and e-liquid preferences and reasons for using e-cigarettes. This longitudinal study adds to the literature by providing an understanding of shifts in tobacco and nicotine product use over time among adolescents based on self-report and biomarkers of exposure.Adolescents from the San Francisco Bay Area who reported having used an e-cigarette at least once in the past 30 days and at least 10 times in their lives were recruited for a longitudinal study on teen vaping between May 2015 and April 2017. Advertisements were posted on social media and in the community around the Bay Area. Interested individuals were directed to the study Web site, where they could submit their information to be contacted by study staff to complete eligibility screening.

Nation states became more and more interested in representing their population along identity criteria, and the census then arose as the most visible means by which states could depict and even invent collective identities . In this way, previous ambiguous and context-dependent identities were, by the use of the census technology, ‘frozen’ and given political significance. “The use of identity categories in censuses was to create a particular vision of social reality. All people were assigned to a single category and hence conceptualized as sharing a common collective identity” , yet certain groups were assigned a subordinate position. In France, for example, the primary distinction was between those who were part of the nation and those who were foreigners, whereas British, American, and Australian census designers have long been interested in the country of origin of their residents. In the US, the refusal to enfranchise Blacks or Native Americans led to the development of racial categories, and these categories were in the US census from the beginning. In some of the 50 federated states of the US, there were laws, including the “one drop of blood” rule that determined that to have any Black ancestors meant that one was de jure Black . Soon a growing number of categories supplemented the original distinction between white and black. Native Americans appeared in 1820, Chinese in 1870, Japanese in 1890, Filipino, Hindu and Korean in 1920, Mexican in 1930, Hawaiian and Eskimo in 1960. In 1977, the Office of Management and Budget , which sets the standards for racial/ethnic classification in federal data collections including the US Census data, established a minimum set of categories for race/ethnicity data that included 4 race categories and two ethnicity categories . In 1997, OMB announced revisions allowing individuals to select one or more races,greenhouse growing racks but not allowing a multiracial category. Since October 1997, the OMB has recognized 5 categories of race and 2 categories of ethnicity .

In considering these classifications, the extent to which dominant race/ethnic characterizations are influenced both by bureaucratic procedures as well as by political decisions is striking. For example, the adoption of the term Asian-American grew out of attempts to replace the exoticizing and marginalizing connotations of the externally imposed pan-ethnic label it replaced, i.e. “Oriental”. Asian American pan-ethnic mobilization developed in part as a response to common discrimination faced by people of many different Asian ethnic groups and to externally imposed racialization of these groups. This pan-ethnic identity has its roots in many ways in a racist homogenizing that constructs Asians as a unitary group , and which delimits the parameters of “Asian American” cultural identity as an imposed racialized ethnic category . Today, the racial formation of Asian American is the result of a complex interplay between the federal state, diverse social movements, and lived experience.In fact, the OMB itself admits to the arbitrary nature of the census classifications and concedes that its own race and ethnic categories are neither anthropologically nor scientifically based . Issues of ethnic classification continue to play an important role in health research. However, some researchers working in public health have become increasingly concerned about the usefulness or applicability of racial and ethnic classifications. For example, as early as 1992, a commentary piece in the Journal of the American Medical Association, challenged the journal editors to “do no harm” in publishing studies of racial differences . Quoting the Hippocratic Oath, they urged authors to write about race in a way that did not perpetuate racism. However, while some researchers have argued against classifying people by race and ethnicity on the grounds that it reinforces racial and ethnic divisions; Kaplan & Bennett 2003; Fullilove, 1998; Bhopal, 2004, others have strongly argued for the importance of using these classifications for documenting health disparities . Because we know that substantial differences in physiological and health status between racial and ethnic groups do exist, relying on racial and ethnic classifications allows us to identify, monitor, and target health disparities .

On the other hand, estimated disparities in health are entirely dependent upon who ends up in each racial/ethnic category, a process with arguably little objective basis beyond the slippery rule of social convention . If the categorization into racial groups is to be defended, we, as researchers, are obligated to employ a classification scheme that is practical, unambiguous, consistent, and reliable but also responds flexibly to evolving social conceptions . Hence, the dilemma at the core of this debate is that while researchers need to monitor the health of ethnic minority populations in order to eliminate racial/ethnic health disparities, they must also “avoid the reification of underlying racist assumptions that accompanies the use of ‘race’, ethnicity and/or culture as a descriptor of these groups. We cannot live with ‘race’, but we have not yet discovered how to live without it” . Reinarman and Levine have argued that investigations of ethnicity in alcohol and drugs research have typically taken the form, whether intentionally or not, of linking “a scapegoated substance to a troubling subordinate group – working-class immigrants, racial or ethnic minorities, or rebellious youth” . Different minority ethnic groups have often been framed at one time or another by their perceived use of alcohol and illicit drugs, regardless of their actual substance using behaviors and regardless of their relative use in comparison with drug and alcohol use among whites . Such framing arguably has led to extensive stereotyping of minority cultures, their characters, and their behaviors. For example, in the 18th century, white settlers in the US used stereotypical portrayals of Native drinking to justify the confiscation and exploitation of Native lands . In the early part of the 19th century, Chinese immigrants were victimized and controlled for their supposed opium use, despite the fact that only 6% at the time used opium . In the early 1900s, cannabis was relatively plentiful along the Texas border brought to the US by Mexican migrants, and its popularity among ethnic minorities practically ensured that it would be classified as a narcotic and attributed with addictive qualities . By the early 1930s, cannabis had been prohibited in 30 states. In 1937 the Marijuana Tax Act was passed by Congress which banned cannabis at the Federal level . And, the most recent drug scare, which fueled the development of the War on Drugs, linked crack cocaine to impoverished African Americans and Latinos in inner city neighborhoods .

Since the War on Drugs, an exceptionally high rate of imprisonment of mainly poor ethnic minority people has occurred primarily for non-violent crimes and relatively minor drug offences. For example, in 2012, although African-Americans accounted for only 13% of the national population , nearly 40% of those incarcerated for drug offences in State or Federal prisons were African-Americans . Hispanic/Latinos, while accounting for 17% of the national population in 2013, represented 37% of all those in prison for drug offenses . These statistics lie in sharp contrast to the available empirical data on differential rates of alcohol and substance use between whites and non-whites . The evidence from Monitoring the Future – a longstanding and reliable source of data on drug use among youth in the US – suggests that crack cocaine cannot be considered a drug consumed primarily by Blacks in American nor can marijuana be considered a drug used primarily by Latino/as. Rather, white youth have higher rates of use for most drugs of abuse. For example, Terry McElrath and colleagues reviewing 30 years’ worth of data from MTF,vertical hydroponic garden found that for all drugs except heroin, past year prevalence rates were significantly higher among whites compared to blacks and Latinos . In spite of the backdrop, the vast majority of alcohol and drug research has failed to mention the injustices of drug laws and high rates of imprisonment of ethnic minority youth. Instead of situating research within a context of oppression and inequality, researchers have tended to ignore this situation and instead focus on risk factors associated with drug use among racial/ethnic groups, an approach that dominates alcohol and drugs research today.This trajectory in alcohol and drug research is unfortunate in light of recent debates in social epidemiology about the importance of examining health disparities within a framework that considers “social structures and social dynamics that encompass individuals” . Social epidemiologists have argued that mainstream research tends “to focus on the body, lifestyle, behaviour, sex/gender, race/ethnicity and perhaps the personality, emotional state or socioeconomic status of the single person” . Just as mainstream epidemiology has been criticized for having little regard for social structures, social dynamics, and social theory , most existing studies of ethnicity within drug and alcohol research can similarly be critiqued for failing to adopt a structural approach as well as neglecting contemporary social science theories of and debates about ethnicity. In mainstream drug and alcohol research, traditional ethnic group categories continue to be assessed in ways which suggest little critical reflection in terms of the validity of the measurement itself. This is surprising given that social scientists since the early 1990s have critiqued the propensity of researchers to essentialize identity as something ’fixed’ or ’discrete’ and to neglect to consider how social structure shapes identity formation. Recent social science literature on identity suggests that people are moving away from rooted identities based on place and towards a more fluid, strategic, positional, and context-reliant nature of identity. This does not mean, however, that there is an unfettered ability to freely choose labels or identities, as if off of a menu . An individual’s ability to choose an identity is constrained by social structure, context, and power relations.

Structural constraints on identity formation cannot be ignored, as people do not exist as free floating entities but instead are influenced and constrained in various ways by their socioeconomic and geographical environment . As such, an identity is not just claimed by an individual but is also recognized and validated by an audience, resulting in a dialectical relationship between an individual and the surrounding social structures . Similarly, a ‘new’ perspective on ethnic identity specifically has emphasized the fluidity and contextually-dependent nature of ethnicity, minimizing notions about ethnicity as a cultural possession or birthright and instead emphasizing ethnicity as a socially, historically, and politically located struggle over meaning and identity . Ethnicity or ethnic identity is not some immutable sense of one’s identity but rather something produced through the performance of socially and culturally determined boundaries . Hence, individuals are not passive recipients of acquired cultures but instead active agents who constantly construct and negotiate their ethnic identities within given social structural conditions . In spite of these sociological contributions, which have enriched our understanding of identity generally and ethnicity specifically, the alcohol and drugs fields have not adequately integrated these perspectives, thwarting our ability to understand the relationships between ethnicity and substance use. As such, the field is ripe with correlations between ethnic group categories and substance use problems, resulting in solutions to problems that focus on reifying questionable social group categorizations and revealing little about how drugs are connected to identities and shaped by broader social and cultural structures. It is important to note that we do not intend to argue that existing categories of ethnicity be disregarded in the alcohol and drugs fields. As Krieger and colleagues have noted in another context , surveillance data documenting health disparities, in our case in substance use, are exceedingly important in terms of identifying potential inequities in health. However, without understanding the complexity of ethnic identity and its relationship to substance use, these surveillance data may perpetuate stereotypes and the victimization of specific socially-delineated ethnic groupings, obfuscate the root causes of substance use and elated problems, and reify politicized categories of ethnicity which may have little meaning for the people populating those categories. While acknowledging that socially-deliented ethnic categories are important for documenting social injustices, we must also be vigilant about questioning the appropriateness of those categories . Conceptually this type of critical approach is important for considering how substance use is related to negotiations of ethnicity over time and place and bounded by structure.

