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Introduction: The role of gender in interprofessional interactions is poorly understood. This mixed-methods study explored perceptions of gender bias in interactions between emergency medicine (EM) residents and nurses. Methods: We analyzed qualitative interviews and focus groups with residents and nurses from two hospitals for dominant themes. An electronic survey, developed through an inductive-deductive approach informed by qualitative data, was administered to EM residents and nurses. Quantitative analyses included descriptive statistics and between-group comparisons. Results: Six nurses and 14 residents participated in interviews and focus groups. Key qualitative themes included gender differences in interprofessional communication, specific examples of, and responses to, gender bias. Female nurses perceived female residents as more approachable and collaborative than male residents, while female residents perceived nurses’ questions as doubting their clinical judgment. A total of 134 individuals (32%) completed the survey. Females more frequently perceived interprofessional gender bias (mean 30.9; 95% confidence interval {CI}, 25.6, 36.2; vs 17.6 [95% CI, 10.3, 24.9). Residents reported witnessing interprofessional gender bias more frequently than nurses (58.7 (95% CI, 48.6, 68.7 vs 23.9 (95% CI, 19.4, 28.4). Residents reported that gender bias affected job satisfaction (P = 0.002), patient care (P = 0.001), wellness (P = 0.003), burnout (P = 0.002), and self-doubt (P = 0.017) more frequently than nurses. Conclusion: Perceived interprofessional gender bias negatively impacts personal wellbeing and workplace satisfaction, particularly among female residents. Key institutional stakeholders including residency, nursing, and hospital leadership should invest the resources necessary to develop and integrate evidence-based strategies to improve interprofessional relationships that will ultimately enhance residency training, work climate, and patient care.

Health-related social needs (HRSNs), such as food or housing insecurity, are important drivers of disparities in outcomes during public health emergencies. We describe the development of a telehealth follow-up program in Boston, Massachusetts, for patients discharged from the emergency department after coronavirus disease 2019 (COVID-19) testing to identify patients with worsening clinical symptoms, to screen for unmet HRSNs, and to deliver self-isolation counseling and risk-reduction strategies for socially vulnerable people. We prioritized telephone calls to patients with public health insurance and patients without primary care physicians. In the first 43 days of operation, March 30–May 12, 2020, our intervention reached 509 patients, with 209 (41.1%) patients reporting an HRSN, most commonly related to food, housing, or utilities. Thirty-one (6.1%) patients required assessment by a clinician for clinical worsening. This public health intervention may be useful for other institutions developing programs to address the social and health needs of patients discharged with suspected COVID-19.

In response to an imminent surge in COVID-19 cases, the state of Massachusetts (MA) released its Crisis Standards of Care (CSC) guidelines in April 2020. A small group of Boston healthcare providers, community members, lawyers, ethicists and disability advocates brought to bear our collective strengths to forge a formidable coalition now known as the Massachusetts Coalition for Health Equity, to champion the rights of marginalised groups that would be adversely affected by the implementation of the original MA CSC guidelines. In this coalition, members of marginalised communities were adequately represented, led discussions on the implications of implementing inequitable elements of the CSC guidelines and actively involved in creating an alternative framework. In this article, we discuss the process of building a coalition whose concerted advocacy efforts led to the revision of the MA CSC guidelines.

The vast majority of studies on female sex workers (FSW) focus on causes of morbidity while data on causes of mortality are scarce. In low- and middle-income countries, where civil registry and vital statistics data are often incomplete and FSW may not be identified as such in official registries, identifying causes of mortality among FSW has proven challenging.As part of a larger investigation on the maternal health of FSW, the current study used the Community Knowledge Approach (CKA) to identify causes of mortality among FSW in LMIC across three global regions in 2019. The CKA, validated to identify maternal, neonatal, and jaundice-associated deaths among women living in a community, was employed to identify deaths of any cause among communities of FSW. Study participants, recruited by in-country partner non-governmental organizations (NGOs) working with local FSW, provided detailed information about FSW deaths in their communities.1280 FSW participated in 165 group meetings through which 2112 FSW deaths were identified. Of these reported deaths, 57·9% occurred in 2019 and 57·2% were among women aged 20-29. Causes of death included abortion (35·5%), other maternal causes (16·6%), suicide (13·6%), murder (12·5%), unclassified causes (11·6%), HIV/AIDS (7·9%), and accidents (3·2%). A total of 3659 children lost their mothers.Maternal death comprised the leading cause of FSW mortality in our sample. This methodology can be used by local governments and NGOs to identify unrecognized patterns and clusters of FSW deaths in near-real time and urgently steer targeted preventative strategies.New Venture Fund.

