Conference season

Are conferences dead_

Having just returned from Dublin and the SMACC conference, and a few weeks earlier having travelled to the wonderful IFEM conference in Cape Town it’s time to reflect on the worth of the travel, expense and family disruption that ensues. Our work families too have to pull extra shifts and adapt to those of us lucky enough to get away for a few days away from the department.

In an era of web based technologies, podcasts, vodcasts and associated social media it’s questionable whether we need conferences at all. There are surely cheaper, less expensive and more convenient ways of communicating and in an era of social media it is ever easier to make those connections across the planet.

We should of course not forget the enormous environmental impact of many conferences, notably those large international conferences where 100s of tons of jet fuel are burned into the atmosphere to fuel knowledge dissemination that might so easily have been delivered online.

This is a theme we touched on in the EMJ in a paper looking at the future of conferences where the case for future more environmentally aware and better disseminated conferences was explored.

Innovation in the field of medical conferences.

So are conferences dead?

My experience last week and in South Africa would suggest not. Take the SMACC conference which has gained a bit of a reputation for blending social media, education and entertainment. The participants are almost all involved in online learning and so might be expected to shun the traditional travel to meet and great type affair.  Yet it is precisely this audience of online engaged clinicians who seek out the ability to meet, to network, to share, to laugh, cry and share together. This year the conference sold out in a matter of hours with competitions being held for the remaining tickets. The interest and anticipation to meet with like minded enthusiasts from across the globe was palpable and at times a little over the top and uncomfortable. The demographic was young, multicultural and multiprofessional. This is not typical behaviour for medical conferences, and perhaps is more akin to pop concert tickets. It’s a situation that makes some feel uncomfortable, but there is no doubt that it is engaging a worldwide population of learners.

A paradox perhaps, that the conference espousing an online socially connected world is one that sells out in hours and has a waiting list of those wanting to attend.

I’ve not quite got my head round this yet, but I think there may be at least two elements at work. Firstly there is a natural human desire to connect and conferences allow that, online interactions are good, but they are not the real thing and it’s great to meet in person, to explore ideas and to satisfy a human need to put faces to names. Secondly, although I find the online education world fascinating, there is only so much it can do. A live presentation of high quality is unsurpassed as a learning experience and you simply can’t do some things online.

Take the on stage discussion at SMACC on the future of medical journals as discussed by Richard Smith (ex BMJ editor). That was a great session that simply could not work as well in any other setting. A blend of science, politics, fun and entertainment with some really important discussion points and views.

Richard Smith: What will the post journal world look like?

So, the conference is far from dead, but it is changing. It’s role as a prime means of delivering information is perhaps waning, but as an opportunity to form and build social links, collaborations and understanding it is surely on the rise.

So I guess I’ll probably see you in an auditorium soon. If you do then say ‘hi’. After all, the people are just as important as the presentations. Collaborations, discussions and developments come from interaction, not from powerpoint.

vb

S

 

DOI: I’ve had supporting expenses to travel to many conferences, including SMACC last week. I am unbelievably lucky and priviliged to do so. I’ve actively supported a range of innovative conferences and believe that the old model of boring lectures given by boring speakers on boring subjects is a waste of time.

The Case for Outpatient Alcohol Detoxification

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Editor: Christie Lech

Background: 

The prevalence of adult alcohol abuse and dependence in the United States ranges from 7% to 16% (Muncie 2013). There are an estimated 500,000 cases of alcohol withdrawal syndrome (AWS) requiring pharmacologic intervention every year (Hoffman 2015).  In addition, alcoholism has a large economic burden with annual health related costs estimated to be over $220 billion (Bouchery 2006).

Emergency providers (EPs) are frequently faced with the difficult decision of whether or not to discharge home or provide these patients with inpatient detoxification, even though studies have demonstrated short length of stays and high against medical advice (AMA) discharge rates among this patient group (Stephens 2014). Outpatient alcohol detoxification programs are common however their structures and coordination with emergency departments (EDs) are highly variable. In fact, very few EDs can provide direct referral to an outpatient program. In today’s emergency medicine practice is outpatient detoxification a viable option in the treatment of alcohol withdrawal?