Of particular interest to this study is a common polymorphism involving a Val to Met substitution at codon 158. The Val allele of the COMT Val158Met polymorphism is 40% more enzymatically active than the Met allele. Thus, carriers of the Met allele metabolize dopamine at a less efficient rate, resulting in higher levels of dopamine in the synapse and ultimately an escalation in dopamine receptor activation. This differentiation of dopamine receptor activity dependent on COMT genotype has led to several investigations into the relationship between COMT and executive dysfunction in which the Val allele has been putatively linked to poor performance on executive functioning tasks. However, to our knowledge no work has examined the relationship between COMT and sexual risk behavior; albeit studies of similar behaviors such as novelty seeking, reward dependence, as well as affective arousal and regulation have demonstrated significant relationships. Given the aforementioned paucity of research in the current literature addressing the contribution of genetic and neurocognitive factors on sexual risk behavior, the primary aim of this study was to examine the main effects of executive functioning as well as the main effects of the COMT Val158Met polymorphism on sexual risk behavior among a ethnically diverse population of men with and without METH dependence and/or HIV infection. Within this aim, we hypothesized that the highly active COMT Val/Val genotype and its putatively associated deficits in executive functioning would be independently associated with sexual risk behaviors. In addition, as a result of previously mentioned research that has demonstrated an association between COMT genotype and executive functioning we also explored the potential interaction effects of COMT and executive dysfunction on sexual risk behavior.Participants were volunteers evaluated at the HIV Neurobehavioral Research Center at the University of California in San Diego as part of a cohort study focused on central nervous system effects of HIV and methamphetamine. The current study comprised 192 sexually active non-monogamous men with and without methamphetamine dependence and/or HIV infection . Men were classified as nonmonogamous if they stated they had “no current partner” at time of assessment. Monogamous men were excluded because unsafe sexual behavior within a monogamous relationship is less risky than in non-monogamous relationships.

All participants underwent a comprehensive characterization procedure that included collection of demographic, neuromedical,hydroponic rack system psychiatric as well as neuropsychiatric information. HIV serological status was determined by enzyme linked immunosorbent assays plus a confirmatory test. Lifetime METH dependence was determined by the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders Version IV . However, participants were not actively using other substances, with the exception of cannabis and alcohol. Potential participants were excluded if they met lifetime dependence criteria for other drugs, unless the dependence was judged to be remote and episodic in nature by a doctoral level clinician. Alcohol dependence within the last year was also an exclusion criterion. All participants were seronegative for hepatitis C infection. Additional information for each participant was collected as it relates to current depressed mood as well as lifetime diagnosis of Major Depression Disorder and/or Bipolar Disorder I or II. Current depressed mood was assessed utilizing the Beck Depression Inventory-I and MDD and Bipolar Disorder were ascertained using the SCID-IV. Information was also collected to determine lifetime dependence on sedatives, cannabis, opioids, cocaine,hallucinogens, and alcohol, using the SCID-IV. For METH+ participants, additional information was collected regarding age at first use, years of use, and days since last use of METH; whereas for HIV+ participants, HIV RNA plasma copies was ascertained as part of a larger neuromedical evaluation. All participants gave written consent prior to enrollment and all procedures were approved by the Human Research Protection Program of the University of California, San Diego and San Diego State University.Executive functioning was determined as part of a larger comprehensive battery of tests covering seven ability domains . The executive functioning domain deficit score, of particular focus in this study, was made up of perseverative responses on the Wisconsin Card Sorting Test; errors on the Halstead Category Test, which measures abstraction and cognitive flexibility; and time to complete the Trail Making Test part B, reflecting ability to switch and maintain attention between ongoing sequences.

Raw scores for each of these component tests were converted to demographically-adjusted T-scores , including adjustments for age, education, gender, and ethnicity as available for each test. The demographically adjusted T-scores for each test were then converted into deficit scores, which reflect degree of impairment by setting performances within the normal range at zero with a range from 0 to 5 . Finally, the individual deficit scores were averaged to derive the domain deficit score, which reflects the severity of executive functioning deficit. Previous work has demonstrated that deficit scores achieve good diagnostic agreement with classifications made by blind clinical ratings. All neurocognitive testing and scoring was performed by trained psychometrists blinded to participants’ genotypes.A multiplex PCR technique designed using Sequenom SpectroDESIGNER software was employed by inputting a sequence containing 100 bp of flanking sequence on either side of the COMT Val158Met polymorphism. The SNP was then grouped into multiplexes so that the extended product would not overlap in mass with any other oligonucleotide present in the reaction mix, and where no primer-primer, primer-product, or nonspecific interactions would occur. The PCR was carried out in 384-well reaction plates in a volume of 5 μl using 10 ng genomic or whole-genome amplified DNA. All subsequent steps, up until the reaction, were spotted onto the SpectroCHIP and carried out in the same reaction plate. After PCR, any unincorporated dNTPs from the PCR were removed from the reaction by digestion with Shrimp alkaline phosphatase. dNTPs were removed so that they could not play any role in the extension of the oligonucleotide at the SNP site. The extension reaction was then carried out in the presence of the extension oligonucleotide and a termination mix containing mass-modified dideoxynucleotides which extended the oligonucleotide over the SNP site with one base. Before spotting onto the SpectroCHIP, the reaction was cleaned by incubation with a cation-exchange resin which removed any salts present. The extension product was then spotted onto a 384-well spectroCHIP before being flown in the MALDI-TOF mass spectrometer. Data were collected, in real time, using SpectroTYPER Analyzer 3.3.0.15, SpectraAQUIRE 3.3.1.1 and SpectroCALLER 3.3.0.14 algorithms.

All statistical tests and procedures were conducted using SPSS 10.0 . Univariate comparisons across the three COMT genotypes were performed using one-way analysis of variance for continuous and chi-squared tests for categorical variables. In cases, where data violated normality assumptions medians were calculated and nonparametric tests performed. To examine the main and explore the interaction effects of executive functioning and COMT on sexual risk behaviors, hierarchical multiple linear regressions in accord with Barron and Kenny’s approach were conducted for each of the seven sexual risk behaviors under study. Prior to running each analysis, the executive functioning variable was centered and the COMT genotype contrast coded to reduce problems resulting from multi-collinearity . In addition, interaction terms were created by multiplying COMT genotype by the centered executive functioning variable. Next, multiple linear regressions were used to examine potential confounders based on univariate genotype comparisons described above. These confounders included: ethnicity, METH status, HIV status and age at first intercourse. We also included BDI scores based on inclusion of this measure in recent work testing a similar hypothesis. Results showed that METH status, HIV status,rolling benches canada and age at first intercourse accounted for a significant unique variance for all sexual behaviors under investigation . Thus to control for these potential confounding effects, the residuals derived from each of the sexual behavior models were used as the dependent variables for all subsequent regression models. The centered executive functioning variable and COMT genotype as well as the new interaction term were then entered as independent variables into seven individual hierarchical multiple regression models using the residuals described above as the dependent variable. For models in which a significant interaction was observed, a final round of regressions were conducted stratified by COMT genotype to determine the nature of the interaction between executive functioning and COMT on the particular sexual risk behavior. Due to the exploratory nature of the interaction analysis we selected a relaxed alpha threshold alpha < .10 to reduce Type II errors, albeit the traditional alpha threshold of .05 was used for all other analyses.To our knowledge this study is the first to examine main effects as well as explore the interaction effects of COMT genotype and executive functioning on sexual risk behavior. Our main findings suggest significant executive dysfunction main effects for number of sexual partners as well as frequency of oral sex and condom use. In addition, results of our exploratory interaction analyses provide evidence that COMT genotype and executive dysfunction interact in models of number of sexual partners, condom use, insertive and receptive anal sex, as well as oral sex. Stratified analyses further suggest that the strength of these associations is dependent on the number of Met alleles the individual was carrying, with the exception of oral sex in which Val/Val was the informative genotype. Our significant executive dysfunction main effects for sexual risk behaviors are discordant with the only other study, to our knowledge, that has examined the association between executive dysfunction and sexual risk behavior. In that study, no association was found between executivedys function and sexual risk behavior among an African American sample of men and women poly-substance abusers with and without HIV infection. However, three major methodological differences may explain our discordant findings. First, Gonzalez et al.estimated sexual risk behavior in the past 6 months compared to our window of 12 months and also utilized a composite score rather than individual sexual risk behaviors as their dependent variable. Second, executive dysfunction was assessed using the Iowa Gambling Task, delayed non-matching to sample paradigm, and Stroop task-reaction time version which, respectively, measure decision-making, working memory, and response inhibition. Although these tests are well justified, other components of executive functioning such as perseveration, cognitive sequencing, and concept formation which were assessed in the current study, were not examined.

Third and finally, regression models were adjusted for sensation seeking, a factor shown in previous research to be associated with sexual risk behavior [34–37]; however, in the current study sensation seeking data was not available and was not adjusted for. Thus, future work examining the association between executive dysfunction and sexual risk behaviors are warranted; particularly research utilizing larger samples with diverse measures of executive functioning and models adjusting for sensation seeking and other personality covariates. Novel to the current study, we demonstrated several genotype by endophenotype interactions for sexual risk behaviors. A relaxed significance criterion produced significant interactions for number of sexual partners, condom use, insertive and receptive anal sex, as well as oral sex. These interactions collectively advocate for further investigation of genotypeendophenotype interactions for sexual risk behavior. However, due to the exploratory nature of these interactions our discussion will be confined to interactions observed for number of sexual partners, frequency of insertive anal sex and condom use, as interactions observed in these models met the traditional significance criterion . We observed both a main and interaction effect for number of sexual partners, albeit only within the model including the composite executive functioning deficit score. In this model we found that among carriers of the Met allele , a positive association between executive functioning deficit and number of sexual partners was present. Thus, among Met allele carriers those with greater deficit scores reported greater number of sexual partners; whereas among Val/Val carriers this association was not significant. Similar to results for number of sexual partners, stratified analysis showed that among carriers of the Met/Met but not Val/Met or Val/Val genotype an positive association between executive dysfunction and frequency of insertive anal sex was present, although only statistically significant for models including the Trails B test. Thus, individuals with lower T-scores on Trails B reported greater frequency of insertive anal sex only if they were carriers of the Met/Met genotype. Finally, the strongest interaction observed was between COMT and the Halstead Category Test for frequency of condom use. Contrary to the expected association, results suggest a negative association among carriers of the Met/Met genotype in which lower T-scores on the Category Test was associated with an increased frequency of condom use.

