Mark Foran

mHealth in sub-Saharan Africa

Mobile phone penetration rates have reached 63% in sub-Saharan Africa (SSA) and are projected to pass 70% by 2013. In SSA, millions of people who never used traditional landlines now use mobile phones on a regular basis. Mobile health, or mHealth, is the utilization of short messaging service (SMS), wireless data transmission, voice calling, and smartphone applications to transmit health-related information or direct care. This systematic review analyzes and summarizes key articles from the current body of peer-reviewed literature on PubMed on the topic of mHealth in SSA. Studies included in the review demonstrate that mHealth can improve and reduce the cost of patient monitoring, medication adherence, and healthcare worker communication, especially in rural areas. mHealth has also shown initial promise in emergency and disaster response, helping standardize, store, analyze, and share patient information. Challenges for mHealth implementation in SSA include operating costs, knowledge, infrastructure, and policy among many others. Further studies of the effectiveness of mHealth interventions are being hindered by similar factors as well as a lack of standardization in study design. Overall, the current evidence is not strong enough to warrant large-scale implementation of existing mHealth interventions in SSA, but rapid progress of both infrastructure and mHealth-related research in the region could justify scale-up of the most promising programs in the near future.

Intravenous lipid emulsion in the emergency department: A systematic review of recent literature

BACKGROUND Intravenous lipid emulsion (ILE) has been broadly attempted in the resuscitation of neurologic and cardiac toxic drug overdoses, however, the role of ILE in the emergency department is poorly defined. OBJECTIVE This review aims to identify recent literature on the use of ILE in humans as an antidote and to familiarize emergency providers with the indications, availability, dosing recommendations, and adverse reactions associated with ILE use. METHODS A systemic literature search of MEDLINE, EMBASE, and major toxicology conference abstracts was performed for human cases using ILE as an antidote with documented clinical outcomes through January 2014. RESULTS Ninety-four published articles and 40 conference abstracts were identified, 85% of which had positive outcomes. The most common indication for ILE was for local anesthetic systemic toxicity (LAST). The most common nonlocal anesthetic xenobiotics were tricyclic-antidepressants and verapamil. DISCUSSION No standard of care is defined for the use of ILE, although the American Heart Association recommends use in LAST, and the American College of Medical Toxicology recommends consideration for circumstances of hemodynamic instability resultant from lipid-soluble xenobiotics. ILE should be administered per American Society of Regional Anesthesia and Pain Medicine dosing recommendations. Laboratory interference, pancreatitis, respiratory distress syndrome, and interference with vasopressors should be considered as risks but are uncommon. CONCLUSIONS In the setting of severe hemodynamic compromise by lipid-soluble xenobiotics, ILE may be considered for resuscitation by emergency physicians. As such, ILE may be stocked in emergency departments in close proximity to resuscitation rooms and areas where local nerve blocks are performed.

Review of Recently Approved Alternatives to Anticoagulation with Warfarin for Emergency Clinicians

BACKGROUND Dabigatran and rivaroxaban are novel anticoagulants that have been approved for the prevention of thromboembolic events in atrial fibrillation. These medications are attractive to both patients and clinicians, as, unlike warfarin, they do not require laboratory monitoring or dietary restrictions. However, they carry bleeding risks similar to that of warfarin and are without a reliable reversal agent. OBJECTIVES The objectives of this article are to 1) summarize the pivotal trials leading to the U.S. Food and Drug Administration approvals of dabigatran (Pradaxa; Boehringer Ingelheim, Ridgefield, CT) and rivaroxaban (Xarelto; Janssen Pharmaceuticals, Inc., Titusville, NJ); 2) present the limited data available regarding the management of bleeding patients on these agents; and 3) provide suggestions to guide emergency providers given the limited data. DISCUSSION Dabigatran and rivaroxaban were approved based on large, non-inferiority trials comparing the new agents to warfarin with stroke or systemic embolism as the primary outcome. Traditional coagulation studies cannot be used to determine the degree of anti-coagulation produced by these agents. Fresh frozen plasma is unlikely to be effective in patients on these drugs who are acutely bleeding. Prothrombin complex concentrate can be considered in patients on rivaroxaban. Dabigatran is renally cleared, so dabigatran could be removed by hemodialysis. Theoretically, DDAVP (Sanofi-Aventis U.S. LLC, Bridgewater, NJ), aminocaproic acid, tranexamic acid, or recombinant activated factor VII could also be used in an attempt to control bleeding. CONCLUSION There is a need for assays for the degree of anticoagulation produced by drugs such as dabigatran and rivaroxaban. Additionally, studies are needed to evaluate reversal agents that could be effective in the setting of acute bleeding.