Background Research regarding disparities in physical restraint use in the emergency department (ED) is limited. We evaluated the role of race, ethnicity, and preferred language on the application of physical restraint among ED patients held under a Massachusetts section 12(a) order for mandatory psychiatric evaluation. Methods We identified all ED patient encounters with a section 12(a) order across a large integrated 11-hospital health system from January 2018 through December 2019. Information on age, race, ethnicity, preferred language, insurance, mental illness, substance use, history of homelessness, and in-network primary care provider was obtained from the electronic health record. We evaluated for differences in physical restraint use between subgroups via a mixed-effect logistic regression with random-intercept model. Results We identified 32,054 encounters involving a section 12(a) order. Physical restraints were used in 2,458 (7.7%) encounters. Factors associated with physical restraint included male sex (adjusted odds ratio [aOR] = 1.44, 95% confidence interval [CI] = 1.28 to 1.63), Black/African American race (aOR = 1.22, 95% CI = 1.01 to 1.48), Hispanic ethnicity (aOR = 1.45, 95% CI = 1.22 to 1.73), Medicaid insurance (aOR = 1.21, 95% CI = 1.05 to 1.39), and a diagnosis of bipolar disorder or psychotic disorder (aOR = 1.51, 95% CI = 1.31 to 1.74). Across all age groups, patients who were 25 to 34 years of age were at highest risk of restraint (aOR = 2.01, 95% CI = 1.69 to 2.39). Patients with a primary care provider within our network (aOR = 0.81, 95% CI = 0.72 to 0.92) were at lower risk of restraint. No associations were found between restraint use and language, history of alcohol or substance use, or homelessness. Conclusion Black/African American and Hispanic patients under an involuntary mandatory emergency psychiatric evaluation hold order experience higher rates of physical restraint in the ED. Factors contributing to racial disparities in the use of physical restraint, including the potential role of structural racism and other forms of bias, merits further investigation.

Background and aim Early diagnosis and treatment of intracerebral hemorrhage (ICH) is thought to be critical for improving outcomes. We examined whether racial or ethnic disparities exist in acute care processes in the first hours after ICH. Methods We performed a retrospective review of a prospectively collected cohort of consecutive patients with spontaneous primary ICH presenting to a single urban tertiary care center. Acute care processes studied included time to computerized tomography (CT) scan, time from CT to inpatient bed request, and time from bed request to hospital admission. Clinical outcomes included mortality, Glasgow Outcome Scale, and modified Rankin Scale. Results Four hundred fifty-nine patients presented with ICH between 2006 and 2018 and met inclusion criteria (55% male; 75% non-Hispanic White [NHW]; mean age of 73). In minutes, median time to CT was 43 (interquartile range [IQR] 28, 83), time to bed request was 62 (IQR 33, 114), and time to admission was 142 (IQR 95, 232). In a multivariable analysis controlling for demographic factors, clinical factors, and disease severity, race/ethnicity had no effect on acute care processes. English language, however, was independently associated with slower times to CT (β = 30.7 min, 95% CI 9.9 to 51.4, p = 0.004) and to bed request (β = 32.8 min, 95% CI 5.5 to 60.0, p = 0.02). Race/ethnicity and English language were not independently associated with worse outcome. Conclusions We found no evidence of racial/ethnic disparities in acute care processes or outcomes in ICH. English as first language, however, was associated with slower care processes.

Background Gender and racial disparities in academic medicine have recently garnered much attention. Implicit Association Tests (IATs) offer a validated means of evaluating unconscious associations and preferences. This study examines the perceived role of implicit bias in faculty development in academic emergency medicine (EM). Methods EM faculty at a large urban academic medical center were invited to independently participate in a self-reflection assessment in preparation for a faculty retreat session discussing diversity, equity, and inclusion. Participants completed two IATs designed to examine gender associations (gender IAT) and race preferences (race IAT) followed by a short anonymous survey where IAT scores were recorded. The survey also captured demographic information and perceptions about the impact of gender and racial biases in faculty development. Results Forty faculty members (66%) completed the survey; 70% were male and 80% white. The majority (59%) reported gender IAT results indicating automatic male-sciences and female-liberal arts associations. Nearly half (45%) reported race IAT results indicating an automatic preference for white people. More than 70% of males reported that faculty recruitment, development, and promotion decisions were 'never' or 'seldom' affected by gender bias, while more than 80% reported racial bias 'never' or 'seldom' affects these decisions. Female faculty more frequently perceived adverse effects of unconscious gender and race biases. Conclusion Our group of academic physicians reported IAT results showing different levels of implicit bias compared to the general population. Female faculty may be both more aware of and more susceptible to the adverse effects of unconscious biases. Further study is needed to determine both the extent to which unconscious biases affect the academic workplace, as well as ways in which such unintentional forms of discrimination can be eliminated. Unconscious biases are not unique to EM. Intentional efforts to increase self-awareness of these 'blind spots' may help mitigate their impact and foster a more diverse and inclusive healthcare environment.