We have observed participants with only one transient episode of cutting, those in which it is habitual and compulsive and those who have had on-and-off periods of cutting with varying durations. This periodicity may occur either because conditions of stress may wax and wane or because the relieving effect of the cutting endures for a period of time before it in effect needs to be renewed. Episodes of cutting may be situational or habitual. An instance of the former is a girl who, although she had been cutting herself periodically for several years, indicated that a recent episode was in relation to the conjunction of her grandfather dying and her boyfriend breaking up with her. A habitual instance is the boy who used a pencil or a toothpick as his instruments, though according to his mother he scratched but never broke his skin. He said, “Two months ago I started cutting myself. I just couldn’t stop cutting myself. I had the opportunity to do it, I couldn’t help it . . . sometimes it’s just no reason, other times, it’s just because I want to. It’s because I feel like it.” Notably, this boy indicated that the cutting did not make him feel better. The intentionality of cutting is complex, and as was the case among SWYEPT participants, cutting may be associated with other forms of self-harm such as head-banging, self-choking, bulimia, eraser burns, or drug abuse. The motivations typically reported for cutting in this study were depression, anger, frustration, stress, and tension. The intended results included relief, to feel good, to feel pain, to hurt oneself,hydroponic tables canada and to see the blood. Notably, three of the participants reported that cutting did not make them feel better. With respect to integration of cutting into one’s identity as a mode of self-orientation, it was more common to hear that a young person “started cutting,” “cut myself,” or even “ended up cutting,” but there were instances of girls and a boy who declared either that “I am a cutter” or “I was a cutter.”

The only other study of intentionality among adolescent inpatient cutters we have been able to identify used the self-injury motivation scale II developed by Osuch, Noll, and Putnam , which taps factors including affect modulation, desolation, punitive duality, influencing others, magical control, and self-stimulation. The researchers found that the mean number of reasons cited for cutting themselves was 20 out of the 36 listed in the instrument as contributing to these factors and that 56% described their cutting as impulsive while 60% reported feeling emotional relief after cutting . Notably, males and females cited comparable reasons for self-injury, with a trend for females to use cutting for controlling negative affects more than males . Self-cutting is also not invariably linked to suicidality. Among girls who were SWYEPT participants, 18 reported suicidality, and 17 reported cutting; three of the cutters were not suicidal, and four of the suicidal girls were not cutters. Among boys, 14 participants reported suicidality, and 10 reported cutting; three cutters were not suicidal, and seven of the suicidal boys were not cutters. Moreover, cutting was by no means the only or the most common method for suicide attempts by participants. In this respect, we note the study by Gulbas et al.which expressly focuses on the relation between suicidal behavior and nonsuicidal self-injury among Latina adolescents in the United States.Gulbas and colleagues identify a series of factors relevant to both NSSI and suicide that correspond to features we found among the SWYEPT participants, including family fragmentation, conflict, physical and sexual abuse, and domestic violence. The relationships among these factors are complex and are found cross-culturally, though they tend to be more severe with suicide than with NSSI . Given the multiple challenges faced by our study participants in New Mexico, and the extraordinary conditions that define the contours of struggle for coherence in their lives, a focus on the specific act of cutting offers a necessarily limited but existentially critical insight into the nature of their experience. Without a doubt this requires attending to the question of children’s agency as a capacity with which youth are endowed, as we have invoked by citing childhood studies literature and in our analysis of individual vignettes.

Childhood studies scholars embrace a concept of agency as a reaction against models of childhood with more structural and chronological substrates, allowing children to be recognized as meaning makers rather than passive recipients of action . However, in the present context, we must also see agency as a fundamental human process that is no less fundamental for being challenged by illness . Specifically, self-cutting is a crisis in the agentive relation between adolescent bodies and the surrounding world, or put another way, a crisis of their bodily being in the life-world that they inhabit. In understanding embodiment as an indeterminate methodological field, this relationship between body and world is defined by three modes or moments of agency: the intentionality of our bodies in acting on the world or being-toward-the-world, the reciprocal interplay of body and world embedded in a habitus, and the discursive power of the world upon our bodies to establish expectation and shape subjectivity . To be precise, approaching the interpretation of cutting from the standpoint of agency in these troubled adolescents’ body-world relationship has the immediate effect of shifting interpretive attention from the wounded flesh to the relation between the active hand of the cutter and the self-inflicted wound. It is then not just a matter of the pain, the relief, or the blood that originates at the violated boundary between self and world, and the concomitant breach in bodily integrity. In the first mode of agency, regardless of the implement used to cut with, the cutter’s hand is an agent of self, and the opening of the wound and flow of blood are an emanation of person hood into the world. Cutting is a form of active being toward-the-world whether understood as a form of projecting outward or as a kind of leaking and draining into the world. This mode of agency is epitomized in the statements of identity such as “I am a cutter.” In the second mode or moment of agency, hand and flesh together instantiate the reciprocal relationship of body and world. The cutting hand interpellates the part of the animal and material world that is one’s very own body, and that precise fragment of the world responds with the opening of the flesh . In this way cutting highlights the simultaneity of body as both self and other. The flow of blood marking not only the violation of a boundary but the opening between body and world. The reciprocity between body and world is highlighted in the simultaneous infliction of pain and the granting of relief.

The cutter’s body is also the locus of an anguished subjectivity that elicits the application to itself by an agentive hand ambivalently cruel and kind, of an otherwise inert implement from the material world,microgreen rack for sale whether it is a razor blade or a piece of glass. In the third mode of agency, both hand and flesh are no longer part of an inviolate self but conscripts of the world’s oppressive agency, and one’s body may as well not be one’s own but just a body, any body, “the” body as an object rather than a subject. The cutter’s hand is now the hand of the other, the wound is world-inflicted, and structural violence is incorporated at the most intimate bodily level. That is, it is inflicted by an anonymous oppressive world or the world dominated by the cruelty of others, and one’s flesh becomes an inert object alienated not only from selfhood but from the trajectory of a possible life, isolated from others and immersed in the immediacy of present pain and unproductive bodily transformation. We must take care to distinguish what is specific to each young person and what is fundamental to their bodily experience in the account we have just given. Attending to the immediate life worlds of individual youth reminds us that each has a distinct experience of cutting under distinct circumstances. Gender, ethnicity, and socioeconomic status matter to define these circumstances, while family relations and especially family instability are particularly insistent and frequent themes. Insofar as all the youth we have discussed were psychiatric inpatients, they can be counted among the more extreme instance of adolescent self-cutters, while exhibiting varied diagnostic profiles, levels of functioning, regimes of psychiatric medication, and phases of treatment and recovery. The combination of individual uniqueness and shared extremity across their situations has allowed us to elaborate a multilayered crisis of agency in the relation between body and world and highlights the existential profundity of cutting as a function of its mute immediacy in practice. The possibility for this kind of embodied existential analysis is that cutting is not an idiosyncratic occurrence but a culturally patterned act. Yet it cannot be accounted for just because other kids do it, and this is why it has been important to examine it in the lives of afflicted adolescents rather than simply as an element in the ethnography of “Emo” culture.

The interpretive point is that the trajectory of our argument from experiential specificity on the individual level to the fundamental human process of agency does not define the ends of a continuum. We must instead understand the extraordinary conditions of suffering as simultaneous with the enactment of fundamental human process, because the relation between body and world is always embedded in a specific instance, and each specific instance points to our shared existential condition of embodiment. Identifying the wounded flesh as locus of agency at the intersection of body and world as we have done brings to the fore a particular configuration of relations between self as active and passive, strategy and symptom, subjectivity and subjectivation. The moment of cutting is a fulcrum or hinge between the self as agent or as patient, with an intended pun on the medical sense of patient. From the standpoint of individual experience, cutting in the first sense is a strategy that is part of the self as agent, while in the second sense it is a symptom that is part of a disease process. As a cultural phenomenon, cutting in the first sense exhibits the body as existential ground of culture and wellspring of agentive subjectivity , while in the second sense cutting identifies the body as a site at which cultural practice and structural violence are inscribed and have the effect of subjectivation . In this respect, the distinction between subjectivation and subjectivity in the cut/cutting body is substantively parallel to the distinction between symptom and strategy in the afflicted person. Perhaps the analysis we have presented suggests that self-cutting may indeed be sufficiently complex to serve as the core of a distinct diagnostic category and too problematic with respect to agency to be defined as a symptom in the ordinary sense. Whether or not this proves to be the case, the existential complexity to which we have pointed is precisely what one would expect by bringing attention to bear on cutting as a crisis of agency with its locus at the intersection of body and world.Despite viral suppression on combination antiretroviral therapy , people with HIV suffer from depressed mood and chronic inflammation. Depression is the most common psychiatric comorbidity in HIV . Depressed PWH show poorer medication adherence , lower rates of viral suppression , greater polypharmacy , poorer quality of life and shorter survival . A sub-type of treatment-resistant depression in the general population is associated with chronic inflammation . The potential clinical significance of this is high, since the anti-inflammatory TNF-alpha blocker tocilizumab and other drugs such as the antibiotic minocycline, the interleukin 17 receptor antibody, brodalumab, and the monoclonal antibody, sirukumab, have been shown to be effective treatment for this depression subtype , but these have not been studied in the context of HIV. Inflammation is associated with greater symptom severity, differential response to treatment, and greater odds of hospitalization in patients with major depressive disorder.