Characterizing the limited use of point-of-care ultrasound in Colombian emergency medicine residencies

BackgroundEmergency medicine (EM) is a growing specialty in Colombia with five residency programs in the country. EM leadership is interested in incorporating point-of-care (POC) ultrasound into a standardized national EM residency curriculum. This study is a nationwide survey of Colombian EM residents designed to explore the current state of POC ultrasound use within EM residencies and examine specific barriers preventing its expansion.MethodsWe conducted a mix-methodology study of all available current EM residents in the five EM residencies in Colombia. The quantitative survey assessed previous ultrasound experience, current use of various applications, desire for further training, and perceived barriers to expanded use. Focus group discussions (FGDs) were conducted with current EM residents to gather additional qualitative insight into their practice patterns and perceived barriers to clinician-performed ultrasound.ResultsSixty-nine EM residents completed the quantitative survey, a response rate of 85% of all current EM residents in Colombia; 52% of resident respondents had previously used ultrasound during their training. Of these, 58% indicated that they had performed <10 scans and 17% reported >40 scans. The most frequently used applications indicated by respondents were trauma, obstetrics, and procedures including vascular access. A quarter indicated they had previously received some ultrasound training, but almost all expressed an interest in learning more. Significant barriers included lack of trained teachers (indicated by 78% of respondents), absence of machines (57%), and limited time (41%). In FGDs, the barriers identified were inter-specialty conflicts over the control of ultrasonography, both institutionally and nationally, and program-specific curriculum decisions to include POC ultrasound.ConclusionWhile currently limited in their access, EM residents in Colombia have a strong interest in integrating POC ultrasound into their training. Current barriers to expanded use include traditional barriers such as a lack of equipment seen in many developing countries, as well as inter-specialty conflicts typical of developed countries. Further collaboration is underway to help overcome these obstacles and integrate POC ultrasound into Colombian EM residency training.

Global uptake of the Humanitarian Accountability Partnership over its first ten years.

INTRODUCTION Accountability in the delivery of humanitarian aid has become increasingly important and emphasized by the humanitarian community. The Humanitarian Accountability Partnership (HAP) was created in 2003 in order to improve accountability in the humanitarian sector. HAP acts as a self-regulatory body to the humanitarian system. One of the main goals of HAP is the promotion of accountability through self-regulation by members. Humanitarian nongovernmental organizations (NGOs) can become members by meeting standards of accountability and quality management set by HAP. This report describes the growth of HAP membership by the humanitarian community from its inception until present. Hypothesis/Problem The hypothesis for this study was that HAP membership has grown substantially since inception, both in terms of number of member organizations and annual budgets of member organizations, but that near universal membership has not yet been achieved. METHODS A retrospective study was conducted to determine the total number and percentage of humanitarian NGOs that are members of HAP. Total expenditures of HAP members in 2010 also was measured and compared with the total humanitarian expenditure by all humanitarian NGOs for the same year. The reference year of 2010 was chosen in order to be able to compile accurate budgets for the largest possible number of HAP members. The total number of HAP members for the years 2005 through 2012 was divided by the estimated number of humanitarian NGOs active in 2010. The total budgets for HAP members in 2010 were divided by the estimated total humanitarian expenditure of all NGOs for 2010. RESULTS As of the beginning of 2012, the percentage of humanitarian NGOs that were members of HAP was 1.6% (68 members out of 4400 organizations). The combined budgets of the member organizations of HAP in 2010 made up 62.9% of the total humanitarian expenditure for the year 2010 (US

Does Calcium Administration During Cardiopulmonary Resuscitation Improve Survival for Patients in Cardiac Arrest

4.65 billion/7.4 billion). CONCLUSION A very small proportion of humanitarian NGOs have adopted HAP membership. However, HAP members account for almost two-thirds of all humanitarian expenditures. The humanitarian sector, therefore, remains without a universal regulatory and accountability structure, although progress has been made. Efforts should be made to increase the membership within HAP of more small to medium sized organizations.

In Patients With Acute Ischemic Stroke, Do Different Thrombolytic Doses, Agents, or Routes of Administration Lead to Different Outcomes?

TUDY SELECTION his review was conducted to pdate the Guidelines on ardiopulmonary Resuscitation nd Emergency Cardiac Care, using he 2010 International Liaison ommittee on Resuscitation ILCOR) evidence evaluation rocess. Forty-eight articles were etrieved but only 10 included. ach included article matched one f the 5 levels of evidence reported y ILCOR (Table). Editorial articles, bstracts, reviews, commentaries, nd guidelines were excluded.

Sepsis, severe sepsis, and septic shock: A review of the literature

IAS AND DATA ANALYSIS o assess study quality and risk of ias, randomization, allocation oncealment, blinding, and ntention-to-treat analysis data ere collected. Primary outcome as functional outcome at the end f follow-up. An intention-to-treat nalysis was performed for econdary outcomes: early and otal deaths at the end of follow-up, ymptomatic and fatal intracranial leeding events, and major xtracranial bleeding events.