PARTIAL HOSPITALIZATION: AN INTERVENTION FOR YOUTH WITH POORLY CONTROLLED DIABETES MELLITUS.

Objective: To examine the efficacy of an integrated medical/psychiatric partial hospitalization program (PHP) to improve glycemic control in youth with both diabetes mellitus and mental health disorders. Methods: This retrospective chart review is of patients admitted to a PHP between 2005-2015 with concerns about diabetes mellitus care. Clinical characteristics, laboratory data, diabetic ketoacidosis hospitalizations, and outpatient clinic visit frequency were collected from the year prior to the year after PHP admission. Results: A total of 43 individuals met inclusion criteria: 22 (51%) were female, 40 (93%) had type 1 diabetes, the mean age was 15.2 ± 2.3 years, and the mean diabetes mellitus duration was 4.6 ± 3.6 years. Of those individuals, 35 of these patients had hemoglobin A1c (HbA1c) data available at baseline, 6 months, and 1 year after PHP. The average HbA1c before PHP admission was 11.3 ± 2.3% (100.5 ± 25 mmol/mol), and decreased to 9.2 ± 1.3% (76.7 ± 14.8 mmol/mol) within 6 months of PHP admission (P<.001). The average HbA1c 1 year after PHP was 10.7 ± 1.7 % (93.3 ± 19.1 mmol/mol). Overall, 24 patients (68%) had lower HbA1c, and 75% of those with improvement maintained an HbA1c reduction of ≥1% (≥10 mmol/mol) at 1 year compared to before PHP. Conclusion: Most patients demonstrated improved glycemic control within 6 months of PHP admission, and many of those maintained a ≥1% (≥10 mmol/mol) reduction in HbA1c at 1 year following PHP admission. This program may represent a promising intervention that could serve as a model for intensive outpatient management of youth with poorly controlled diabetes mellitus. Abbreviations: ADA = American Diabetes Association; DKA = diabetic ketoacidosis; EMR = electronic medical record; HbA1c = hemoglobin A1c; ICD-9 = International Classification of Diseases, 9th revision; PHP = partial hospitalization program.

Pediatric Diabetic Ketoacidosis With Hyperosmolarity: Clinical Characteristics and Outcomes.

OBJECTIVE: Studies of hyperglycemic emergencies with hyperosmolality, including hyperglycemic hyperosmolar state (HHS) and "mixed presentation" with features of diabetic ketoacidosis (DKA) and HHS, are lacking in children. Objectives were to determine the incidence of DKA, HHS, and mixed presentation in a pediatric population, to characterize complications, and to assess accuracy of associated diagnosis codes. METHODS: Retrospective cohort study of 411 hyperglycemic emergencies in pediatric patients hospitalized between 2009 and 2014. Hyperglycemic emergency type was determined by biochemical criteria and compared to the associated diagnosis code. RESULTS: Hyperglycemic emergencies included: 333 DKA, 54 mixed presentation, and 3 HHS. Altered mental status occurred more frequently in hyperosmolar events ( P<.0001), and patients with hyperosmolarity had 3.7-fold greater odds of developing complications compared to those with DKA ( P = .0187). Of those with DKA, 98.5% were coded correctly. The majority (81.5%) of mixed DKA-HHS events were coded incorrectly. Events coded incorrectly had 3.1-fold greater odds of a complication ( P = .02). CONCLUSION: A mixed DKA-HHS presentation occurred in 13.8% of characterized hyperglycemic emergencies, whereas HHS remained a rare diagnosis (0.8%) in pediatrics. Hyperosmolar events had higher rates of complications. As treatment of hyperosmolarity differs from DKA, its recognition is essential for appropriate management. ABBREVIATIONS: AMS = altered mental status; DKA = diabetic ketoacidosis; EMR = electronic medical record; HHS = hyperglycemic hyperosmolar state; ICD-9 = International Classification of Diseases, Ninth Revision; ISPAD = International Society of Pediatric and Adolescent Diabetes; NODM = new-onset diabetes mellitus; T1DM = type 1 diabetes mellitus; T2DM = type 2 diabetes mellitus.

Effect of Fecal Microbiota Transplantation on Recurrence in Multiply Recurrent Clostridium difficile Infection: A Randomized Trial.