Evidence:

Multiple studies in the field of psychiatry and addiction medicine have investigated the efficacy of inpatient versus substance abuse intensive outpatient programs (IOPs). A comprehensive literature review of 12 of these studies performed between 1995 and 2012 showed great variation among outpatient programs. While outpatient detoxification programs generally consisted of a multidisciplinary approach involving psychiatric, social and pharmacologic agents, there would be a range in the intensities. Some programs had short weekly meetings and others with intense bi to tri-weekly sessions. Follow up also ranged from a few weeks in these studies to a few months and up to a year. Attempting to correct for these variations, the authors concluded that there were reductions in substance use and increased abstinence at close follow-up in both inpatient and outpatient treatment arms without any significant difference between the two groups. Additionally, the effectiveness of abstinence was more a reflection of “intensity and duration of treatment rather than a specific setting or patient population.” (McCarty 2012)

Similar efficacy rates of outpatient and inpatient detoxification for the treatment of alcohol withdrawal would be attractive to a variety of healthcare professionals as it could decrease resource utilization without detrimental effects to the patient. A randomized controlled trial of US military veterans presenting with alcohol abuse compared inpatient versus outpatient detoxification and showed a total decrease in cost and duration of treatment in the outpatient group. There were no serious medical complications noted in either group (Hayashida 1989).

Inpatient vs Outpatient

Determining candidates for inpatient versus outpatient detoxification is a task that EPs face on nearly every shift. It can depend on numerous factors including clinical history and presentation, physical exam, substance use history, follow up reliability, age, concurrent medical condition, co-morbidities, psychosocial dynamics, etc. The most important considerations may be the severity of past withdrawal such as history or delirium tremens, ICU admission, and large parenteral therapy requirement. Ultimately, patients may need inpatient treatment given the full clinical risk of moderate to severe may be impossible to assess upon presentation to the ED. Institutional factors also play a large role in placing patients in outpatient detoxification programs. Despite identifying appropriate candidates for these programs, EDs are often limited by oversaturation of programs, referral capabilities and other resources like personnel for patient education and transportation.

A study in the EDs at the University of North Carolina utilized a proposed standardized protocol for evaluation of patients for alcohol detoxification that combined clinical history, laboratory values, substance use and psychiatric history, and objective CIWA markers. They found that after implementation of the protocol there was a statistically significant decrease in the number of inpatient alcohol detoxification admissions per month without change in readmission rate or length of stay (Stephens 2014)

Outpatient Treatment

There are no absolute criteria for deciding which patients require inpatient alcohol withdrawal. However multiple studies have identified certain factors that suggest a patient should receive inpatient treatment (Myrick 1998, Muncie 2013)

Contraindications to Outpatient Treatment of Alcohol Withdrawal Syndrome

While there is great variation in approaches to outpatient detoxification, limited studies have shown that it can be an effective alternative to inpatient detoxification in terms of patient outcomes. Outpatient programs should be tailored to each patient with a combination of pharmacologic and psychosocial therapy in a setting that embraces autonomy with close and consistent medical follow up. Further institutional investment in these programs from a multidisciplinary approach with closer coordination with EDs is sorely needed, and could go a long way in both safely assisting these patients with long term detoxification as well as reducing their burden on the health care system as a whole.

References

Bouchery E, Henrick J et al “Economic Costs of Excessive Alcohol Consumption in the U.S., 2006” Am J Prev Med 2011; 41(5) 516-524 PMID: 22011424

Hayashida M, Alterman Al et al “Comparative effectiveness and costs of inpatient

and outpatient detoxification of patients with mild-to-moderate alcohol withdrawal

syndrome” N Engl J Med 1989 Feb 9 PMID: 2913493

Hoffman R, Weinhouse G et al “Management of moderate and severe alcohol withdrawal symptoms” UptoDate Nov 12, 2015 http://www.uptodate.com/contents/management-of-moderate-and-severe-alcohol-withdrawal-syndromes

McCarty D, Braude L et al “Substance Abuse Intensive Outpatient Programs: Assessing the Evidence” Psychiatry  Serv. 2014 June 1; 65(6): 718-726 PMID: 24445620

Muncie HL, Yasinian Y et al “Outpatient management of alcohol withdrawal

syndrome” Am Fam Physician. 2013 Nov 1 PMID 24364635

Myrick H, Anton R “Treatment of Alcohol Withdrawal” Alcohol Health & Research World. 1998 Vol 22. No. 1 38-43 National Institute on Alcohol Abuse and Alcoholism PMID: 15706731

Stephens J, Liles EA et al “Who Needs Inpatient Detox? Development and Implementation of a Hospitalist Protocol for the Evaluation of Patients for Alcohol Detoxification” J Gen Intern Med 2014 29(4): 587-93 PMID: 24395104

SMACCDUB – A Trainee’s Perspective. St.Emlyn’s — St.Emlyn’s

St.Emlyn's – Meducation in Virchester #FOAMed Having recently returned to the real world after attending SMACCDUB in Dublin, we thought we should try to articulate some of the things we learnt. Rich: Having only lost my SMACC virginity last year, I had little by way of comparison other that what had been a monumental…

via SMACCDUB – A Trainee’s Perspective. St.Emlyn’s — St.Emlyn's


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