The fourth factor was policy issues, referring to cases where the government or the facility itself does not allow for compliance with the signal functions. The fifth factor was designated as “no indication,” meaning that there was no patient group who needed this function. Supplemental Table 4 describes the reasons respondents provided on the survey for each unavailable signal function. Inappropriate supplies/equipment/drugs was the most common reason, as might be expected, and shortage of human resources was another causal factor. One intermediate hospital did not agree with the use of emergency signal functions for sentinel conditions, and answered “no indication” as their reason for non-compliance.It is widely recognized that there is a huge burden caused by trauma and non-communicable diseases in LMICs, where capability for emergency care is believed to be suboptimal.Many studies have tried to assess the state of emergency care in the health facilities of LMICs. Due to the accessibility issue, most studies examined teaching hospitals located in urban areas. Assessment tools were not standardized and were usually developed by the researchers themselves. Domains for assessment were usually related to the availability of resources, and functional aspects were surveyed with qualitative measures, if any. To our knowledge, this study is the first to survey urban and rural Myanmar hospitals using ECAT, the newly developed objective tool for assessing emergency care in health facilities. Our study demonstrated that the performance of emergency signal functions in Myanmar hospitals is inadequate, especially in trauma care. Trauma care in LMICs has been regarded as a role for large hospitals, and direct referral to upper-level facilities is a common practice. Burke et al. found that lack of readily accessible equipment for trauma care and shortage of skilled staff were the main reasons for poor quality trauma care in lower-level health facilities in LMICs.Another study pointed out the limited training opportunities for trauma management in LMICs.

We found similar obstacles to trauma care in Myanmar hospitals,flood and drain tray including the unavailability of items necessary for signal functions. Unlike other LMICs, Myanmar faces a singular geographic and demographic situation. Road conditions are poor. Almost 20 million people live in areas not connected by basic roads. The roads that do exist are unpaved and narrow, contributing to the overall lack of accessibility. The cause of this problem might be found in continuous armed conflicts. Since the independence of Myanmar in 1948, a continuing civil war has devastated the population and infrastructure of the rural areas, which has led to the deterioration of the health status of the country. In areas dominated by violence, residential zones are located away from road access, and the level of medical care is behind the times. Financial support is also lacking.For example, a referral and transport from Matupi Hospital to an adjacent upper-level facility takes as long as 16 hours during rainy seasons due to road damage . In this situation, timely management of patients in a critical condition is virtually impossible, and demands for higher levels of emergency care in basic-level facilities can be raised. Moreover, the results of our study show that some intermediate-level hospitals could not provide resuscitation for critical patients due to the lack of advanced airway management, mechanical ventilators, and defibrillation. Imbalances in the quality of emergency care in both basic- and intermediate-level facilities should be addressed carefully. However, in Myanmar’s special situation where highway infrastructure is lacking and there are problems with long transport times, the ability to administer emergency medical care at a large hospital should be established based on skilled labor and resources. Ouma et al. emphasized that all countries should reach the international benchmark of more than 80% of their populations living within a two-hour travel time to the nearest hospital.Although it cannot be realized in the near future, measures to alleviate accessibility problems can be applied.

Extension of critical signal functions for time-dependent conditions should be considered in selected basic-level facilities.In this regard, ECAT should be validated to include a time factor, such as the referral time to the nearest upper-level facility. We identified the following urgent issues in need of remediation: 1) improvement of trauma-related signal functions in basic-level facilities; 2) improvement of traumaand critical care-related signal functions in intermediate level facilities; and 3) implementation of a comprehensive nationwide survey to uncover emergency care deficiencies in rural areas, with emphasis on the time required for referral to higher-level facilities. Our suggestions to address the issues identified in our study can be summarized as relating to the reinforcement of infrastructure and human resources within each level of facility. In addition, prehospital care and care during inter-facility transportation should receive special attention considering the unique context of Myanmar, with its dispersed residences and extremely long transport times. There has been an effort to establish formal EM in Myanmar. In 2014, the Emergency Medicine Postgraduate Diploma course provided by Australia graduated 18 Myanmar medical officers.These emergency providers will be an imperative asset to setting up a modern emergency medical care delivery system in Myanmar, although most of them will practice in advanced-level facilities. Measures to build the capacity to respond to medical emergencies in rural areas should be pursued in Myanmar. There have already been efforts to improve first-aid skills among local healthcare workers who have a high degree of understanding of the local context, and to employ them as community emergency responders.These local healthcare workers are well informed about the population, hygiene, disease distribution, and the geographical and cultural characteristics of the area; thus, they are able to provide essential first aid and find appropriate health facilities for referrals. This practice has been expanded to the concept of out-of-hospital emergency care . It refers to a wide range of emergency treatments, from the process of recognizing an emergent care situation, to the initial emergency treatments outside the hospital, and transport to the hospital.

The establishment of OHEC has played a role particularly in LMICs by reducing mortality rates by 80%, especially in trauma cases.Since 2000, several organizations have implemented the trauma training course program with non-physician clinicians in Eastern Myanmar. The program comprises various skills for carrying out the initial treatment of trauma, taught through simple simulations and feedback. The findings indicated that survival rates improved significantly among major trauma patients following the implementation of this program. We recognize that some skills covered in the TTC, such as surgical airway management, would be relatively dangerous for health workers to perform in the field, and believe that development and implementation of a training program focused on the operation of emergency signal functions would be more practical for the rural context. Those who are trained in this program could act as prehospital emergency care providers, and also aid basic-level facilities to fill the functional gaps identified in this study. In addition to the above suggestions, a national or provincial strategic plan for reinforcing emergency care in rural areas of Myanmar should be established and implemented. Following a thorough investigational survey, essential resources for each level of health facility should be supplemented. Public education to recognize emergency conditions is another area to be strengthened. In many LMICs, including Myanmar, hydroponic tables canada folk remedies are still commonly attempted before people seek medical attention, especially in the field of obstetrics and gynecology.Recognizing the need for emergency care is crucial because it is the first step leading the patient to the emergency medical care system. Community education should play an important role in preventing delays in the detection of emergency situations.Traditional medicine providers have been the first to participate in this training thus far, and it has been reported to be effective.One limitation of the present study is the possibility of recall bias because we collected the data retrospectively. To minimize this bias, we selected five hospitals first, each of which had a key staff member whom we could contact frequently in a direct way. The other four hospitals were contacted via e-mail as a result of guidance we received from our initial five participants, who put us in direct contact with these additional research hospitals. Another limitation of our study is selection bias, given that the research hospitals taking part were not randomly selected. While the research hospitals were dispersed across various rural areas of Myanmar, they cannot be taken to represent each region,; however, they do provide a snapshot of the different levels of health facilities in Myanmar, and provide us with the basis for planning a more comprehensive survey on a larger scale in the future. Patients are commonly discharged from the emergency department without a pathological diagnosis to explain their symptoms, with one study finding that over one third of patients leave the ED with a symptom-based diagnosis .Studies exploring reasons for return ED visits have identified high levels of patient uncertainty related to lack of a definitive diagnosis as one cause for return.Introduction: Many patients who are discharged from the emergency department with a symptom-based discharge diagnosis have post-discharge challenges related to lack of a definitive discharge diagnosis and follow-up plan. There is no well-defined method for identifying patients with a SBD without individual chart review. We describe a method for automated identification of SBDs from ICD-10 codes using the Unified Medical Language System Metathesaurus. Methods: We mapped discharge diagnosis, with use of ICD-10 codes from a one-month period of ED discharges at an urban, academic ED to UMLS concepts and semantic types. Two physician reviewers independently manually identified all discharge diagnoses consistent with SBDs.

We calculated inter-rater reliability for manual review and the sensitivity and specificity for our automated process for identifying SBDs against this “gold standard.” Results: We identified 3642 ED discharges with 1382 unique discharge diagnoses that corresponded to 875 unique ICD-10 codes and 10 UMLS semantic types. Over one third of ED discharges were assigned codes that mapped to the “Sign or Symptom” semantic type. Inter-rater reliability for manual review of SBDs was very good . Sensitivity and specificity of our automated process for identifying encounters with SBDs were 84.7% and 96.3%, respectively. We describe a novel automated electronic approach using the UMLS to identify groups of patients who have been discharged from the ED with a SBD instead of a disease-specific diagnosis . Using manual physician review as the “gold standard,” we demonstrated a high sensitivity and specificity for the identification of SBDs using the UMLS semantic type of “Sign or Symptom.” The UMLS has been used in prior studies on ED EHR data for purposes including epidemiologic surveillance, constructing chief complaint dictionaries, and automated screening of rare conditions.These applications typically use UMLS with NLP, where free text is analyzed for concepts that were not otherwise captured in the EHR. Our work is different in that it was not intended for use with NLP or decision support, but rather was focused on automating the categorization of data fields that are not disease-specific for the purpose of identifying patients for research. Our recent work suggests that many patients discharged from the ED with a SBD have struggles related to their lack of a definitive diagnosis, with further work needed to explore the challenges unique to this patient population.3,4,16-18 Until now, there has not been a well-defined automated process for identifying these patients based upon their category of diagnosis instead of a specific diagnosis name . Our software was able to identify SBDs with a high sensitivity and specificity on the encounter level. False positives generally appeared to be pain or neurologic syndromes such as “seizure” and “musculoskeletal pain.” Some of these diagnoses are inherently ambiguous, as there are both primary conditions and secondary causes for many of these diagnoses. False negatives appear from predominantly three semantic types: “Finding,” “Disease or Syndrome” and “Pathologic Function.” Further refinement of our software may reduce the frequency of false negatives as we believe many of these diagnoses, such as “acute left ankle pain” or “vaginal discharge,” could also be described as a “Sign or Symptom.” However, it is important to note that the sensitivity of our analysis significantly improved when examining our results on the more clinically-relevant patient encounter level, as opposed to the diagnosis level.