BACKGROUND: To date, evidence for the efficacy of fecal microbiota transplantation (FMT) in recurrent Clostridium difficile infection (CDI) has been limited to case series and open-label clinical trials. OBJECTIVE: To determine the efficacy and safety of FMT for treatment of recurrent CDI. DESIGN: Randomized, controlled, double-blind clinical trial. (ClinicalTrials.gov: NCT01703494). SETTING: Two academic medical centers. PATIENTS: 46 patients who had 3 or more recurrences of CDI and received a full course of vancomycin for their most recent acute episode. INTERVENTION: Fecal microbiota transplantation with donor stool (heterologous) or patient's own stool (autologous) administered by colonoscopy. MEASUREMENTS: The primary end point was resolution of diarrhea without the need for further anti-CDI therapy during the 8-week follow-up. Safety data were compared between treatment groups via review of adverse events (AEs), serious AEs (SAEs), and new medical conditions for 6 months after FMT. Fecal microbiota analyses were performed on patients' stool before and after FMT and also on donors' stool. RESULTS: In the intention-to-treat analysis, 20 of 22 patients (90.9%) in the donor FMT group achieved clinical cure compared with 15 of 24 (62.5%) in the autologous FMT group (P = 0.042). Resolution after autologous FMT differed by site (9 of 10 vs. 6 of 14 [P = 0.033]). All 9 patients who developed recurrent CDI after autologous FMT were free of further CDI after subsequent donor FMT. There were no SAEs related to FMT. Donor FMT restored gut bacterial community diversity and composition to resemble that of healthy donors. LIMITATION: The study included only patients who had 3 or more recurrences and excluded those who were immunocompromised and aged 75 years or older. CONCLUSION: Donor stool administered via colonoscopy seemed safe and was more efficacious than autologous FMT in preventing further CDI episodes. PRIMARY FUNDING SOURCE: National Institute of Diabetes and Digestive and Kidney Diseases.

AUTONOMOUSLY FUNCTIONING THYROID NODULES IN PATIENTS <21 YEARS OF AGE: THE RHODE ISLAND HOSPITAL EXPERIENCE FROM 2003-2013.

OBJECTIVE: This study evaluates the clinical characteristics, workup, treatment, and outcomes of pediatric patients diagnosed with an autonomously functioning thyroid nodule (AFTN) in a large cohort of patients presenting for evaluation of a thyroid nodule. There are few prior studies on AFTN in pediatrics, with limited data on treatment and outcomes. Rates of malignancy in AFTN are perceived as low, but prior studies have varying reports. METHODS: This is a retrospective chart review of patients less than 21 years of age at Rhode Island Hospital over an 11-year period (2003-2013). We reviewed 354 charts, which yielded 242 patients with a diagnosis of thyroid nodule and 17 patients with AFTN. RESULTS: The prevalence of AFTN in patients presenting with thyroid nodules was 7%. Mean age of patients was 15.8 years at diagnosis, and mean nodule size was 3.3 cm. There was female predominance. Thyroid-stimulating hormone levels were suppressed at diagnosis in 87% of patients. Six patients were treated with surgery, 5 patients with radioactive iodine therapy (RAI), 2 patients with medication, and 1 patient was observed without treatment. Three patients treated with RAI required subsequent treatment for hypothyroidism or continued hyperthyroidism. One patient had papillary thyroid carcinoma based on final surgical pathology. CONCLUSION: Our study found a higher prevalence of AFTN compared to the reported prevalence in adults. We concur with the new guidelines on management of thyroid nodules in recommending surgery for treatment of AFTN, based on the variability of outcomes after treatment with RAI.

The effect of sagittal rotation of the glenoid on axial glenoid width and glenoid version in computed tomography scan imaging.

BACKGROUND: Computed tomography (CT) scans of the shoulder are often not well aligned to the axis of the scapula and glenoid. The purpose of this paper was to determine the effect of sagittal rotation of the glenoid on axial measurements of anterior-posterior (AP) glenoid width and glenoid version attained by standard CT scan. In addition, we sought to define the angle of rotation required to correct the CT scan to optimal positioning. METHODS: A total of 30 CT scans of the shoulder were reformatted using OsiriX software multiplanar reconstruction. The uncorrected (UNCORR) and corrected (CORR) CT scans were compared for measurements of both (1) axial AP glenoid width and (2) glenoid version at 5 standardized axial cuts. RESULTS: The mean difference in glenoid version was 2.6% (2° ± 0.1°; P = .0222) and the mean difference in AP glenoid width was 5.2% (1.2 ± 0.42 mm; P = .0026) in comparing the CORR and UNCORR scans. The mean angle of correction required to align the sagittal plane was 20.1° of rotation (range, 9°-39°; standard error of mean, 1.2°). CONCLUSION: These findings demonstrate that UNCORR CT scans of the glenohumeral joint do not correct for the sagittal rotation of the glenoid, and this affects the characteristics of the axial images. Failure to align the sagittal image to the 12-o'clock to 6-o'clock axis results in measurement error in both glenoid version and AP glenoid width. Use of UNCORR CT images may have notable implications for decision-making and surgical treatment.

