Introduction: To determine the prevalence of hunger and food insecurity among patients presenting to the emergency department (ED) over 3 consecutive years.

Methods: This was a cross-sectional study of patients presenting to the ED at Hennepin County Medical Center, and urban, Level I trauma center. We prospectively screened adult (age >18) patients presenting to the ED during randomized daily 8-hour periods between June 1 and August 31, 2007 and 2008, and randomized every-other-day periods between June 1 and August 31, 2009. We excluded patients with high acuity complaints, altered mental status, prisoners, those who did not speak Spanish or English, or those considered to be vulnerable. Consenting participants completed a brief demographic survey. The main outcome measures included age, gender, ethnicity, employment, housing status, insurance, access to food, and having to make choices between buying food and buying medicine. All responses were self reported.

Results: 26,211 patients presented during the study; 15,732 (60%) were eligible, 8,044 (51%) were enrolled, and 7,852 (98%) were included in the analysis. The rate of patients reporting hunger significantly increased over the 3-year period [20.3% in 2007, 27.8% in 2008, and 38.3% in 2009 (P < 0.001)]. The rate of patients reporting ever having to choose between food and medicine also increased [20.0% in 2007, 18.5% in 2008, and 22.6% in 2009 (P = 0.006)].

Conclusion: A significant proportion of our ED patients experience food insecurity and hunger. Hunger and food insecurity have become more prevalent among patients seen in this urban county ED over the past 3 years. Emergency physicians should be aware of the increasing number of patients who must choose between obtaining food and their prescribed medications, and should consider the contribution of hunger and food insecurity to the development of health conditions for which ED treatment is sought. [West J Emerg Med. 2013;14(3):253–262.]

Background: Penetrance is the annual rate of human exposure calls per 1000 persons, a measurethat historically describes poison center (PC) utilization. Penetrance varies by sociodemographiccharacteristics and by geography. Our goal in this study was to characterize the geospatial distributionof PC calls and describe the contribution of geospatial mapping to the understanding of PC utilization.

Methods: This was a single-center, retrospective study of closed, human, non-healthcare facilityexposure calls to a regional PC over a five-year period. Exposure substance, gender, age, andzone improvement plan (ZIP) Code were geocoded to 2010 US Census data (household income,educational attainment, age, primary language) and spatially apportioned to US census tracts, andthen analyzed with linear regression. Penetrance was geospatially mapped and qualitatively analyzed.

Results: From a total of 304,458 exposure calls during the study period, we identified 168,630non-healthcare exposure calls. Of those records, 159,794 included ZIP Codes. After exclusions,we analyzed 156,805 records. Penetrance ranged from 0.081 - 38.47 calls/1000 population/year(median 5.74 calls/1000 persons/year). Regression revealed positive associations between >eighthgradeeducational attainment (β = 5.05, p = 0.008), non-Hispanic Black (β = 1.18, p = 0.032) andAmerican Indian (β = 3.10, p = 0.000) populations, suggesting that regions with higher proportionsof these groups would display greater PC penetrance. Variability explained by regression modellingwas low (R2 = 0.054), as anticipated. Geospatial mapping identified previously undocumentedpenetrance variability that was not evident in regression modeling.

Conclusion: PC calls vary substantially across sociodemographic strata. Higher proportionsof non-Hispanic Black or American Indian residents and >eighth-grade educational attainmentwere associated with higher PC call penetrance. Geospatial mapping identified novel variationsin penetrance that were not identified by regression modelling. Coupled with sociodemographiccorrelates, geospatial mapping may reveal disparities in PC access, identifying communities atwhich PC resources may be appropriately directed. Although the use of penetrance to describe PCutilization has fallen away, it may yet provide an important measure of disparity in healthcare accesswhen coupled with geospatial mapping.