Men and patients with Medicare or Medicaid insurance were more likely to have 14-day revisits, as were patients with a primary diagnosis of alcohol-related disorder; complication of device, implant or graft; congestive heart failure; and schizophrenia and other psychotic disorders. As a sensitivity analysis, we estimated the same model among adult patients only and found the results did not show any meaningful differences. Further, we repeated the analysis for each definition of frequent visitor definition and time horizons , and each combination of frequent visitor and time horizon. Skin and subcutaneous tissue infections were the strongest predictor of three-day revisits for each of the definitions of frequent visitor, followed by frequent visitor as the next largest association. In all other specifications, frequent visitor was the factor with the strongest association with revisits. There were 476,665 frequent visitors, who had a total of 1,251,082 visits, of which 340,381 were 14-day revisits. While frequent visitors represent 10.7% of all patients, they accounted for 18.7% of all encounters and 40.2% of all 14-day revisits. They were more likely to have a return visit at all times as compared to non-frequent visitors. Figure 2 demonstrates the percentage of patients revisiting the ED according to day after the index visit. The blue line represents all patients and shows that revisits peak on days one and two, and steadily decline thereafter, with slight peaks at days 7 and 14. The red line shows the revisit rate for patients with no or one visit in the six months prior to the index visit; as with all patients, the revisit rate peaks on days 1-2 and declines thereafter, dropping to below 0.3% by day 14. Patients defined as frequent visitors have revisits peaking on day 1 and decrease thereafter. The daily revisit rate for frequent visitors declines to a value of about 1.0% at 14 days,indoor grow cannabis after which the revisit percentage decreases by less than 0.1% for each subsequent day.

Encounters showing 0 days to first revisit reflect patients who returned to the ED on the same day as their index visit. Same day revisits represented 3.7% of the total encounters with an associated revisit. Frequent visitors had a significantly higher risk of a 14-day return visit resulting in admission than non-frequent visitors . Table 3 shows the unadjusted proportion of encounters resulting in return at 3 and 14 days according to different thresholds defining frequent visitor. For each threshold number of visits in the preceding six months, the unadjusted risk of return visit was more than double among frequent visitors as compared to non-frequent visitors. The remainder of the analysis uses two or more previous visits as the threshold defining frequent visitor, unless otherwise specified. This retrospective analysis of almost seven million patient visits found that recent previous ED visits was the strongest predictor of an ED return visit. This finding held true across multiple cutoffs defining frequent use, and also under both univariate analysis and a multivariate model including patient, visit, hospital, and county characteristics. Along with recent frequent use, public insurance and three diagnoses were associated with an increased risk of a return visit. This suggests that our understanding of short-term revisits could be informed by considering frequency of ED use.Previous studies have evaluated predictors of ED revisit using patient-level data such as age, sex, race, insurance status, and diagnosis at initial ED visit, as well as hospital-level data. Surprisingly, the relationship between frequent ED use and risk of revisit after discharge is poorly characterized.Further, there is no consensus on what defines “frequent,” with definitions ranging from 2–12 visits per year.We had the striking finding that even one previous visit increased risk of return by a clinically-significant margin. This finding held true even when accounting for patient, visit, hospital, and community characteristics.

Our definition focused on visits within the previous six months because other work has shown that episodes of frequent ED use are usually self-limited,42 which suggests that the recent past is more relevant to current health and risk of short-term return visit. A second, related finding is that the threshold used to define frequent visitors is arbitrary with respect to risk of return visit. In the hope of informing the wide range in the literature on the number of visits or length of time used to define frequent users,we considered our definition of frequent user in relation to risk of return visit. We had the surp finding that any number of previous visits used to define frequent vs non-frequent ED users predicted an increased risk of revisit. Given that the reason to label certain patients as frequent visitors is often in order to identify them for interventions, future work may consider an outcome-based definition of frequent users and define the term “frequent” with a qualifier – eg, with respect to propensity to revisit after a visit, risk of becoming a persistent frequent user, or risk of death. As with existing literature, we transformed the number of previous visits from a continuous variable to a binary one. This has the disadvantage of losing some information, but is standard in the literature regarding frequent ED use, and can easily be applied in the midst of clinical practice.Our sensitivity analysis demonstrated that any threshold was significantly associated with return visits, suggesting that knowing whether a patient had four vs three previous visits would provide marginally more information than simply knowing the patient had more than two previous ED visits. As with the definition of frequent user, the time to return visit defining a return visit is somewhat arbitrary. While the risk of return visit is highest on the first day following the ED visit, the risk gradually decreases and, as found previously by Rising et al., there is no clear timeline that defines a return visit.

This finding may suggest something other than inadequate care at the index visit is the driving factor for most short-term revisits, and that both frequent use and revisits may simply be proxies for certain patients with increased healthcare-seeking behavior. Further complicating this issue is that patients may be instructed to return to the ED for a re-evaluation. Thus, an ED in a setting with limited outpatient resources might appear to give poor care as measured by revisits when in fact it serves to provide followup care that patients otherwise would not obtain. Despite the variation in the literature and thus our broad range of models, we consistently found that the strongest predictor of a revisit is a high number of previous visits. This finding held true in our sensitivity analysis using different thresholds for number of previous visits and also days after index visit. The observation that previous visits predicts future visits may seem obvious or mechanical, but it does not necessarily follow that a patient with one or two visits in the prior six months would be at double the risk of a revisit within three days. Further,growing cannabis that this relationship was stronger than any other patient, hospital, or community characteristic is an important finding that has been overlooked in the literature regarding revisits. In fact, it appears that the literature on frequent visitors and the literature regarding revisits have to this point largely functioned in parallel and have not yet begun to inform each other. Whether frequent users are merely frequently-ill people, and whether sicker patients are at increased risk of short-term revisits deserves future research. Likewise, future work should investigate the extent to which patients are frequent users because they received poor care or face limitations in their ability to obtain outpatient resources, the extent to which revisits are avoidable, and the degree to which frequent use persists over time. Understanding the extent to which follow-up with primary care, referrals to specialists, and ability to obtain further evaluation such as advanced imaging, cardiac stress test, or even a wound check is essential to understanding why patients return to the ED. The data for this study were obtained from a single multi-state physician partnership and do not necessarily generalize to other providers or provider groups, or to other populations. However, the sample size was large and spans many cities and rural areas across several states, includes a broad set of hospital owner types, a large range of hospital sizes, and both teaching and non-teaching hospitals. This source of data may lead to a biased sample with respect to patient population, hospital characteristics, and provider characteristics. In particular, the income distribution is narrower than the distribution for the entire U.S., so the patient population could have a lower proportion of low- and high income patients than typical for the U.S. We addressed these potential sources of bias by controlling for patient demographics, patient insurance, and local income; hospital characteristics including volume and a performance metric, and clinician degree. Second, because not all hospitals within a region were observed, measures of frequent visitors and repeat visits may underestimate the actual numbers of frequent visitors and repeat visits, as patients may have gone to another ED either prior to or after the observed index visit.

This limitation is typical of this research,and in this dataset patients were linked across hospitals, although this was limited to the hospitals served by this company. Thus, it is unknown whether patients had an unobserved revisit at another ED, or whether what was considered an index visit actually represented a revisit after an initial visit at another ED. Next, we were unable to distinguish between planned and unplanned return visits. Thus, a patient who is instructed to return for a check over the weekend to ensure their illness is improving, for example, would appear to be a revisit, but this should not imply that their initial treatment was inadequate or inappropriate in any way. Research using administrative datasets, such as HCUP, likewise suffers from this limitation. Finally, as with related research, this study does not identify the extent to which high rates of frequent visits and revisits are driven by patient factors, ED care, or non-ED healthcare resources. This analysis was limited in its ability to examine patient psychosocial attributes or local resources, which are likely to contribute to ED visits and revisits, although we did consider proxies for access to care: patient insurance and community-level factors such as income and number of hospitals in the county. Acute heart failure is a gradual or rapid decompensation in heart failure requiring urgent management.The condition covers a large spectrum of disease, ranging from mild exacerbations with gradual increases in edema to cardiogenic shock. HF affects close to six million people in the United States and increases in prevalence with age.Currently, the emergency department initiates the evaluation and treatment of over 80% of patients with AHF in the U.S.As the population ages, increasing numbers of patients with HF will present to the ED for evaluation and management. However, making the correct diagnosis can be challenging due to the broad differential diagnosis associated with presenting symptoms and variations in patient presentations. Over one million patients are admitted for HF in the U.S. and Europe annually.In the U.S. population, people have a 20% risk of developing HF by 40 years of age.Patients with HF average at least two hospital admissions per year.Among patients who are admitted with AHF, over 80% have a prior history of HF, referred to as decompensated heart failure.De novo HF is marked by no previous history of HF combined with symptom appearance after an acute event.Mortality in patients with HF can be severe, with up to half of all patients dying within five years of disease diagnosis.Other studies have found that post-hospitalization mortality rates at 30 days, one year, and five years are 10.4%, 22%, and 42.3%, respectively.AHF expenditures approach $39 billion per year, which is expected to almost double by 2030.Normal cardiac physiology is dependent on appropriately functioning ventricular contraction, ventricular wall structural integrity, and valvular competence.At normal functional status, a person’s stroke volume is approximately one milliliter per kilogram for every heartbeat.SV is dependent upon the preload , after load , and contractility . In patients with HF, left ventricular dysfunction can be due to impaired LV contraction and ejection , impaired relaxation and filling , or a combination of both.