Impact of a state concussion law on pediatric emergency department visits.

OBJECTIVE: Many states have passed concussion laws that mandate that players undergo medical clearance before returning to play. Few data have been collected on the impact of such laws on emergency department (ED) visits. This study measures the impact of Rhode Island concussion legislation on sports-related concussion visits to a pediatric ED. METHODS: International Classification of Diseases, Ninth Revision, Clinical Modification codes with injury mechanism-associated E-codes were extracted from hospital databases from 2004 to 2011 for both sports-related concussions and sports-related ankle ligamentous injuries (comparison group). Visit rates for sports-related concussions were compared before and after the passage of the state concussion law.Secondary outcome measures included rates of head imaging per ED visit for concussion before and after passage of the law. Times series analysis was used to analyze season-to-season count and rate changes. RESULTS: Overall rate of sports-related concussion visits more than doubled (2.2-fold increase; 95% confidence interval, 1.3-3.6; adjusted P = 0.01) during the fall sports season following the implementation of legislation (2010) relative to the previous year (3.6% vs 1.4%). Rates of sports-related ankle sprain visits tended to increase during the fall sports season but did not achieve statistical significance. Rates of computed tomography scan imaging of the head did not change over time. CONCLUSIONS: The data from this study revealed an increase in pediatric ED visits for sports-related concussions, without a corresponding increase in head imaging, suggesting that the passage of a state concussion law has led to increased vigilance in evaluation of sports-related concussions, without an increase in diagnostic computed tomography scans.

Activated chlorine dioxide solution can be used as a biocompatible antiseptic wound irrigant.

OBJECTIVE: The purpose of this study was to compare cosmesis at 3 to 4 months and infection in simple lacerations irrigated with normal saline (NS) versus activated chlorine dioxide (CD). DESIGN: This was a prospective, randomized trial of a convenience sample of patients. This study was approved by the institutional review board and Food and Drug Administration as a physician-sponsored trial (FDA investigational new drug no. 68762). SETTING: The study was conducted in a large urban, academic emergency department. PATIENTS: Patients aged 18 to 100 with simple, uncomplicated lacerations requiring repair that were less than 8 hours old were enrolled. INTERVENTIONS: Patients were randomized to receive either NS or CD wound irrigation. MAIN OUTCOME MEASURES: Demographics, infection, and cosmesis were analyzed and assessed. Cosmetic outcome was assessed at 3 to 4 months using a visual analog scale (VAS), wound evaluation score (WES), patient VAS (VASPt), and digital imaging VAS by 2 plastic surgeons (VASPlast). MAIN RESULTS: One hundred ninety-three patients were enrolled. Data analysis was available for 175 cases (86 NS and 89 CD). Wound infection follow-up was obtained in 74.9% of the patients. The 3- to 4-month cosmesis follow-up was 37.7% for VAS/WES, 40.0% for VASPt, and 37.7% for VASPlast. There were no significant differences in demographics, key wound characteristics, infection, adverse reactions, and cosmesis. CONCLUSION: The authors report the use of a novel antimicrobial irrigation solution. Chlorine dioxide appears to be a safe biologically acceptable antiseptic wound irrigant that does not appear to interfere with cosmetic outcomes.

Time to first antibiotics for pneumonia is not associated with in-hospital mortality.

BACKGROUND: Time to first antibiotic (TTFA) is postulated to impact pneumonia mortality. The Joint Commission/Centers for Medicare and Medicaid Services national quality standards previously indicated that TTFA should be <6 h (modified from <4 h when the study was initiated, now eliminated as a time measure entirely). OBJECTIVE: The purpose of this article was to determine whether TTFA is associated with inpatient mortality. METHODS: The records of 444 consecutive patients admitted with pneumonia at a single institution were retrospectively reviewed for a correlation between TTFA and inpatient complications, including death. Statistical significance was set at p < 0.01 due to multiple comparisons. RESULTS: Patients whose TTFA was <4 h had more complications (27% vs. 3%; p < 0.01) including death, intensive care unit admission, and intubation. These patients were judged sicker on arrival (median Emergency Severity Index 2 vs. 3; p < 0.001) and were more likely to be triaged to a critical care bed (36% vs. 5%; p < 0.001). Shortness of breath was the only presenting factor that was more frequent in the TTFA <4-h group (61% vs. 16%; p < 0.01). CONCLUSIONS: Shorter TTFA is not associated with improved inpatient mortality. TTFA should not be considered to be a marker of quality of care but rather a reflection of patient disease severity.