The authors appreciate the comments of Dr. Corbin and his colleagues, as well as those of our colleagues suggesting our findings are "premature conclusions." A primary concern of our colleagues pertains to the limited number of confounders adjusted in our analyses. Indeed, while we were able to adjust for two of the variables noted (substance use and mental health diagnoses), we did not have the data available in this study to analyze potential effects of infection, neurovascular or metabolic complications, or trauma.

INTRODUCTION: Emergency clinicians on the frontline of the coronavirus pandemic experience a range of emotions including anxiety, fear, and grief. Debriefing can help clinicians process these emotions, but the coronavirus pandemic makes it difficult to create a physically and psychologically safe space in the emergency department (ED) to perform this intervention. In response, we piloted a video-based debriefing program to support emergency clinician well-being. We report the details of our program and results of our evaluation of its acceptability and perceived value to emergency clinicians during the pandemic. METHODS: ED attending physicians, resident physicians, and non-physician practitioners (NPP) at our quaternary-care academic medical center were invited to participate in role-based, weekly one-hour facilitated debriefings using Zoom. ED attendings with experience in debriefing led each session and used an explorative approach that focused on empathy and normalizing reactions. At the end of the pilot, we distributed to participants an anonymous 10-point survey that included multiple-answer questions and visual analogue scales. RESULTS: We completed 18 debriefings with 68 unique participants (29 attending physicians, 6 resident physicians, and 33 NPPs. A total of 76% of participants responded to our survey and 77% of respondents participated in at least two debriefings. Emergency clinicians reported that the most common reasons to participate in the debriefings were "to enhance my sense of community and connection" (81%) followed by "to support colleagues" (75%). Debriefing with members of the same role group (92%) and the Zoom platform (81%) were considered to be helpful aspects of the debriefing structure. Although emergency clinicians found these sessions to be useful (78.8 +/- 17.6) interquartile range: 73-89), NPPs were less comfortable speaking up (58.5 +/- 23.6) than attending physicians (77.8 +/- 25.0) (p = < 0.008). CONCLUSION: Emergency clinicians participating in a video-based debriefing program during the coronavirus pandemic found it to be an acceptable and useful approach to support emotional well-being. Our program provided participants with a platform to support each other and maintain a sense of community and connection. Other EDs should consider implementing a debriefing program to safeguard the emotional well-being of their emergency clinician workforce.

OBJECTIVE Race-based bias in health care occurs at organizational, structural, and clinical levels and impacts emergency medical care. Limited literature exists on the role of race on patient restraint in the emergency setting. This study sought to examine the role of race in physical restraint in an emergency department (ED) at a major academic medical center. METHODS Retrospective chart analysis was performed, querying all adult ED visits over a 2-year period (2016-2018) at Massachusetts General Hospital. The associations between race and restraint and selected covariates (sex, insurance, age, diagnosis, homelessness, violence) were analyzed. RESULTS Of the 195,092 unique ED visits by 120,469 individuals over the selected period, 2,658 (1.4%) involved application of a physical restraint by health care providers. There was a significant effect of race on restraint (p

The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) is the system used by clinicians and medical coders to document diseases, symptoms, social circumstances, and external causes of illness and injury. ICD-10-CM codes for various forms of abuse and violence perpetrated against children and adults exist and facilitate the study of incidence, social context, and comorbid illness and injury. Extant abuse codes, however, fail to capture the profoundly exploitative nature of trafficking and adequately distinguish trafficking patients from other types of abuse patients. As a result, the first trafficking-specific codes have been approved for the 2019 ICD-10-CM update and are expected to strengthen data collection on incidence of and risk factors for trafficking, the burden of comorbid illness and injury, and resources needed to effectively care for trafficked persons.

Because of a soaring number of opioid-related deaths during the past decade, opioid use disorder has become a prominent issue in both the scientific literature and lay press. Although most of the focus within the emergency medicine community has been on opioid prescribing-specifically, on reducing the incidence of opioid prescribing and examining alternative pain treatment-interest is heightening in identifying and managing patients with opioid use disorder in an effective and evidence-based manner. In this clinical review article, we examine current strategies for identifying patients with opioid use disorder, the treatment of patients with acute opioid withdrawal syndrome, approaches to medication-assisted therapy, and the transition of patients with opioid use disorder from the emergency department to outpatient services.