Introduction: Acetaminophen poisoning is commonly treated by emergency physicians. First-line therapy is N-acetylcysteine (NAC), traditionally administered intravenously via a US Food and Drug Administration (FDA)-approved three-bag protocol in which each bag has a unique concentration and infusion duration. Recently, simplified, off-label two-bag NAC infusion protocols have become more common. The purpose of this review is to summarize the effectiveness and safety of two-bag NAC.

Methods: We undertook a comprehensive search of PubMed, EMBASE, and MEDLINE from inception to December 13, 2022, for articles describing human acetaminophen poisonings treated with two-bag NAC, defined as any regimen involving two discrete infusions in two separate bags. Outcomes included effectiveness (measured by incidence of liver injury); incidence of non-allergic anaphylactoid reactions (NAAR); gastrointestinal, cutaneous, and systemic reactions; treatments for NAARs; incidence of NAC-related medication errors; and delays or interruptions in NAC administration.

Results: Twelve articles met final inclusion, 10 of which compared two-bag NAC to the three-bag regimen. Nine articles evaluated the two-bag/20-hour regimen, a simplified version of the FDA-approved three-bag regimen in which the traditional first and second bags are combined into a single four-hour infusion. Nine articles assessed comparative effectiveness of two-bag NAC in terms of liver injury, most commonly assessed for by incidence of hepatotoxicity (aspartate aminotransferase or alanine aminotransferase >1,000 international units per liter). No difference in liver injury was observed between two-bag and three-bag regimens. Of nine articles comparing incidence of NAARs, eight demonstrated statistically fewer NAARs with two-bag regimens, and one showed no difference. In seven articles evaluating treatment for NAARs (antihistamines, corticosteroids, epinephrine), all showed that patients received fewer medications for NAARs with two-bag NAC. Three articles evaluated NAC-related medication errors; two demonstrated no difference, while one study evaluating only children showed fewer errors with two-bag NAC. Two studies evaluated delays and/or interruptions in NAC infusions; both favored two-bag NAC.

Conclusion: For patients with acetaminophen poisoning, two-bag NAC regimens appear to have similar outcomes to the traditional three-bag regimen in terms of liver injury. Two-bag NAC regimens are associated with fewer adverse events and fewer treatments for those events than the three-bag regimen and fewer interruptions in antidotal therapy.

Introduction: Expanding naloxone availability is important to reduce opioid-related deaths. Recent data suggest low, variable urban naloxone availability. No reports describe naloxone availability at the point of sale (POSN). We characterize POSN without prescription across a Midwestern metropolitan area, via a unique poison center-based study.

Methods: Pharmacies were randomly sampled within a seven-county metropolitan area, geospatially mapped, and distributed among seven investigators, who visited pharmacies and asked, “May I purchase naloxone here without a prescription from my doctor?” Following “No,” investigators asked, “Are you aware of the state statute that allows you to dispense naloxone to the public under a standing order?” Materials describing statutory support for POSN were provided. Responses were uploaded to REDCap in real time. We excluded specialty (veterinary, mail order, or infusion) pharmacies a priori. POSN availability is presented as descriptive statistics; characteristics of individual sites associated with POSN availability are reported.

Results: In total, 150 pharmacies were prospectively randomized, with 52 subsequently excluded or unavailable for survey. Thus, 98 were included in the final analysis. POSN was available at 71 (72.5%) of 98 pharmacies. POSN availability was more likely at chain than independent pharmacies (84.7% vs 38.5%, p<0.001); rural areas were more commonly served by independent than chain pharmacies (47.4% vs 21.5%, p = 0.022). Five chain and five independent pharmacies (18.5% each) were unaware of state statutory support for collaborative POSN agreements. Statutory awareness was similar between independent and chain pharmacies (68.8% vs 54.6%, p = 0.453). Rationale for no POSN varied.

Conclusion: POSN is widely available in this metropolitan area. Variability exists between chain and independent pharmacies, and among pharmacies of the same chain; awareness of statutory guidance does not. Poison centers can act to define local POSN availability via direct inquiry in their communities.