Digital imaging analysis of scar aesthetics.

OBJECTIVE: Aesthetic outcome is an important end point of wound care. The purpose of this study was to compare a wound aesthetic scoring system by emergency physicians, patients, and digital imaging by blinded plastic surgeons. The goal was to see if digital photography could accurately analyze the aesthetics of closed lacerations for future research. METHODS: This was a subanalysis of a prospective, randomized trial conducted in an urban, academic emergency department. Patients aged 18 to 100 years were included if they had simple, uncomplicated lacerations 8 hours old or less located on the trunk, head or neck (not scalp), or extremities that required repair by sutures. Exclusion criteria included immunocompromised state of health, a complicated laceration, specialty consultant intervention in management of the wound, or current use of or need for antibiotics for wound prophylaxis. Complicated lacerations were defined in the article. Infection outcomes, demographics, and aesthetic outcomes were assessed. Scar appearance was assessed at 3 to 4 months after closure using a previously validated 0-to 100-mm visual analog scale (VAS) score and 6-point wound evaluation score (WES) done by 2 trained emergency physicians (MD1 and MD2). Patients also performed self-VAS (VAS(Pt)), whereas VAS was done using digital imaging by 2 trained plastic surgeons (VAS(Plast1) and VAS(Plast2)). Data were evaluated when both plastic surgeons independently believed that the digital images were able to be adequately scored. Pearson correlation coefficients were performed using mean values. RESULTS: Three- to 4-month VAS(MD) and WES(MD) follow-up was obtained in 66 of 175 (37.7%), 3- to 4-month VAS(Pt) follow-up was obtained in 70 of 175 (40.0%), and 3- to 4-month digital imaging assessment was obtained in 66 of 175 (37.7%). Digital images were evaluated for VAS(Plast) in 34 of 66 (51.5%). Mean scores for VAS(MD1) and VAS(MD2) were 84.2 (SD, 12.4) mm and 87.8 (SD, 10.5) mm. Mean scores for WES(MD1) and WES(MD2) were 5.5 (SD, 1.0) and 5.4 (SD, 1.0). Mean scores for VAS(Pt) were 86.6 (SD, 16.6) mm. Mean scores for VAS(Plast1) and VAS(Plast2) were 78.7 (SD, 26.6) mm and 66.2 (SD, 30.2) mm. Moderate correlation was noted for VAS(MD1) and VAS(MD2) (r = 0.63; n = 34; P < .001), WES(MD1) and WES(MD2) (r = 0.70; n = 34; P < .001), and VAS(Plast1) and VAS(Plast2) (r = 0.74; n = 34; P < .001). Correlations were also moderate for VAS(MD) and VAS(Plast) (r = 0.56; n = 34; P < .001), VAS(Pt) and WES(MD) (r =0.60; n = 34; P < .001), and VAS(MD) and WES(MD) (r = 0.64; n = 34; P < .001). However, correlations were weak for VAS(Pt) and VAS(Plast) at r = 0.25 (n = 34; P = .16), VAS(Pt) and VAS(MD) at r = 0.37 (n = 34; P =.03), and WES(MD) and VAS(Plast) at r = 0.13 (n = 34; P =.45). Three- to 4-month VAS(MD) and WES(MD) follow-up was obtained in 66 of 175 (37.7%), 3- to 4-month VAS(Pt) follow-up was obtained in 70 of 175 (40.0%), and 3- to 4-month digital imaging assessment was obtained in 66 of 175 (37.7%). Digital images were evaluated for VAS(Plast) in 34 of 66 (51.5%). Mean scores for VAS(MD1) and VAS(MD2) were 84.2 (SD, 12.4) mm and 87.8 (SD, 10.5) mm. Mean scores for WES(MD1) and WES(MD2) were 5.5 (SD, 1.0) and 5.4 (SD, 1.0). Mean scores for VAS(Pt) were 86.6 (SD, 16.6) mm. Mean scores for VAS(Plast1) and VAS(Plast2) were 78.7 (SD, 26.6) mm and 66.2 (SD, 30.2) mm. Moderate correlation was noted for VAS(MD1) and VAS(MD2) (r = 0.63; n = 34; P < .001), WES(MD1) and WES(MD2) (r = 0.70; n = 34; P < .001), and VAS(Plast1) and VAS(Plast2) (r = 0.74; n = 34; P < .001). Correlations were also moderate for VAS(MD) and VAS(Plast) (r = 0.56; n = 34; P < .001), VAS(Pt) and WES(MD) (r = 0.60; n = 34; P < .001), and VAS(MD) and WES(MD) (r = 0.64; n = 34; P < .001). However, correlations were weak for VAS(Pt) and VAS(Plast) at r = 0.25 (n = 34; P = .16), VAS(Pt) and VAS(MD) at r = 0.37 (n = 34; P =.03), and WES(MD) and VAS(Plast) at r = 0.13 (n = 34; P =.45).Three-to 4-month VAS(MD) and WES(MD) follow-up was obtained in 66 of 175 (37.7%), 3- to 4-month VAS(Pt) follow-up was obtained in 70 of 175 (40.0%), and 3- to 4-month digital imaging assessment was obtained in 66 of 175 (37.7%). Digital images were evaluated for VAS(Plast) in 34 of 66 (51.5%). Mean scores for VAS(MD1) and VAS(MD2) were 84.2 (SD, 12.4) mm and 87.8 (SD, 10.5) mm. Mean scores for WES(MD1) and WES(MD2) were 5.5 (SD, 1.0) and 5.4 (SD, 1.0). Mean scores for VAS(Pt) were 86.6 (SD, 16.6) mm. Mean scores for VAS(Plast1) and VAS(Plast2) were 78.7 (SD, 26.6) mm and 66.2 (SD, 30.2) mm. Moderate correlation was noted for VAS(MD1) and VAS(MD2) (r = 0.63; n = 34; P < .001), WES(MD1) and WES(MD2) (r = 0.70; n = 34; P < .001), and VAS(Plast1) and VAS(Plast2) (r = 0.74; n = 34; P < .001). Correlations were also moderate for VAS(MD) and VAS(Plast) (r = 0.56; n = 34; P < .001), VAS(Pt) and WES(MD) (r = 0.60; n = 34; P < .001), and VAS(MD) and WES(MD) (r = 0.64; n = 34; P < .001). However, correlations were weak for VAS(Pt) and VAS(Plast) at r = 0.25 (n = 34; P = .16), VAS(Pt) and VAS(MD) at r = 0.37 (n = 34; P =.03), and WES(MD) and VAS(Plast) at r = 0.13 (n = 34; P =.45). CONCLUSIONS: Correlations were moderate for VAS(MD) and VAS(Plast); however, correlations were weak for VAS(Pt) and VAS(Plast), VAS(Pt) and VAS(MD), and WES(MD) and VAS(Plast). This small study assessing digital imaging as a tool for evaluating scar aesthetics demonstrated limitations in its use. Future studies with larger populations and improved imaging modalities, such as 3-dimensional cameras and high-dynamic-range imaging, may provide potential for better assessment.