Trafficking of adults and children for both sex and labor is a human rights violation occurring with alarming frequency throughout the world, and resulting in profound harm to close-knit communities and severe health consequences for victims. Certain areas, such as the country of Paraguay, are at a higher risk for trafficking due to unique economic, cultural, and geographic factors. Thousands of people, especially children, are trafficked within Paraguay’s borders, and many eventually are transported to neighboring countries and sometimes to Europe and elsewhere. Using case study methodology and “city” as the unit of study, researchers interviewed 18 key anti-trafficking stakeholders from government and nongovernmental organizations in two major metropolitan centers for trafficking in Paraguay, Asunción, and Encarnación. Through semistructured interviews, this qualitative study examines risk factors for trafficking, health outcomes, interventions needed within the health care sector, and programs needed to combat trafficking. We identified risk factors including poverty, marginalization of indigenous people, gender inequality, domestic servitude of children (criadazgo), and political hesitance to enact protective legislation. Victims of trafficking were reported to suffer from physical injuries, unintended pregnancies, sexually transmitted infections, and mental health issues such as depression and posttraumatic stress disorder. These predispose victims to difficulties reintegrating into their communities and ultimately to retrafficking. A major gap was identified in the lack of sufficient lodging and rehabilitation services for rescued victims, affordable access to trauma-sensitive health care for victims, and scarce mental health services. Many of the findings are applicable across the world and may be of use to guide future anti-trafficking efforts in Paraguay and beyond.

A Man with Episodes of Confusion and Hypoglycemia A 36-year-old man presented with episodes of altered mental status that had increased in frequency over 6 years. The episodes typically occurred at...

Human trafficking, also known as modern-day slavery, is an egregious human rights violation associated with wide-ranging medical and mental health consequences. Because of the extensive health problems related to trafficking, health care providers play a critical role in identifying survivors and engaging them in ongoing care. Although guidelines for recognizing affected patients and a framework for developing response protocols in health care settings have been described, survivors' ongoing engagement in health care services is very challenging. High rates of disengagement, lost contact, premature termination, and attrition are common outcomes. For interventions to be effective in this marginalized population, challenges in engaging survivors in long-term therapeutic primary and mental health care must be better understood and overcome. This article uses the socioecological model of public health to identify barriers to engagement; offers evidence- and practice-based recommendations for overcoming these barriers; and proposes an interdisciplinary call to action for developing more flexible, adaptable models of care.

It is estimated that 21 million people are trafficked worldwide, including 11.4 million women and girls. Approximately 4.5 million are forced to do sexual labor. The exact prevalence of human trafficking is difficult to ascertain, however, given the limitations of data collection in an illegal industry. Obstetrician-gynecologists should not only be aware of the widespread nature of human trafficking, but also have the tools to assess patients for trafficking and respond to victim identifications. Patients may present with signs of physical abuse, depression, anxiety, posttraumatic stress disorder, substance use, sexually transmitted infections, pregnancy, and nonspecific somatic complaints. As with intimate partner violence, clinicians should be suspicious if the patient is accompanied by an individual who refuses to leave her side. Other potential red flags include patients with wounds in various stages of healing, patients appearing fearful or unable to answer specific questions, and patients who do not have any personal identification. Health care providers should speak with the patient privately, using professional interpreters when indicated. Although there are no validated screening questions for the health care setting, in this article, we provide sample questions such as, "Is anyone forcing you to do anything physically or sexually that you do not want to do?" The physical examination should be thorough with appropriate workup, sexually transmitted infection prophylaxis, and emergency contraception. Physicians and patients should be aware of their state's mandatory reporting requirements and careful documentation is essential. Finally, to ensure a comprehensive, interdisciplinary response to trafficked patients, practitioners should engage hospital-based and community-based services when appropriate.

Human trafficking is an egregious human rights violation with profound negative physical and psychological consequences, including communicable diseases, substance use disorders, and mental illnesses. The health needs of this population are multiple, complex, and influenced by past and present experiences of abuse, neglect, and exploitation. Effective health care services for trafficked patients require clinicians to consider individual patients' needs, wishes, goals, priorities, risks, and vulnerabilities as well as public health implications and even resource allocation. Applying the bioethical principles of respect for autonomy, nonmaleficence, beneficence, and justice, this article considers the ethics of care model as a trauma-informed framework for providing health care to human trafficking victims and survivors.