Even putting aside the questionable pharmacological and moral aspects of this differential policy, there is no evidence whatsoever for its effectiveness in controlling crime. Caulkins and colleagues show that conventional sentencing is significantly more cost effective. Although the crack mandatory sentences were trimmed somewhat in 2007, and the Supreme Court recently acted to restore some judicial discretion in these cases . Whether these changes will translate into a closing of the large racial differential remains to be seen. The optimal level of drug law enforcement is surely well above zero, but just as surely, well below current levels . Caulkins and Reuter argue that we could reduce the drug prisoner population by half without harmful consequences; they note that this would still leave us with system “a lot tougher than the Reagan administration ever was.” Kleiman suggests tactics for getting more mileage out of less punishment through the use of small, quick sanctions, strategically deployed. In 2005, there were about 1.8 million people in substance abuse treatment in the US, about 40 percent for alcohol, 17 percent for the opiates, 14 percent for cocaine, and 16 percent for marijuana . There are certainly many thousands of people who need treatment and are not receiving it. Whether expanding the available treatment capacity would bring them in is an open question. We should be wary of assuming that a purely “public health” approach to drugs can work; the police and courts play a crucial role in bringing people into treatment – increasingly so with the expansion of drug courts and initiatives like California’s Proposition 36, the 2001 law which permits treatment in lieu of incarceration for those convicted for the first or second time for nonviolent drug possession . For most primary drugs of abuse, criminal justice referrals are a major basis for treatment: in 2005, 57 percent of marijuana treatment, 49 percent of methamphetamine,indoor hydroponics cannabis and 27 percent of smoked cocaine. But 36 percent of clients in alcohol treatment were referred by the criminal justice system, so legal status may not be the crucial lever.

In a sophisticated cost-effectiveness analysis, Rydell and Everingham estimate that the U.S. could reduce cocaine consumption by 1 percent by investing $34 million in additional treatment funds, considerably cheaper than achieving the same outcome with domestic drug law enforcement , interdiction , or source country controls . But because treatment effects are usually estimated using pre-post change scores that are vulnerable to two potential biases . First, the post treatment reduction could reflect a simple “regression to the mean” in which an unusually extreme period of binge use would be followed by a return to the user’s more typical levels, even in the absence of treatment. Second, treatment pre- and post tests are vulnerable to selection biases because clients who enter and remain in treatment until post-treatment measurement are a non-random and perhaps very unrepresentative sample of all users. Regression artifacts would inflate treatment estimates; selection biases could either inflate or deflate the estimates. We believe that the full weight of the evidence makes it clear that treatment is both effective and cost-effective, but until these problems are better addressed, we cannot be sure that the benefits of expanded treatment would be as large as Rydell and Everingham implied. Even its most passionate advocates recognize that treatment’s benefits are often fleeting. About three quarters of heroin clients and half of cocaine clients have had one or more prior treatment episodes . Forty to sixty percent of all clients will eventually relapse, though relapse rates are at least as high for hypertension and asthma treatment . Importantly, Rydell and Everingham recognized that treatment can provide considerable health and public safety benefits even if it only reduces drug use while the client is enrolled. Held up to a standard of pure prevalence reduction , treatment is unimpressive. But by the standards of quantity reduction and harm reduction, treatment looks pretty good. American providers – steeped in the Twelve Step tradition – recoil at the phrase “harm reduction” – but it is a service that they can and often do perform quite well. Perhaps the most socially beneficial treatment modality is one that some are reluctant to view as treatment at all – methadone maintenance for heroin addicts. In 2006, there were 254,049 people receiving methadone, only about 20 to 25 percent of all opiate addicts in the US .

The gap is partly due to spotty service provision outside major cities, but in even urban centers, many addicts won’t voluntarily seek out methadone, preferring heroin even with its attendant risks. But Switzerland, the Netherlands, and Germany have amassed an impressive body of evidence that hard-core addicts significantly improve their health and reduce their criminality when they are able to obtain heroin directly from government clinics . Similar ideas were rejected in the US several decades ago, but perhaps it is time for a second look . In the US, the dominant form of prevention takes place in the classroom, generally administered by teachers . Ironically, prevention is the least well funded but most thoroughly tested drug intervention. Drug prevention has very modest effects on drug and alcohol use; e.g., the mean effect size in the most recent comprehensive meta-analysis was about 1/20th of a standard deviation . Considering that 1/5th of a standard deviation is usually considered the benchmark “small” effect size, this is not very encouraging. Making matters worse, the single most popular program, Drug Abuse Resistance Education , accounts for nearly a third of all school prevention programs , but numerous studies show it has little or no detectable effect on drug use . It is not clear whether its ineffectiveness stems from its curriculum or from its reliance on classroom visits by police officers. But classroom based prevention is quite inexpensive, so it doesn’t have to be very effective to be cost-effective. Caulkins and colleagues estimate over $800 in social benefits from an average student’s participation, for a cost of only $150. Most of the benefits involve tobacco prevention, then cocaine, and only minimally marijuana. Classroom-based prevention materials can’t be effective if the messages aren’t salient in real-world settings where drug taking opportunities occur. But a well-funded campaign of magazine, radio, and television ads by the Office of National Drug Control Policyc appears to have had no positive impact on levels of use . We should be wary of thinking we have evaluated “the impact of mass media”; it may just be that the messages we’ve been using aren’t very helpful. Note that our prevention messages are almost exclusively aimed at prevalence reduction rather than quantity reduction or harm reduction .

A greater emphasis on secondary prevention and harm reduction might have real payoffs with respect to social costs,pots for cannabis plants but we won’t know unless we try . Evidence from classroom sex education is instructive in this regard; programs that teach safe sex are reliably more effective at reducing risky behavior than are abstinence-based programs . We can hazard some guesses about where American drug policy might head in the future. The medical marijuana movement is likely to diminish in visibility as sprays like Sativex reduce the role of marijuana buyers’ clubs, yet adult support for marijuana legalization will continue to increase as the tumultuous “generation gap” of the 1960s becomes a distant memory. Methamphetamine will soon peak, if it hasn’t already , leaving us to deal with a costly aging cohort of addicts, much like our earlier heroin epidemic. And vaccines against nicotine and cocaine addiction may soon hit the market, with both desirable and unintended consequences . But rather than developing the case supporting these speculations, we close with two trends that are already well underway, each of which has the potential to seriously subvert current cultural assumptions about drugs and drug control. The conventional wisdom is that ecstasy is a “love drug” or “empathogen,” and that it is the drug of choice for European and Asian American college students and young professionals. But there are many reports of increased ecstasy use by minorities living in several cities . Many observers have noted its prevalence in the “hyphy” movement and the associated rap music . There is evidence of an increase in the number of references to ecstasy use in hip-hop music starting in 1996 . The reported rise in ecstasy use in the hip-hop scene has ignited alarming claims that ecstasy is “the new crack” ; a CBS television story asked whether Ecstasy was a “hug drug or thug drug” . In fact, researchers have only begun to examine the diffusion of ecstasy into inner-city neighborhoods . There is laboratory evidence of heightened aggression in the week following MDMA ingestion , but in a 2001 study of arrestees, ecstasy use was not associated with race, and negatively associated with arrest for violent crimes . It is also unclear whether self reported “ecstasy” use always involves MDMA, as opposed to closely related drugs like methamphetamine . Thus the emerging “thizzle” scene does raise intriguing questions about psychopharmacology, culture, and their intersection, but whether there is any meaningful causal connection between Ecstasy, race, and crime is far from certain. Earlier, we offered a thought experiment about a hypothetical drug called Rhapsadol. We now ask the reader to consider a newly created synthetic stimulant, “Quikaine.” Quikaine targets the neural system by increasing the speed of ion transfer between synaptic gaps. Thus, it reduces reaction time and increases the speed with which physical tasks can be accomplished.Neither does it affect intellectual functioning. Second, consider “Intellimine.” Its sole impact on the human body is to improve cognitive capacity; it has no other emotional or physical impact, and no lingering effect on mental functioning once the drug leaves the system. In addition, because variants of this drug have been used for decades to help with ADHD/ADD and Alzheimer’s it has a long and empirically sound safety record. In fact, children and the elderly receive maximum benefit of the drug. How should we regulate these drugs? Should they be legally available for purchase by adults? If not, are there more limited circumstances in which their use might acceptable? For example, would Quikane’s use be warranted by those charged with protecting others from danger, such as certain military operatives or police officers? What about for completing tasks faster and more safely, such as on an assembly line? How about for simply reducing the amount of time spent on household chores? Should we allow surgeons, crisis managers, and other high-stakes problem solvers to take Intellimine? These drugs are hypothetical, but new synthetics already have some of their properties, and there is every reason to expect rapid advances in the development of performance enhancers in the near future . They will raise vexing questions about personhood, agency, freedom, and virtue. For centuries, we have associated psychoactive substances with the pursuit of purely personal goals: fun, seduction, escape, transcendence, ecstasy. New drugs like Intellimine and Quikane will force us to come to grips with a radically new framing: Drug use as a tool for enhanced economic competitiveness. Parents who now worry about how marijuana might jeopardize their children’s Ivy League prospects may soon worry about whether abstinence lowers SAT scores. Employers who now screen urine for marijuana may come to view abstainers as slackers. It will be fascinating to see how we learn to reconcile these new pressures with our traditional attitudes toward drugs. We close with a brief list of topics that are sorely in need of research attention. Rather than a long wish list, we confine our attention to priorities that are implied by our analytical framework; specifically, the argument that quantity reduction and harm reduction deserve a more equal footing with prevalence reduction. The first priority is to give far greater attention to the development of quantity and harm indicators in epidemiological research. Our national drug surveys devote far more attention to prevalence than to dosage, settings of use, or consequences of use, and the reliance on household and classroom populations over represents casual users and under represents the heaviest users .