The development of a urinary tract infection is associated with increased mortality in trauma patients.

BACKGROUND: In October 2008, Medicare and Medicaid stopped paying for care associated with catheter-related urinary tract infections (UTIs). Although most clinicians agree UTIs are detrimental, there are little data to support this belief. METHODS: This is a retrospective review of trauma registry data from a Level I trauma center between 2003 and 2008. Two proportional hazards regressions were used for analyses. The first predicted acquisition of UTI as a function of indwelling urinary catheter use, adjusting for age, diabetes, gender, and injury severity. The second predicted hospital mortality as a function of UTI, covarying for age, gender, chronic obstructive pulmonary disease, congestive heart failure, hypertension, diabetes, pneumonia, and injury severity. RESULTS: After excluding patients who stayed in the hospital <3 days and those with a UTI on arrival, 5,736 patients were included in the study. Of these patients, 680 (11.9%) met criteria for a UTI, with 487 (71.6%) indwelling urinary catheter-related infections. Predictors of UTI included the interaction between age and gender (p = 0.0018), Injury Severity Score (p = 0.0021), and indwelling urinary catheter use (p < 0.001). The development of a UTI predicted the risk of in-hospital death as a patient's age increased (p = 0.002). Similar results were seen when only catheter-associated UTIs are included in the analysis. CONCLUSIONS: Indwelling urinary catheter use is connected to the development of UTIs, and these infections are associated with a greater mortality as the age of a trauma patients increases.