Human trafficking is associated with a profound burden of physical and psychological trauma. Survivors of trafficking interact with the health care system during and after their experiences of trafficking. Socioeconomic isolation, stigma, shame, guilt, fear of judgment, fear of retribution by traffickers, fear of law enforcement authorities, and other factors known to inhibit disclosure can exert a formative influence on survivors’ health care experiences, health care access, and health services engagement. Using a mixed qualitative-quantitative social science research method, known as by-person factor analysis (or Q-methodology), the current analysis systematically examines the scope of trafficking survivors’ health care experiences and perceptions of medical care, health care access behaviors, and degree of engagement with health services. Among 33 survivors of human trafficking surveyed, 21 met inclusion criteria for this analysis. Three distinct profiles of survivor health care experiences and health services engagement— Avoidant, Distrustful, and Constrained—are identified from the aggregate of survivors’ perceptions of medical care. Although there are salient differences across the three survivor profiles, a feeling of disenfranchisement is a common thread and directly related to health care access behaviors and health services engagement. Understanding that the feeling of disenfranchisement functions as a filter through which trafficking survivors perceive and experience medical care can help health care professionals take appropriate countermeasures. Implications for improving health care access and engagement include the implementation of trauma-responsive, culturally sensitive, and survivor-centered care practices.

Injection drug use is a major public health problem in the United States. Cocaine, heroin, and methamphetamine are the most commonly injected illicit drugs, whereas opioids are responsible for the majority of overdose fatalities. Although recent emergency department (ED) efforts have focused on expanding capacity for buprenorphine induction for opioid use disorder treatment, the injection of illicit drugs carries specific health risks that require acknowledgment and management, particularly for patients who decline substance use treatment. Harm reduction is a public health approach that aims to reduce the harms associated with a health risk behavior, short of eliminating the behavior itself. Harm-reduction strategies fundamental to emergency medicine include naloxone distribution for opioid overdose. This clinical Review Article examines the specific health complications of injection drug use and reviews the evidence base for 2 interventions effective in reducing morbidity and mortality related to drug injection, irrespective of the specific drug used, that are less well known and infrequently leveraged by emergency medicine clinicians: syringe service programs and supervised injection facilities. In accordance with the recommendations of health authorities such as the Centers for Disease Control and Prevention, emergency clinicians can promote the use of harm-reduction programs in the community to reduce viral transmission and other risks of injection drug use by providing patients with information about and referrals to these programs after injection drug use–related ED visits.

Background Lead toxicity from retained bullet fragments is difficult to both predict and diagnose, but important to treat early, given the potential severity of disease. Blood lead levels > 25 μg/dL and 40 μg/dL are considered toxic in children and adults, respectively. Symptoms may range from nonspecific constitutional symptoms to seizures and coma. Chelation is the mainstay therapy for lead poisoning and levels to treat depend on patient age, blood lead levels, and the presence of symptoms. Case Report We present the case of a woman with symptoms of severe lead toxicity from 20-year-old retained bullet fragments. She had been seen by multiple providers for evaluation of each symptom, but a unifying diagnosis had not been found. After identifying this complication, she was treated appropriately and more serious complications were prevented. Why Should an Emergency Physician Be Aware of This? We present this case to increase awareness among emergency physicians of lead toxicity in patients with a seemingly unrelated constellation of symptoms and a history of a previous gunshot wound with retained bullet or bullet fragments.

Emergency clinicians are on the frontlines of identifying and caring for trafficked persons. However, most emergency providers have never received training on trafficking, and studies report a significant knowledge gap involving this important topic. Workshops often employ a “train‐the‐trainer” model to address clinicians’ knowledge gaps involving various topics (including trafficking). By offering participants knowledge and skills needed to both understand relevant content and teach this content to future learners, this model aims at promoting widespread dissemination of essential information. However, current train‐the‐trainer workshops typically involve full or multiday sessions and employ multimodal instructional techniques, making them time and resource intensive for both participants and facilitators. To address these challenges, we created a 50‐minute train‐the‐trainer workshop to teach emergency clinicians the knowledge and skills needed to recognize and care for trafficked patients while providing instructional techniques to teach learners this content in the clinical environment. Learning theory and principles informed the choice of instructional methods and were employed when designing the paper‐based learning guides that functioned as this intervention's primary instructional resource. Guides contained detailed scripts used to perform role‐playing exercises. These “scripted guides” were designed for participants to learn important content while simultaneously practicing techniques to teach this content to one another. They provided the scaffolding necessary to independently direct learning during the workshop (with minimal facilitator intervention), while also being carefully formatted and organized to create an accessible tool for future use during clinical teaching. The session was implemented at the 2018 Society for Academic Emergency Medicine Annual Meeting in Indianapolis, Indiana. Based on participants’ self‐assessment using a retrospective pre–post test, the workshop was successful in creating a train‐the‐trainer model that is brief, requiring minimal facilitator resources and offers instruction on both content knowledge and instructional methods to disseminate this knowledge to future learners.