It should be appreciated that these adolescents are at high risk for future economic disengagement. It is not our intention to foster stigma or damage the prospects of NEET youth by adding the stereotype of ‘mentally ill’ to the stereotype of ‘unmotivated.’ Instead, our view is that treating their mental health problems early may be an intervention target with long-term dividends for the children themselves as well as society . Recent reports suggest that most British adolescents visit their GPs several times per year, which could provide opportunities to query mental health and substance abuse issues in primary care settings . However, the level of investment in child and adolescent mental health services in the United Kingdom is low and has further decreased in the face of the economic downturn ; moreover, coordination of care for young people transitioning out of adolescent mental health services into adult services is poor . Health service models that increase engagement and provide intensive employment support among economically inactive youths with mental health problems may be a more useful approach . There are limitations to our study. Our analysis was restricted to 18-year olds, a subset of the larger NEET population. We could not examine whether the associations between NEET status, self-perceived economic prospects, and mental health are similar among previous cohorts of young people. Our sample comprised twins, and whether their experience of NEET matches that of singletons is unknown. However, the NEET rate among our twins is similar to the official 12.5% rate reported by the UK Department for Education , and base rates of mental health problems in twins are very similar to population prevalence estimates . Our findings are also consistent with earlier work showing that NEET youths are much more likely to come from socioeconomically deprived families and neighbourhoods . The E-Risk study was not designed purposely to investigate NEET, as youth unemployment rose after the study began.

As a result, what is needed to grow marijuana we lacked information on how long participants have been NEET, and lacked the month to-month assessments needed to pin down sequential order between onset of 18-year-olds’ NEET status and changes in their mental status. Nevertheless, our prospective study waves revealed that some NEET youths’ mental health problems were of long standing. Additional methodological strengths of our study include its use of a representative birth cohort with good retention, and a comprehensive interview assessment of young people’s attitudes about work and their own economic abilities. The current high levels of youth unemployment in Europe and the United States are of grave concern. Policymakers and social welfare advocates continue to look for ways to improve the labour market outcomes of economically inactive young people . Our study contributes to this effort by highlighting the necessity of incorporating mental health services into youth career support initiatives. NEET youths are often assumed to be unwilling to work . Our analyses suggest, instead, that NEETs are as motivated as their peers, but many face longstanding psychological challenges that put them at a disadvantage when seeking employment. In an economic context that presents structural barriers to all would-be workers, NEET youths’ psychological vulnerabilities place them at even greater risk for a constellation of long-term socioeconomic perils.Electronic cigarettes and vaping products are new devices for inhaling various substances such as nicotine and cannabinoids, with or without flavoring chemicals. “Vaping,” or “Juuling,” is a term used to describe the use of e-cigarettes and vaping products.1 These devices, also known as e-cigs, vape pens, vapes, mods, pod-mods, tanks and electronic nicotine delivery systems, are available in different shapes and sizes.All e-cigarettes and vaping products are made of three components. The first component is the cartridge that contains e-liquid and the atomizer, a coil that heats and converts e-liquid into aerosols.

E-liquids can be broadly categorized into two types: regular e-liquids made of propylene glycolLoma Linda University, Department of Emergency Medicine, Loma Linda, California containing chemical flavors and vegetable glycerine used to dissolve nicotine or cannabis e-liquids containing tetrahydrocannabinol and cannabidiol. The second component is the sensor that activates the coil, and the third component is the battery.The hookah, also known as a water pipe, is an ancient method of smoking nicotine. In this method, the coal heats the tobacco and then the smoke passes through the water reservoir before it is inhaled.4 Contrary to public perception, hookah use is also associated with oral, lung, and esophageal cancers, similar to smoking cigarettes.4 In our study, we focused on e-cigarettes, and vaping, product-use associated lung injuries . According to the United States Centers for Disease Control and Prevention , in 2018 e-cigarettes were used by 3.05 million high school and 570,000 middle school students.EVALI is a diagnosis of exclusion, with a definition outlined by the CDC for confirmed and probable cases.6 EVALI was first identified in August 2019 after the Wisconsin Department of Health Services and the Illinois Department of Public Health received multiple reports of a pulmonary disease of unclear etiology, possibly associated with the use of e-cigarettes and related products.Since then, more than 2000 cases of EVALI have been reported, and in 80% tetrahydrocannabinol -containing products were used.Our study aimed to identify the clinical characteristics and hospital course of adolescents diagnosed with EVALI.We performed a retrospective chart review of adolescents presenting to our hospital between January– December 2019, with diagnosis of EVALI. Subjects were identified by the International Classification of Diseases, Tenth Revisiondiagnostic codes outlined by official ICD-10 guidelines.9The following codes were used: J68.0 ; J69.19 ; J80 ; J82 ; J84.114 ; J84.89 ; J68.9 ; T65.291 ; and T40.7X1 . We used a standardized data collection sheet. Data were collected by trained personnel who were not blinded to the objectives of study. The data extracted from the medical records were age, gender, weight, and vital signs obtained in the ED. We also compiled data on duration of symptoms, history of cough, shortness of breath, chest pain, vomiting, wheezing, rales, use of accessory muscles, and presence of altered mental status.

We also included data on respiratory support, duration of hospital stay, use of steroids during treatment, and laboratory tests and imaging obtained in the hospital and a negative infectious workup or the decision by the clinical care team to treat as a case of EVALI.Exclusion criteria were gastrointestinal and central nervous system manifestations without interstitial pulmonary involvement, ingestions of cannabinoids, duplicate visits, and if it was unclear whether vaping device was used or not. We used descriptive statistics to analyze the data. Median and interquartile range were calculated for continuous variables, and proportions were calculated with 95% confidence intervals for categorical variables. The study was approved by the Loma Linda University Institutional Review Board.We identified 16 encounters with the ICD-10 codes for EVALI during the one-year period. Using the exclusion criteria mentioned in the Methods section,heavy duty propagation trays we excluded seven patients. Four of these patients presented with CNS manifestations and vomiting without pulmonary involvement. In one patient, the history of vaping was unclear. One patient had ingested cannabinoids without vaping. Two encounters were excluded because they were duplicate visits. Of the seven patients included in the analysis, sixwere male. The median age was 16 years . The median weight in our series was 70 kilograms . The medians for vital signs recorded in the ED were the following: temperature of 100.2º Fahrenheit ; respiratory rate 24 breaths per minute ; oxygen saturation, 90% ; heart rate 130 beats per minute ; systolic blood pressure 128 millimeters of mercury; and diastolic blood pressure 76 mm HG . Three patients had documented fever in the ED. The most common symptoms reported in our study were cough, shortness of breath, and vomiting, each occurring separately in five patients. Three patients presented with chest pain. Two patients presented with altered mental status in the form of unresponsiveness, with one patient requiring intubation. The other unresponsive patient, a 16-year-old male, returned to a normal mentation with bag-valve-mask ventilation and naloxone but required high-flow nasal cannula for shortness of breath. On physical examination, accessory muscle use was the most common finding, reported in four patients. Rales were appreciated in two patients, while no patients were found to have wheezing . In our study, six patients presented with respiratory failure. Four required HFNC. One patient was intubated; one patient required simple nasal cannula oxygen at two liters per minute; and one patient maintained normal oxygen saturations in room air during his ED visit and was discharged home. A brief clinical presentation, summary of findings on imaging, and type of respiratory support needed are summarized in Table 2. Five patients were admitted to the pediatric intensive care unit, and one patient was admitted to the normal pediatric unit. The median hospital length of stay was six days . All patients were discharged with no comorbidities or deaths reported. Six patients were treated with steroids.Our patients had a variety of laboratory tests ordered. Most common were complete blood count, respiratory virus panel, respiratory cultures, and urine drug screen.

All patients had a complete blood count, and the median for white cell count was 16 thousand cells per cubic millimeter . A respiratory virus panel was collected from five patients and it was negative in all of them . Respiratory cultures were collected from two patients and both resulted negative. A urine drug screen was performed for six patients and was positive for cannabinoids in all six . Three patients followed up at different intervals in the pulmonology clinic . Spirometry showed normal results in all three patient sat that time. Case 1 followed up one week after discharge, at which time spirometry showed evidence of obstructive lung disease, which returned to normal at three-month follow-up visit. No repeat imaging was performed for that patient. Case 2 followed up six weeks after discharge with near-complete resolution of ground-glass appearance on repeat CT and normal spirometry. Case 4 followed up two weeks after discharge with improvement in lung opacities on repeat radiograph and normal spirometry. All three patients had received steroids for 10 days when they were originally diagnosed with EVALI. No follow-up data was available for the remaining four patients.EVALI was an emerging disease entity in 2019. In our case series, we describe adolescents diagnosed with EVALI and their clinical course in the ED and the hospital. In our study, the most common symptoms of cough, shortness of breath, and vomiting presented with an equal frequency of 71%. In a study by Layden et al, shortness of breath and cough was noticed in 85% of patients and vomiting in 61%; whereas, according to Belgaev et al, 90% of patients in their study presented with gastrointestinal and respiratory symptoms.In a report by the CDC, 85% of the EVALI population had respiratory symptoms and 57% had GI symptoms.11 The results of our study are similar to previous literature in suggesting that respiratory and GI symptoms are common in patients with EVALI. According to Balgaev et al, 67% of patients had clinical and radiological improvement with residual findings on radiological and pulmonary function tests at time of followup.In our study, the three patients who had documented follow-up visits had normal spirometry without residual deficits. Only two of those patients had repeat imaging, and both showed improvement without residual abnormalities. E-cigarette liquids and aerosols have been shown to contain a variety of chemical constituents including flavors that can be cytotoxic to human pulmonary fibroblasts and stem cells.Exposure to heavy metals such as chromium, nickel, and lead has also been reported.None of our patients were tested for heavy metal exposure. Most of the delivery systems have nicotine in them, with one cartridge providing the nicotine equivalent to a pack of cigarettes.In addition to nicotine, e-cigarette devices can be used to deliver THC-based oils.According to Trivers et al, one-third of the adolescents who used e-cigarettes had used cannabinoids in their e-cigarettes.In our patients with EVALI, urinary drug screen was positive for cannabinoids in all patients. One caveat is that we do not know whether our patients used only THC-containing products or a combination of nicotine and THC-containing products. In our case series, the majority of patients presented with pulmonary disease requiring respiratory support and intensive care unit admission. None of these patients developed acute respiratory distress syndrome .