Prescription Opioid Use Among Patients With Acute Gout Discharged From the Emergency Department.

OBJECTIVE: Acute gout is among the most painful inflammatory arthritides and a frequent cause of emergency department (ED) visits. Prescription opioids are the leading contributor to the ongoing opioid epidemic; EDs are often the source of the index prescription. Our aim was to assess the burden of opioid use and factors associated with its use among gout patients discharged from the ED. METHODS: In the electronic health records system of Lifespan Healthcare System (currently contains 2.2 million records), adult gout patients discharged from the ED or hospital were identified using International Classification of Diseases, Ninth Revision or Tenth Revision diagnostic codes. The study period was March 2015 to September 2017, and only patients with a primary diagnosis of gout were included. If a patient was seen multiple times, only the first encounter was included. For these patients, we estimated the frequency, dose, and duration of opioids prescribed. Using multivariable logistic regression, we ascertained the factors associated with increased odds of opioid prescription at discharge among patients with acute gout. RESULTS: Of the 456 patients, 129 (28.3%) received opioids at discharge (~80% were new patients). The average dose of prescription was mean ± SD 37.9 ± 17.2 mg of morphine equivalent for a median duration of 8 days (interquartile range 5-14). We noted that patients with polyarticular gout attack and diabetes mellitus and those taking opioids prior to admission had higher odds of receiving opioids at discharge. CONCLUSION: Despite the availability of effective treatments, opioids are commonly used for the management of acute gout. This study highlights an opportunity to curb the opioid epidemic among gout patients.

Online Patient Portal Use and Time to Renal Transplantation in Patients on Hemodialysis.

BACKGROUND: Online portals have been shown to be a valuable tool for patients to improve compliance with medical treatment in numerous studies across medical specialties. Our aim was to study the effects of the use of web-based applications that allow patients to track their appointments, labs, and provider visit notes on achievement of renal transplantation. STUDY DESIGN: This is a retrospective chart review of patients in 2 outpatient dialysis centers associated with a 719-bed tertiary care academic medical center. RESULTS: Nine percent of portal users at 3 years after initiation of hemodialysis were the recipients of kidney transplants vs 9% of nonusers. At 4 years, 23% of users were transplant recipients vs 13% of nonusers. At 5 years, 40% of users were transplant recipients vs 14% of nonusers. There was statistically significant divergence of the curves, with the greatest difference observed at 5 years (p = 0.047). In addition, increased number of logins per month was associated with shortened time to renal transplantation (p = 0.0067). CONCLUSIONS: Online portal use is associated with a higher likelihood of being approved as a transplantation candidate and increased number of logins is associated with shortened time to renal transplantation.

Emergency department charges for evaluating minimally injured alcohol-impaired drivers.

STUDY OBJECTIVE: The literature on the costs of treating alcohol-impaired motor vehicle crash victims is largely based on inpatient data. Less is known about the more frequent emergency department (ED) evaluations for those who are discharged home. Our objective is to measure the difference in charges and length of stay between alcohol-impaired and nonimpaired drivers in this population. METHODS: This was a retrospective study of charts and billing data for all drivers in motor vehicle crashes, aged 21 to 65 years, treated at an urban Level I trauma center in 2005 and discharged home from the ED. Patients were divided into alcohol-positive and -negative groups according to alcohol level, documentation of recent alcohol use, or clinical intoxication. Itemized charges were tabulated and compared across groups. RESULTS: Of 1,618 eligible patients, median charges were higher for alcohol-positive patients by $4,538 (95% confidence interval [CI] $2,755 to $5,665). Imaging was 69% of the charge differential because of a higher frequency of imaging (91% versus 70%) and more expensive studies (median difference $2,464; 95% CI $1,507 to $3,400) for alcohol-positive patients. Median length of stay was higher for alcohol-positive patients by 3.3 hours (95% CI 2.7 to 4.1 hours). When stratified by trauma-protocoled triage destination, median charges were higher for alcohol-positive versus -negative patients in non-critical care beds by $2,229 (95% CI $1,039 to $2,693). For patients triaged to critical care beds, the difference in charges was only $132 (95% CI -$1,677 to $1,233). CONCLUSION: The presence of alcohol substantially increased charges and length of stay for ED evaluations of injured drivers discharged home, especially for patients who were triaged to non-critical care beds. The magnitudes are striking for this minimally injured population and represent an underreported burden of alcohol-impaired driving.

