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Novel strategies for initiation and continuation of buprenorphine are critical, especially during a pandemic when traditional opioid use disorder treatment pathways may be disrupted. We describe an innovative outpatient to inpatient reallocation initiative for extended-release buprenorphine (XR-BUP) designed to repurpose an expensive medication for use in hospitalized patients facing treatment barriers upon discharge and pilot the feasibility of XR-BUP use in the inpatient setting.We collaborated with our institution's inpatient pharmacy and a New Jersey Medicaid managed care organization to create an alternate pathway to make XR-BUP available to hospitalized patients insured by the same payor. In this process, XR-BUP doses were deidentified and transferred to the inpatient controlled substance inventory for administration to hospitalized patients at no charge by our Addiction Medicine Consult Service after a period of sublingual buprenorphine stabilization. Our reallocation pathway bypassed several existing XR-BUP regulatory barriers to allow for inpatient administration.To date, we have transferred approximately 85 XR-BUP 300 mg doses to the inpatient controlled substance inventory. This equates to a cost savings of nearly $145,000.Reallocation of XR-BUP from an outpatient to inpatient setting increased postdischarge buprenorphine treatment access while also reducing health care costs by repurposing an expensive medication that would otherwise go to waste. Use of reallocated XR-BUP in the inpatient setting may pave the way for addition of XR-BUP to the hospital's formulary to minimize treatment gaps after discharge.

Most studies reporting cardiac changes with exercise have been cross sectional. The few available longitudinal studies have lacked standardization for environmental confounders. We prospectively assessed the relationship between increasing exercise intensity and cardiac remodeling in a highly standardized cohort of healthy young army soldiers.Sixty-three male army recruits (22 ± 3 yr) underwent a 12-wk moderate-intensity mixed strength and endurance exercise program, followed by a further 15-wk high-intensity exercise program, with highly controlled exercise, diet, and sleep patterns. Fitness (multistage fitness test), anthropometry, and 2D echocardiography were assessed.Moderate-intensity exercise was associated with increased fitness and decreased body fat % (both P0.01). There was no significant incremental change in these parameters after high-intensity exercise. By contrast, both moderate- and high-intensity exercises were associated with dose-dependent increases in left atrial and left ventricular (LV) volumes, LV mass, and right ventricular (RV) size (all P0.01). At the end of high-intensity training, 51% had a dilated LV and 59% had a dilated RV compared with published normal ranges. Almost all had normal LV systolic function and strain before and after exercise training. A small number of soldiers had mildly decreased RV systolic function at baseline and after moderate-intensity exercise (3% and 6%, respectively).We describe "soldiers' heart," which is characterized by balanced chamber dilatation, normal LV mass, and largely normal systolic function and myocardial strain. This prospective and highly controlled longitudinal study also found that increasing intensity exercise was associated with increasing chamber dimensions, which paralleled an increase in fitness after moderate-intensity exercise. After high-intensity exercise, however, cardiac chamber size continued to increase, but fitness did not increase further.

To evaluate the efficacy and safety of utilizing emergency medical services units to administer high dose buprenorphine after an overdose to treat withdrawal symptoms, reduce repeat overdose, and provide a next-day substances use disorder clinic appointment to initiate long-term treatment.This was a retrospective matched cohort study of patients who experienced an overdose and either received emergency medical services care from a buprenorphine-equipped ambulance or a nonbuprenorphine-equipped ambulance in Camden, New Jersey, an urban community with high overdose rates. There were 117 cases and 123 control patients in the final sample.Compared with a nonbuprenorphine-equipped ambulance, exposure to a buprenorphine-equipped ambulance was associated with greater odds of engaging in opioid use disorder treatment within 30 days of an emergency medical services encounter (unadjusted odds ratio: 5.62, 95% confidence interval, 2.36 to 13.39). Buprenorphine-equipped ambulance engagement did not decrease repeat overdose compared to the comparison group. Patients who received buprenorphine experienced a decrease in withdrawal symptoms. Their clinical opiate withdrawal scale score decreased from an average of 9.27 to 3.16. buprenorphine-equipped ambulances increased on-scene time by 6.12 minutes.Patients who encountered paramedics trained to administer buprenorphine and able to arrange prompt substance use disorder treatment after an acute opioid overdose demonstrated a decrease in opioid withdrawal symptoms, an increase in outpatient addiction follow-up care, and showed no difference in repeat overdose. Patients receiving buprenorphine in the out-of-hospital setting did not experience precipitated withdrawal. Expanded out-of-hospital treatment of opiate use disorder is a promising model for rapid access to buprenorphine after an overdose in a patient population that often has limited contact with the health care system.

Large vessel occlusion (LVO) strokes are best treated with rapid endovascular therapy (EVT). There are two routes that LVO stroke patients can take to EVT therapy when transported by EMS: primary transport (ambulance transports directly to an endovascular stroke center (ESC) or secondary transport (EMS transports to a non-ESC then transfers for EVT). There is no clear evidence which path to care results in better functional outcomes for LVO stroke patients. To find this answer, an analysis of a large, real-world population of LVO stroke patients must be performed.A pragmatic registry of LVO stroke patients from nine health systems across the United States. The nine health systems span urban and rural populations as well as the spectrum of socioeconomic statuses. We will use univariate and multivariate analysis to explore the relationships between type of EMS transport, socioeconomic factors, and LVO stroke outcomes. We will use geographic information systems and spatial analysis to examine the complex movements of patients in time and space. To detect an 8% difference between groups, with a 3:1 patient ratio of primary to secondary transports, 95% confidence and 80% power, we will need approximately 1600 patients. The primary outcome is the patients with modified Rankin Scale (mRS) ≤ 2 at 90 days. Subgroup analyses include patients who receive intravenous thrombolysis and duration of stroke systems. Secondary analyses include socioeconomic factors associated with poor outcomes after LVO stroke.Using the data obtained from the OPUS-REACH registry, we will develop evidence based algorithms for prehospital transport of LVO stroke patients. Unlike prior research, the OPUS-REACH registry contains patient-level data spanning from EMS dispatch to ninety day functional outcomes. We expect that we will find modifiable factors and socioeconomic disparities associated with poor outcomes in LVO stroke. OPUS-REACH with its breadth of locations, detailed patient records, and multidisciplinary researchers will design the optimal prehospital stroke system of care for LVO stroke patients.