Trafficking survivors most commonly cite the emergency department (ED) as their health care access point while previously trafficked. A majority of trafficking survivors surveyed report accessing medical care at least once while trafficked. ED physicians should adhere to guiding principles of care, keeping in mind at all times the need for patient privacy and the use of paced evaluations and neutral language. It is incumbent upon ED physicians to recognize both the clinician-related barriers to helping trafficked patients (which may include an underappreciation of the relevance of trafficking to clinical practice and a lack of education and training) and patient-related barriers (which range from restriction and confinement by their abuser to the patient’s own shame, guilt, and self-blame; distrust of authorities; and fear). Once the trafficked patient presents to the ED, the physician should acknowledge that the identification of at-risk and trafficked patients can be the first step toward prevention and assistance, respectively. No singular or defined set of diagnostic signs or symptoms has been shown to cut across all forms of trafficking with any degree of sensitivity or specificity, but familiarity with the potential indicators of human trafficking can help the emergency provider recognize patterns and raise the suspicion of trafficking. If a clinician suspects that a patient might be trafficked, the clinician should engage the patient in a trauma-informed and culturally sensitive assessment. This review contains 2 tables and 34 references Key words: commercial sexual exploitation, debt bondage, domestic servitude, forced labor, forced substance use, HIV, modern-day slavery, neutral language, patient privacy, posttraumatic stress disorder, trafficking in persons

Emergency department (ED) physicians must familiarize themselves with all mandatory reporting laws that apply to those whom they suspect of being the victims of human trafficking. Furthermore, ED physicians must be aware of when to require a forensic evaluation and when to enlist social services to help with the process of documentation, keeping in mind the medical, legal, and safety considerations of the patient. Subspecialty consultation should proceed in accordance with typical practice. Following the identification of a trafficked patient, a comprehensive interdisciplinary response should ensue: in addition to social workers, other hospital-based health professionals whose knowledge and skills may be needed include addiction service providers, child protection specialists, forensic and sexual assault nurse examiners, mental health providers, case managers, hospital legal counsel, and risk management specialists. Despite ED physician and related professional intervention, little is known regarding the outcomes of human trafficking. This review contains 1 figure, 3 tables and 13 references Key words: forensic evaluation, mandatory reporting laws, medical record documentation, neutral language, reported human trafficking, suspected human trafficking, trafficking in persons

Trafficking in persons, or human trafficking, is the obtaining of persons by force, fraud, coercion, or other improper means, with the intention of exploiting them for financial gain. According to the US Department of State, the more prominent global forms of human trafficking include forced labor, bonded labor (or debt bondage), forced commercial sexual exploitation (or sex trafficking), involuntary domestic servitude, forced child labor, child sex trafficking, child soldiering, and organ trafficking. In the United States, the forced exploitation of persons in the labor industry (i.e., labor trafficking) and in the commercial sex industry (i.e., sex trafficking) account for the majority of human trafficking cases recognized, reported, investigated, and prosecuted. Women and girls account for 55% (11.4 million) of the global trafficked population, whereas men and boys comprise the difference. Three quarters of trafficked persons are adults, whereas children younger than 18 years represent 26% (5.5 million) of victims. Risk factors that have been associated with increased risk of human trafficking include but are not limited to a childhood history of abuse and neglect; financial insecurity; housing instability associated with homelessness, running away, or being thrown out of the home; kinship placements with distant family members, foster care, and other residential placements; intellectual and learning disabilities; identification as lesbian, gay, bisexual, transgender, and questioning (LGBTQ); racial and ethnic minority status; status as an immigrant, migrant worker, and refugee; and involvement in gangs or illicit substance use. Due to the inherently abusive and violent nature of this crime, human trafficking has profound negative implications for the health and well-being of affected persons. This review contains 2 figures, 4 tables and 53 references Key words: commercial sexual exploitation, debt bondage, domestic servitude, forced labor, forced substance use, HIV, modern-day slavery, posttraumatic stress disorder, trafficking in persons

Human trafficking is an egregious human rights violation with significant impact on the physical, mental, and social health and well-being of individuals, communities, and society. While myriad factors affect the nature of the exploitation and its unique health risks and exposures, the adverse health outcomes of human trafficking are ubiquitous and often long-lasting. This chapter offers a review of the literature on the physical health effects of sex trafficking, labor trafficking, and trafficking for the removal of organs. Variations in the health effects of human trafficking that are mediated by geography and by the stage of trafficking are discussed. Finally, recommendations are made for improving the health sector’s ability to effectively respond to the medical needs of trafficked persons and survivors who present for medical care.