Effect of discontinuing cholinesterase inhibitor therapy on behavioral and mood symptoms in nursing home patients with dementia.

BACKGROUND: Cholinesterase inhibitors (CHEIs) ameliorate some types of behavioral symptoms in patients with Alzheimer's disease. However, there has been little previous study of the outcomes associated with discontinuing these medications. OBJECTIVE: The primary aim of this study was to evaluate the extent to which discontinuing CHEI therapy affected behavioral and mood symptoms in a cohort of nursing home residents with a diagnosis of dementia compared with residents receiving longer-term CHEI therapy. METHODS: This was a retrospective cohort study using Rhode Island Medicaid prescription claims and the Minimum Data Set (MDS). Participants were Rhode Island nursing home residents aged > or =60 years with a diagnosis of Alzheimer's disease or non-Alzheimer's dementia, treated with CHEI monotherapy, and enrolled in the Medicaid program between January 1, 2004, and December 31, 2005. The discontinuation cohort (CHEI-DC) was selected by identifying residents who received 3 to 9 months of uninterrupted CHEI therapy. The continuation cohort (CHEI-CONT) was prescribed continuous CHEI therapy for >9 months. Changes in scores on the Aggressive Behavior Scale (ABS) and the Depression Rating Scale (DRS) for CHEI-DC residents were compared with changes in scores for CHEI-CONT residents. Secondary outcomes included change over time for individual behavioral symptoms and indicators of cognitive and functional status coded on the MDS. RESULTS: The final matched sample (N = 178) included 62 CHEI-DC cases and 116 CHEI-CONT controls. More than half of the cohort was aged > or =85 years, and the sample was predominantly female. A diagnosis of Alzheimer's disease was documented in 40.3% of the CHEI-DC patients and in 46.5% of the CHEI-CONT patients. Behavioral worsening, indicated by an increase in the estimated mean monthly point change in ABS score, occurred in the CHEI-DC group (0.08; 95% CI, 0.01 to 0.16) but not in the CHEI-CONT group (-0.01; 95% CI, -0.06 to 0.04), and the between-group difference was significant (0.09; 95% CI, 0.01 to 0.18). There were no significant between-group differences in the mean monthly point change in mood symptoms on the DRS (0.04; 95% CI, -0.03 to 0.12). For the secondary outcomes, the mean monthly MDS point change for frequency of repetitive verbal behaviors indicated that CHEI-DC patients exhibited significantly more episodes of repetitive questioning (0.17; 95% CI, 0.05 to 0.29) and repetitive health complaints (0.16; 95% CI, 0.04 to 0.27) compared with CHEI-CONT residents. Continued use of CHEIs was associated with more time spent in leisure-related activities over the study period (-0.26; 95% CI, -0.50 to -0.02), with the CHEI-DC group spending less time in activities (0.11; 95% CI, 0 to 0.23); the between-group difference was also significant (0.37; 95% CI, 0.10 to 0.65). CONCLUSION: Results of this retrospective analysis suggest that, compared with longer duration of CHEI therapy, discontinuation of CHEIs in these nursing home residents with dementia was associated with some adverse behavioral changes and decreased time spent engaging in leisure-related activities.

Do internal medicine residents find pain medication agreements useful?

BACKGROUND: Little is known about whether internal medicine residents find pain management agreements (PMAs) useful or whether PMA use is associated with more positive attitudes toward patients with chronic noncancer pain (CNCP). METHODS: We surveyed all internal medicine residents at Rhode Island Hospital regarding whether they found PMAs useful, what percentage of their patients taking chronic opioids had a signed PMA, and their attitudes toward and experiences with managing CNCP. RESULTS: Survey response rate was 89% (110/124). Ninety percent of respondents reported finding PMAs useful. A majority of respondents reported that PMAs were at least somewhat helpful for reducing multiple prescribers (76%), reducing requests for early refills (67%), reducing calls and pages from patients (57%), making it easier to discuss potential problems associated with chronic opioid use (73%), and making it easier to identify patients who are abusing pain medications (66%). Residents who reported greater use of PMAs reported a greater sense of preparation (r=0.20, P=0.04), greater confidence (r=0.18, P=0.06), and a greater sense of reward (r=0.24, P=0.02) for managing CNCP. In a multivariate analysis, PMA use was significantly associated with greater sense of preparation and greater sense of reward for managing CNCP. CONCLUSIONS: Among internal medicine residents, PMA use was associated with more positive attitudes toward CNCP management.

Comparing HbA1C by POC and HPLC.