The Challenges Rural and remote Australians and New Zealanders have a higher rate of adverse outcomes due to acute myocardial infarction, driven by many factors. The prevalence of cardiovascular disease (CVD) is also higher in regional and remote populations, and people with known CVD have increased morbidity and mortality from coronavirus disease 2019 (COVID-19). In addition, COVID-19 is associated with serious cardiac manifestations, potentially placing additional demand on limited regional services at a time of diminished visiting metropolitan support with restricted travel. Inter-hospital transfer is currently challenging as receiving centres enact pandemic protocols, creating potential delays, and cardiovascular resources are diverted to increasing intensive care unit (ICU) and emergency department (ED) capacity. Regional and rural centres have limited staff resources, placing cardiac services at risk in the event of staff infection or quarantine during the pandemic. Main Recommendations Health districts, cardiologists and government agencies need to minimise impacts on the already vulnerable cardiovascular health of regional and remote Australians and New Zealanders throughout the COVID-19 pandemic. Changes in management should include: • Improved access to telehealth consultation for regional and rural outpatients. Specialist-led 24/7 electrocardiograph (ECG) reading and acute cardiology services, uniformly covering all rural inpatients, to minimise potential impacts on acute care. • Transfer models incorporating discussion between clinicians and ambulance, balancing urgency with considerations of ambulance capacity in rural locations. • Protection of the role of specialist cardiovascular nurses, avoiding COVID-19 redeployment to maintain rural cardiac service capacity. • An urgent shift to regional models for pacing services, utilising remote monitoring supported by local device implantation and local technicians.

Objective: We evaluated the use of the Simple Triage and Rapid Treatment (START) method by Emergency Medical Services (EMS) and hypothesized that EMS can categorize patients using the START algorithm accurately. Design: Retrospective Chart Review. Setting: Inner-city Tertiary-Care Institutional Emergency Department (ED). Participants: Patients ≥ 18 years transported by EMS with a START color of Red, Yellow, or Green during the state triage tag exercise, October 9-15, 2011. Interventions: EMS assigned each patient a START triage tag. Chart review of the electronic EMS run sheets was performed by investigators to determine a START color. Main Outcome Measures: START triage colors were re-categorized as Red = 1, Yellow = 2, and Green = 3. The difference between the investigators’ color and EMS color were coded as: 0 for agreement in triage, -1 for undertriage by one category, -2 for undertriage by two categories, 1 for overtriage by one category, 2 for overtriage by two categories. Results: Of 224 participants, START triage colors were: Red = 7.1 percent, Yellow = 19.2 percent, Green = 73.7 percent. The mean difference in triage categories was 0.228 (95% CI: 0.114-0.311, p

OBJECTIVE Patients receiving naloxone for suspected opioid overdose in the prehospital setting are typically transported to the emergency department (ED) for further evaluation, regardless of Glasgow Coma Scale (GCS). The objective of our study is to determine whether patients with GCS ≥14 after receiving prehospital naloxone received additional doses of naloxone and medical interventions in the ED compared with those with GCS

Objective: To compare Emergency Severity Index (ESI) triage levels and Simple Triage and Rapid Treatment (START) triage colors for urgent care and hospitalization. Design: Cross sectional. Setting: Inner city emergency department (ED). Participants: Patients years transported by Emergency Medical Services (EMS) participating in the state triage tag exercise, October 9-15, 2011. Interventions: EMS assigned each patient a START triage tag. ED staff recorded tag number and color. Demographics, vital signs, 22 emergent interventions, and disposition were obtained via chart review. Institutional review board approval was obtained. Main outcome measures: Presence of more than two abnormal vital sign on arrival and need for more than one emergent intervention in ED were considered indicators of acuity and severity. START triage colors were recategorized as urgent (Red, Yellow) and less acute (Green, White), and ESI was recategorized as urgent (1, 2, 3) and less acute (4, 5). Results: Both ED and EMS staff were blinded to the study, and 95% confidence intervals were presented for statistical significance. Of 233 participants, START triage colors were Black = 0, Red = 12 percent, Yellow = 26 percent, Green = 53 percent, and White = 9 percent. ESI triage levels were level 1 = 1 percent, level 2 = 34 percent, level 3 = 51 percent, level 4 = 14 percent, and level 5 = 1 percent. ESI (1, 2, 3) identified 88 percent (75-95 percent) of 49 patients with abnormal vital signs; START (Red, Yellow) only identified 51 percent (35-64 percent). Twenty-one patients needed emergent intervention. ESI (1, 2, 3) identified 95 percent (76-99 percent) of these patients; START (Red, Yellow) identified 33 percent (17-55 percent). ESI (1, 2, 3) identified 98 percent of the 96(92-100 percent) admitted patients; only 48 percent (38-58 percent) were tagged START (Red, Yellow). Conclusion: ESI better identified patients with abnormal vital signs, those who needed emergent interventions, and those admitted than START.