Implementing a Novel Statewide Network to Support Emergency Department-initiated Buprenorphine Treatment

Introduction: Medications for opioid use disorder (MOUD), including buprenorphine, represent an evidence-based treatment that supports long-term recovery and reduces risk of overdose death. Patients in crisis from opioid use disorder (OUD) often seek care from emergency departments (ED). The New York Medication for Addiction Treatment and Electronic Referrals (MATTERS) network is designed to support ED-initiated buprenorphine and urgent referrals to long-term care for patients suffering from OUD.Methods: Using the PRECEDE-PROCEED implementation science framework, we provide an overview of the creation of the MATTERS network in Western New York. We also include an explanation of how the network was designed and launched as a response to the opioid epidemic. Finally, we analyzed the program’s outputs and outcomes, thus far, as it continues to grow across the state.Results: The New York MATTERS network was created and implemented in 2019 with a single hospital referring patients with OUD to three local clinics. In the social assessment and situational analysis phase, we describe the opioid epidemic and available resources in the region at the outset of the program. In the epidemiological assessment phase, we quantify the epidemic on the state and regional levels. In the educational and ecological assessment, we review local ED practices and resources. In the administrative and policy assessment and intervention alignment phase, the program’s unique framework is reviewed. In the piloting phase, we describe the initial deployment of New York MATTERS. Finally, in the process evaluation phase, we depict the early lessons we learned. By the beginning of 2021, the New York MATTERS network included 35 hospitals that refer to 47 clinics throughout New York State.Conclusion: The New York MATTERS network provides a structured approach to reduce barriers to ED-initiated buprenorphine and urgent referral to long-term care. An implementation framework provides a structured means of evaluating this best practice model

Deep Learning for Video-Based Assessment of Endotracheal Intubation Skills

Endotracheal intubation (ETI) is an emergency procedure performed in civilian and combat casualty care settings to establish an airway. Objective and automated assessment of ETI skills is essential for the training and certification of healthcare providers. However, the current approach is based on manual feedback by an expert, which is subjective, time- and resource-intensive, and is prone to poor inter-rater reliability and halo effects. This work proposes a framework to evaluate ETI skills using single and multi-view videos. The framework consists of two stages. First, a 2D convolutional autoencoder (AE) and a pre-trained self-supervision network extract features from videos. Second, a 1D convolutional enhanced with a cross-view attention module takes the features from the AE as input and outputs predictions for skill evaluation. The ETI datasets were collected in two phases. In the first phase, ETI is performed by two subject cohorts: Experts and Novices. In the second phase, novice subjects perform ETI under time pressure, and the outcome is either Successful or Unsuccessful. A third dataset of videos from a single head-mounted camera for Experts and Novices is also analyzed. The study achieved an accuracy of 100% in identifying Expert/Novice trials in the initial phase. In the second phase, the model showed 85% accuracy in classifying Successful/Unsuccessful procedures. Using head-mounted cameras alone, the model showed a 96% accuracy on Expert and Novice classification while maintaining an accuracy of 85% on classifying successful and unsuccessful. In addition, GradCAMs are presented to explain the differences between Expert and Novice behavior and Successful and Unsuccessful trials. The approach offers a reliable and objective method for automated assessment of ETI skills

A pilot study on physiological indicators of expertise in pre-hospital emergency medical services (EMS) providers during endotracheal intubation

BackgroundPrehospital intubation is a high risk, low frequency skill. Manikin intubations, the most common means of evaluating providers’ competency, may be insufficient to predict procedural success.ObjectiveThe objective of this pilot study was to explore whether physiological measures, including gaze behavior, pupil response, and cortical activation, differed between groups of pre-hospital emergency medical services (EMS) providers during simulated endotracheal intubation.MethodsFifteen certified paramedics (expert clinicians) and fifteen Advanced Emergency Medical Technicians (intermediate clinicians) participated in this pilot study. Each participant performed three intubations on a standard airway manikin. During the intubations, pupillometry and gaze data were collected using eye tracking glasses and brain activation using functional near infrared spectroscopy (fNIRS). Groups were compared based on the eye tracking and neuroimaging metrics.ResultsTwenty-seven out of 30 participants successfully intubated the manikin across all repetitions, and expert clinicians finished the task on average 11.6s faster than intermediate clinicians. Experts spent less task time in gaze fixation (39.8 % vs. 55.2 %, p = 0.03). Peaks in pupil diameter during the task most often occurred during the sub-task of inserting the tube in the trachea (76% of the time). Neuroimaging results revealed significant group-level differences in the left supramarginal gyrus.ConclusionThis study explored physiological responses during simulated intubation by pre-hospital emergency medicine providers. While some group-level differences were observed in gaze behavior and brain activation, these findings were not sufficient to differentiate expertise. Further research is needed to better understand how physiological responses may reflect task demands in clinical settings