Introduction: Alcohol use disorders (AUD) place a significant burden on individuals and society. Theemergency department (ED) offers a unique opportunity to address AUD with brief screening tools andearly intervention. We undertook a systematic review of the effectiveness of ED brief interventions forpatients identified through screening who are at risk for AUD, and the effectiveness of these interventionsat reducing alcohol intake and preventing alcohol-related injuries. Methods: We conducted systematic electronic database searches to include randomized controlled trialsof AUD screening, brief intervention, referral, and treatment (SBIRT), from January 1966 to April 2016. Twoauthors graded and abstracted data from each included paper. Results: We found 35 articles that had direct relevance to the ED with enrolled patients ranging from12 to 70 years of age. Multiple alcohol screening tools were used to identify patients at risk for AUD.Brief intervention (BI) and brief motivational intervention (BMI) strategies were compared to a controlintervention or usual care. Thirteen studies enrolling a total of 5,261 participants reported significantdifferences between control and intervention groups in their main alcohol-outcome criteria of number ofdrink days and number of units per drink day. Sixteen studies showed a reduction of alcohol consumptionin both the control and intervention groups; of those, seven studies did not identify a significant interventioneffect for the main outcome criteria, but nine observed some significant differences between BI and controlconditions for specific subgroups (i.e., adolescents and adolescents with prior history of drinking anddriving; women 22 years old or younger; low or moderate drinkers); or secondary outcome criteria (e.g.reduction in driving while intoxicated). Conclusion: Moderate-quality evidence of targeted use of BI/BMI in the ED showed a small reduction inalcohol use in low or moderate drinkers, a reduction in the negative consequences of use (such as injury),and a decline in ED repeat visits for adults and children 12 years of age and older. BI delivered in the EDappears to have a short-term effect in reducing at-risk drinking.

Context Human trafficking is an increasingly well-recognized human rights violation that is estimated to involve more than 2 million victims worldwide each year. The health consequences of this issue bring victims into contact with health systems and healthcare providers, thus providing the potential for identification and intervention. A robust healthcare response, however, requires a healthcare workforce that is aware of the health impact of this issue; educated about how to identify and treat affected individuals in a compassionate, culturally aware, and trauma-informed manner; and trained about how to collaborate efficiently with law enforcement, case management, and advocacy partners. This article describes existing educational offerings about human trafficking designed for a healthcare audience and makes recommendations for further curriculum development. Evidence acquisition A keyword search and structured analysis of peer-reviewed and gray literature, conducted in 2011 and 2012, yielded 27 items that provide basic guidance to health professionals on human trafficking. Evidence synthesis The 27 resources differed substantially in format, length, scope, and intended audience. Topic areas covered by these resources included trafficking definitions and scope, health consequences, victim identification, appropriate treatment, referral to services, legal issues, and security. None of the educational resources has been rigorously evaluated. Conclusions There is a clear need to develop, implement, and evaluate high-quality education and training programs that focus on human trafficking for healthcare providers.

Human trafficking, a form of modern slavery, is an egregious violation of human rights with profound personal and public health implications. It includes forced labor and sexual exploitation of both U.S. and non-U.S. citizens and has been reported in all 50 states. Victims of human trafficking are currently among the most abused and disenfranchised persons in society, and they face a wide range of negative health outcomes resulting from their subjugation and exploitation. Medicine has an important role to play in mitigating the devastating effects of human trafficking on individuals and society. Victims are cared for in emergency departments, primary care offices, urgent care centers, community health clinics, and reproductive health clinics. In addition, they are unknowingly being treated in hospital inpatient units. Injuries and illnesses requiring medical attention thus represent unique windows of opportunity for trafficked persons to receive assistance from trusted health care professionals. With education and training, health care providers can recognize signs and symptoms of trafficking, provide trauma-informed care to this vulnerable population, and respond to exploited persons who are interested and ready to receive assistance. Multidisciplinary response protocols, research, and policy advocacy can enhance the impact of antitrafficking health care efforts to interrupt the cycle of abuse and violence for these victims.

Human trafficking is a form of modern day slavery. Globally, an estimated 20.9 million persons are exploited for their labor in a multitude of industries, including the commercial sex industry. In the United States, the prevalence of human trafficking is unknown and published figures vary widely based on definitional criteria and data sources used. This chapter focuses specifically on the commercial sexual exploitation and sex trafficking of minors in the United States. Minors under the age of 18 years account for one of the groups most vulnerable to exploitation in the commercial sex industry. In the United States, 100,000–300,000 minors are at risk for commercial sexual exploitation each year. Minors who have experienced complex trauma in their childhood are particularly vulnerable to these forms of polyvictimization. Their complex traumatic experiences as young children not only elevate their risk for re-victimization through commercial sexual exploitation and sex trafficking but also give rise to a destructive cycle of stigmatization that permeates their lives before, during, and well beyond their exploitation. The short- and long-term physical and mental health effects of commercial sexual exploitation and sex trafficking are profound, and the cumulative effects of complex trauma and stigma place victims and survivors at a disadvantage in a number of health metrics. Trafficked minors are challenged by unfavorable social determinants of health, high-risk health behaviors, poor health outcomes, numerous barriers to health care, and retraumatization in the health care setting. Indeed, sex trafficking of minors is thought to be the most underreported form of child abuse. Through education and training, health care providers who are knowledgeable about the experiences of trafficked minors and trained to provide trauma-informed care can help break the cycle of trauma and stigmatization, lessen health care disparities, and contribute to their healing and recovery.