The CAGE-AID has demonstrated validity, with high internal consistency in screening for problematic drug and alcohol use; a cutoff point of 2+ on the CAGE-AID has a sensitivity of 70% and specificity of 85% for identifying individuals with SUDs. Study exclusion criteria were current pregnancy, history of severe alcohol or drug-related medical problems , opioid overdose requiring Narcan , current opioid misuse without medication-assisted treatment, or attempted suicide within the past year. For this study, the target sample size was 50 participants; however, due to a high level of response and efficiency, enrollment was more than double our recruitment goal. Between March 27, 2020 and May 6, 2020, 3597 individuals were screened for study participation, with 3422 ineligible and 175 eligible individuals. Figure 1 shows the reasons for study exclusion, most frequently residing outside of the United States and endorsing fewer than 2 criteria on the CAGE-AID . Of the 175 eligible participants, 141 provided informed consent to participate in the study, of whom 128 completed the baseline survey.Among the 101 participants enrolled, 11reported previous use of the Woebot app. Described in detail previously, Woebot is an automated conversational agent that delivers CBT in the format of brief, daily text-based conversations. The Woebot program is deployed through its own native apps on both iPhone and Android smartphones or devices. The app on boarding process introduces the automated conversational agent, explains the intended use of the device, how data are treated,cannabis equipment and the limitations of the service .

The user experience is centered around mood tracking and goal-oriented, tailored conversations that can, depending on user input and choice, focus on CBT psycho education, application of psychotherapeutic skills for change , mindfulness exercises, gratitude journaling, and/or reflecting upon patterns and lessons already covered. Each interaction begins with a general inquiry about context and moodto ascertain affect in the moment. Additional therapeutic process-oriented features of Woebot include delivery of empathic responses with tailoring to users’ stated mood, goal setting with regular check-ins for maintaining accountability, a focus on motivation and engagement, and individualized weekly reports to foster reflection. Users become familiar with Woebot, which is a friendly, helpful character that is explicitly not a human or a therapist but rather a guided self-help coach. Daily push notifications prompt users to check in. We adapted W-SUDs, drawing upon motivational interviewing principles, mindfulness training, dialectical behavior therapy, and CBT for relapse prevention. Sample screenshots from the W-SUDs app are shown in Figure 2. In total, the W-SUDs intervention was developed as an 8-week program with tracking of mood, substance use craving, and pain, with over 50 psycho educational lessons and psychotherapeutic skills. CBT evidence-based, guided self-help treatments have ranged in length from 2 to 12 weeks, and the National Institutes for Clinical Excellence describes guided self-help as including 6 to 8 face-to-face sessions. Early responsiveness to SUD treatment is predictive of long-term outcomes, and brief addiction treatments are efficacious. Brief intervention can minimize potential dropout, a problem common to SUD treatment;therefore, we designed W-SUDs as an 8-week treatment. Woebot is not designed to address active suicidal ideation or overdose, and this was stated in the study informed consent. In addition, Woebot conversationally informs first-time users that it is not a crisis service. Woebot also has safety net detection that uses natural language processing algorithms to detect and flag several hundred possible harm-to-self phrases with 98% accuracy . Woebot detects crisis language and asks to confirm it with the user. If the user confirms, Woebot offers resources , carefully curated with expert consultation.

Woebot data indicate that users do not use Woebot for crisis management; approximately 6.3% trigger the safety net protocol, with 27% of those confirming that it is indeed a crisis when Woebot asks to confirm . W-SUDs, an automated conversational agent, was feasible to deliver, engaging, and acceptable and was associated with significant improvements pre- to post treatment in self-reported measures of substance use, confidence, craving, depression, and anxiety and in-app measures of craving. The W-SUDs app registration rate among those who completed the baseline survey was 78.9% , comparable with other successful mobile health interventions. As expected, the use of the W-SUDs app was highest early in treatment and declined over the 8 weeks. Study of engagement with digital health apps has been growing, with no consensus yet on ideal construct definitions. Simply reporting the number of messages or minutes spent on an app over time may undermine clarity and genuine understanding of the type and manifestation of app utilization related to clinical outcomes of interest. Further research in this area is warranted. The observed reductions from pre- to post treatment measures of depression and anxiety symptoms were consistent with a previous evaluation of Woebot conducted with college students self-identified as having symptoms of anxiety and depression. Furthermore, in this study, treatment-related reductions in depression and anxiety symptoms were associated with declines in problematic substance use. Declines in depressive symptoms observed from pre- to post treatment were greater among the participants in therapy. This study also examined working alliance, proposed to mediate clinical outcomes in traditional therapeutic settings. Traditionally, working alliance has been characterized as the cooperation and collaboration in the therapeutic relationship between the patient and the therapist. The role of working alliance in relationally based systems and digital therapeutics has been previously considered; the potential of alliance to mediate outcomes in Woebot should be further validated in future studies adequately powered to examine mediators of change.

Measures of physical pain did not change with the use of W-SUDs as reported in pre- and post treatment measures or within the app; however, the sample’s baseline ratings of pain intensity and pain interference were low. Although not a direct intervention target, pain was measured due to the potential for use of substances to self-treat physical pain and the possibility that pain may worsen if substance use was reduced,vertical grow shelf which was not observed here. Within-app lesson completion and content acceptability were high for the overall sample, although there was a wide range of use patterns. Most participants used all facets of the W-SUDs app: tracked their mood, cravings, and pain; completed on average over 7 psycho educational lessons; and used tools in the W-SUDs app. Only about half of the sample completed the post treatment assessment, with better retention among those screening higher on the CAGE-AID. That is, those with more severe substance use problems at the start of the study, and hence in greater need of the intervention, were more likely to complete the post treatment evaluation. None of the other measured variables distinguished those who did and did not complete the post treatment evaluation. This level of attrition is commensurate with other digital mental health solution trial attrition rates.By addressing problematic substance use, including but not limited to alcohol, the W-SUDs intervention supports and extends a growing body of literature on the use of automated conversational agents and other mobile apps to support behavioral health. A systematic review of mobile and web-based interventions targeting the reduction of problematic substance use found that most web-based interventions produced significant short-term improvements in at least one measure of problematic substance use. Mobile apps were less common than web-based interventions, with weaker evidence of efficacy and some indication of causing harm . However, mobile interventions can be efficacious. Electronic screening and brief intervention programs, which use mobile tools to screen for excessive alcohol use and deliver personalized feedback, have been found to effectively reduce alcohol consumption and alcohol-related problems. However, rigorous evaluation trials of digital interventions targeting non-alcohol substance use are limited. Furthermore, although a systematic review concluded that conversational agents showed preliminary efficacy in reducing psychological distress among adults with mental health concerns compared with inactive control conditions, this is the first published study of a conversational agent adapted for substance use. Study strengths include study enrollment being double the initial recruitment goal, reflecting interest in W-SUDs. Most participants reported lifetime psychiatric diagnoses, and approximately half of the participants endorsed current moderate-to-severe levels of depression or anxiety. W-SUDs was used on average twice per week during the 8-week program. From pre- to post treatment with W-SUDs, participants reported significant improvements in multiple measures of substance use and mood. The delivery modality of W-SUDs offered easy, immediate, and stigma-free access to emotional support and substance use recovery information, particularly relevant during a time of global physical distancing and sheltering in place.

More time spent at home, coupled with reduced access to in-person mental health care, may have increased enrollment and engagement with the app. Although further data on recruitment and enrollment are warranted, these early findings suggest that individuals with SUDs are indeed interested in obtaining support for this condition from a fully digitalized conversational agent. This study had a single-group design, and the outcomes were short term and limited to post treatment, thus limiting the strength of inferences that can be drawn. The sample was predominately female and identified as non-Hispanic White, and the majority were employed full-time. Non-Hispanic White participants reported higher program acceptability on 2 of the 4 measures compared with participants from other racial or ethnic groups. Future research on W-SUDs will use a randomized design, with longer follow-up, and focus on recruitment of a more diverse population to better inform racial or ethnic cultural programmatic tailoring, using quotas to ensure racial or ethnic diversity in sampling. Notably, although recruited from across the United States, nearly all participants were sheltering in place at the time of study enrollment due to the COVID-19 pandemic, which may have affected substance use patterns and mood as well as interest in a digital health intervention. Notably, however, alcohol sales in the United States increased during the COVID-19 pandemic. The primary outcomes of substance use, cravings, confidence, mood, and program acceptability were standard measures with demonstrated validity and reliability. The limitations were that all were self-reported, and acceptability measures were not open-ended or qualitative. Few participants were misusing opioids, likely due to study exclusion designed to mitigate risk, namely, the requirement of engagement with medication-assisted treatment and no history of opioid overdose requiring Narcan . Notably, nearly 1400 people with interest in a program for those with substance use concerns were excluded due to low severity on the CAGE-AID screener. Worth testing is the utility of digital health programs for early intervention on substance misuse that is sub-syndromal. Building upon the findings of this study, future research will evaluate W-SUDs in a randomized controlled trial with a more racially or ethnically diverse sample, balanced on sex and primary problematic substance of use; will employ greater strategies for study retention ; and will be conducted during a period with less restrictions on social contacts and physical mobility. Randomized controlled evaluations of conversational agent interventions relative to other treatment modalities are required. The COVID-19 pandemic, caused by the SARS-CoV-2 virus, took the world by surprise in early 2020 and resulted in unprecedented disruptions to normal life throughout the world as measures were put in place to control the spread of the deadly virus . Across North America, COVID-19 swept across the United States and Canada overwhelming health services and health infrastructure as cases exploded, hospitalizations exceeded capacity, and businesses and public programs like schools were forced to shut their doors, go online, or on hiatus . The physical and social impact was enormous – death rates grew exponentially and the healthcare system was pushed to exceed capacity in the face of enormous caseloads and a virus that spread rapidly . As schools, clinics, social venues, and otherwise non-essential businesses shut their doors, the most vulnerable in our society including those marginally housed, those experiencing substance use and/or those with mental health issues were even further marginalized as a result of lost services and support . Early in the pandemic, signs of increases in substance use raised concerns that substance use would skyrocket . Overdoses and particularly overdose deaths hit unprecedented levels and partially because of the reduced availability of emergency medical services .