Limiting Albuterol Use by EMS at the Start of the COVID-19 Pandemic: A Retrospective Analysis of Rapid Deimplementation

Introduction: Deimplementation is the process through which an existing practice, procedure, or protocol is discontinued. Past deimplementation efforts in emergency medical services (EMS), such as reduction of liberal oxygen administration, backboard use, and lights and sirens responses, have been slow in rates of change and had varying levels of adoption. Our objective in this study was to analyze the deimplementation of albuterol administration in the beginning of the 2019 novel coronavirus (COVID-19) pandemic for the adoption of deimplementation guidelines, rate of change, and factors leading to this change in EMS practice. Methods: Using the 2020 National Emergency Medical Services Information System (NEMSIS) dataset, we analyzed the change in EMS calls with albuterol administration following the US Centers for Disease Control and Prevention (CDC) advisory recommending limiting aerosol-generating procedures in response to the COVID-19 pandemic. Results: The 2020 NEMSIS dataset included 43,488,767 total records, and 449,290 (1.0%) records included at least one albuterol administration. Calls with albuterol administration dropped 61.7% in a near-linear fashion in the six weeks following the publication of the CDC’s guidance (from March 8–April 18, 10,426 absolute reduction; from 16,891 to 6,465, in average calls per week with albuterol administration). In the period before the guidance, there were on average 16,891 calls with albuterol administration of 640,597 (2.6%) calls per week. In the period after the guidance, there were, on average, 6,465 calls with albuterol administration of 601,943 (1.1%) calls per week. Therefore, while total EMS calls declined by 6% during the transition period, the proportion of albuterol calls within this decline went down by 1.5% (2.6% to 1.1%), reflecting rapid deimplementation. Conclusion: Deimplementation of albuterol administration in the beginning of the COVID-19 pandemic was significant in its rate and success in adherence to guidelines when compared to other changes in EMS policies, procedures, and protocols. A better understanding of deimplementation can guide future EMS efforts to phase out ineffective practices while minimizing disruption to care

2021 Interim Guidance to Health Care Providers for Basic and Advanced Cardiac Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19

In April 2020, the American Heart Association (AHA) Emergency Cardiovascular Care (ECC) Committee and Get With The Guidelines-Resuscitation Adult and Pediatric Task Forces published their Interim Guidance for Basic and Advanced Cardiac Life Support in Adults, Children, and Neonates With Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) at the start of the SARS-CoV-2 pandemic. In October 2020, the AHA published new cardiopulmonary resuscitation (CPR) guidelines with the latest evidence-based algorithms and recommendations for Basic Life Support, Advanced Cardiac Life Support, Pediatric Advanced Life Support, Neonatal Advanced Life Support, and Maternal Cardiac Arrest Resuscitation

Sex differences in oncogenic mutational processes.

Sex differences have been observed in multiple facets of cancer epidemiology, treatment and biology, and in most cancers outside the sex organs. Efforts to link these clinical differences to specific molecular features have focused on somatic mutations within the coding regions of the genome. Here we report a pan-cancer analysis of sex differences in whole genomes of 1983 tumours of 28 subtypes as part of the ICGC/TCGA Pan-Cancer Analysis of Whole Genomes (PCAWG) Consortium. We both confirm the results of exome studies, and also uncover previously undescribed sex differences. These include sex-biases in coding and non-coding cancer drivers, mutation prevalence and strikingly, in mutational signatures related to underlying mutational processes. These results underline the pervasiveness of molecular sex differences and strengthen the call for increased consideration of sex in molecular cancer research

Retrospective evaluation of whole exome and genome mutation calls in 746 cancer samples

Funder: NCI U24CA211006Abstract: The Cancer Genome Atlas (TCGA) and International Cancer Genome Consortium (ICGC) curated consensus somatic mutation calls using whole exome sequencing (WES) and whole genome sequencing (WGS), respectively. Here, as part of the ICGC/TCGA Pan-Cancer Analysis of Whole Genomes (PCAWG) Consortium, which aggregated whole genome sequencing data from 2,658 cancers across 38 tumour types, we compare WES and WGS side-by-side from 746 TCGA samples, finding that ~80% of mutations overlap in covered exonic regions. We estimate that low variant allele fraction (VAF < 15%) and clonal heterogeneity contribute up to 68% of private WGS mutations and 71% of private WES mutations. We observe that ~30% of private WGS mutations trace to mutations identified by a single variant caller in WES consensus efforts. WGS captures both ~50% more variation in exonic regions and un-observed mutations in loci with variable GC-content. Together, our analysis highlights technological divergences between two reproducible somatic variant detection efforts