Background West Nile virus (WNV) has spread rapidly across the United States since 1999, causing epidemics of neurologic illnesses including meningitis, encephalitis, and acute flaccid paralysis. West Nile encephalitis can be fatal; recovery can be incomplete; and constitutional and neurological symptoms can persist for months to years. Objectives To raise awareness of an important epidemiologic cause of febrile illness with neurologic involvement in the United States. Case Report We report the case of a 46-year-old woman who presented with fever, altered mental status, and maculopapular rash, who was diagnosed with locally acquired WNV encephalitis. Conclusion Infection with WNV should be considered in patients presenting to emergency departments with fever and neurologic symptoms. Recommended evaluation includes serologic testing of cerebrospinal fluid and serum.

This chapter describes the nexus of urbanization, human trafficking, and public health and identifies promising innovations to address global human trafficking. First, we briefly describe why human trafficking is an urban health concern. Second, we provide a brief overview of the social determinants of human trafficking. Third, we highlight innovative anti-trafficking efforts, including public awareness campaigns, vocational training, community education, and victim identification and support initiatives. Finally, we summarize the implications of these anti-trafficking interventions on urbanization and global health.

Study objective Drug-related emergency department (ED) visits have steadily increased, with substance users relying heavily on the ED for medical care. The present study aims to identify clinical correlates of problematic drug use that would facilitate identification of ED patients in need of substance use treatment. Methods Using previously validated tests, 15,224 adult ED patients across 6 academic institutions were prescreened for drug use as part of a large randomized prospective trial. Data for 3,240 participants who reported drug use in the past 30 days were included. Self-reported variables related to demographics, substance use, and ED visit were examined to determine their correlative value for problematic drug use. Results Of the 3,240 patients, 2,084 (64.3%) met criteria for problematic drug use (Drug Abuse Screening Test score ≥3). Age greater than or equal to 30 years, tobacco smoking, daily or binge alcohol drinking, daily drug use, primary noncannabis drug use, resource-intense ED triage level, and perceived drug-relatedness of ED visit were highly correlated with problematic drug use. Among primary cannabis users, correlates of problematic drug use were age younger than 30 years, tobacco smoking, binge drinking, daily drug use, and perceived relatedness of the ED visit to drug use. Conclusion Clinical correlates of drug use problems may assist the identification of ED patients who would benefit from comprehensive screening, intervention, and referral to treatment. A clinical decision rule is proposed. The correlation between problematic drug use and resource-intense ED triage levels suggests that ED-based efforts to reduce the unmet need for substance use treatment may help decrease overall health care costs.

Sex trafficking, trafficking for the purpose of forced sexual exploitation, is a widespread form of human trafficking that occurs in all regions of the world, affects mostly women and girls, and has far-reaching health implications. Studies suggest that up to 50 % of sex trafficking victims in the USA seek medical attention while in their trafficking situation, yet it is unclear how the healthcare system responds to the needs of victims of sex trafficking. To understand the intersection of sex trafficking and public health, we performed in-depth qualitative interviews among 277 antitrafficking stakeholders across eight metropolitan areas in five countries to examine the local context of sex trafficking. We sought to gain a new perspective on this form of gender-based violence from those who have a unique vantage point and intimate knowledge of push-and-pull factors, victim health needs, current available resources and practices in the health system, and barriers to care. Through comparative analysis across these contexts, we found that multiple sociocultural and economic factors facilitate sex trafficking, including child sexual abuse, the objectification of women and girls, and lack of income. Although there are numerous physical and psychological health problems associated with sex trafficking, health services for victims are patchy and poorly coordinated, particularly in the realm of mental health. Various factors function as barriers to a greater health response, including low awareness of sex trafficking and attitudinal biases among health workers. A more comprehensive and coordinated health system response to sex trafficking may help alleviate its devastating effects on vulnerable women and girls. There are numerous opportunities for local health systems to engage in antitrafficking efforts while partnering across sectors with relevant stakeholders.