OBJECTIVE: Point-of-care (POC) Hemoglobin A1C (HbA1C) testing is frequently used to assess glycemic control in diabetes management. Studies are lacking on the comparison of POC with high performance liquid chromatography (HPLC) when the POC HbA1C is ≥ 14%. METHODS: Retrospective chart review of children with T1DM at Rhode Island Hospital from 2007-2013. Primary objective was to delineate the range of HPLC HbA1C values when the POC is ≥ 14% and characterize these patients. PRIMARY RESULTS: There were 72 patients, 5-21 years old, with corresponding POC and HPLC tests. Nineteen children, mean age 16.1 years, had a POC HbA1C ≥ 14%. Their mean HPLC value was 14.1% (95% CI [13.4, 14.8]), with range 11.1-16.3 and standard deviation 1.4%. CONCLUSION: There is wide variation when POC HbA1C values are ≥ 14%. We suggest routine central HbA1C testing when the POC is ≥ 14% for proper counseling and follow-up of glycemic control. Tracking relative changes in HbA1C at subsequent clinic visits is important as it allows clinicians to gauge whether or not interventions are effective. Additionally, knowledge that their HbA1C is trending down may provide positive reinforcement to adolescents.

Self-confidence in and perceived utility of the physical examination: a comparison of medical students, residents, and faculty internists.

BACKGROUND AND OBJECTIVES: Little is known about the differences in attitudes of medical students, Internal Medicine residents, and faculty Internists toward the physical examination. We sought to investigate these groups' self-confidence in and perceived utility of physical examination skills. DESIGN AND PARTICIPANTS: Cross-sectional survey of third- and fourth-year medical students, Internal Medicine residents, and faculty Internists at an academic teaching hospital. MEASUREMENTS: Using a 5-point Likert-type scale, respondents indicated their self-confidence in overall physical examination skill, as well as their ability to perform 14 individual skills, and how useful they felt the overall physical examination, and each skill, to be for yielding clinically important information. RESULTS: The response rate was 80% (302/376). The skills with overall mean self-confidence ratings less than "neutral" were interpreting a diastolic murmur (2.9), detecting a thyroid nodule (2.8), and the nondilated fundoscopic examination using an ophthalmoscope to assess retinal vasculature (2.5). No skills had a mean utility rating less than neutral. The skills with the greatest numerical differences between mean self-confidence and perceived utility were distinguishing between a mole and melanoma (1.5), detecting a thyroid nodule (1.4), and interpreting a diastolic murmur (1.3). Regarding overall self-confidence, third-year students' ratings (3.3) were similar to those of first-year residents (3.4; p = .95) but less than those of fourth-year students (3.8; p = .002), upper-level residents (3.7; p = .01), and faculty Internists (3.9; p < .001). CONCLUSIONS: Self-confidence in the physical exam does not necessarily increase at each stage of training. The differences found between self-confidence and perceived utility for a number of skills suggest important areas for educational interventions.

Lower syringe sharing and re-use after syringe legalization in Rhode Island.

Increased access to sterile syringes reduces the transmission of HIV, viral hepatitis and other infectious diseases, without increasing injection drug use. In Rhode Island, in 2000, syringes were legalized to reduce spread of disease but remained outlawed in Massachusetts until 2006. Drug users undergoing inpatient detoxification in Rhode Island and Massachusetts were surveyed about their syringe usage between October 2001 and August 2003. Two hundred forty-seven Rhode Island, and 226 Massachusetts inpatients completed surveys. Of these, 61% (n=151) from Rhode Island and 46% (n=105) from Massachusetts reported injecting within 6 months. Respondents from Rhode Island reported reusing a syringe in the last 30 days less often than Massachusetts respondents (0.35 versus 0.50; 95% CI on difference 0.01-0.29). Syringe re-use and sharing among drug injectors in Rhode Island was markedly lower than in Massachusetts. This difference is attributed at least in part to the legalization of non-prescription sterile syringes in Rhode Island in 2000. Laws and policies that increase legal syringe availability can decrease injection related transmission of HIV and other infectious diseases.

Pediatric Diabetes Outpatient Center at Rhode Island Hospital: The impact of changing initial diabetes education from inpatient to outpatient.

BACKGROUND: This study compared outcomes and costs for new-onset Type 1 diabetes mellitus (T1DM) patients educated at the outpatient versus inpatient settings. METHODS/DESIGN: Retrospective study examining the following variables: 1) hemoglobin A1c (HbA1c), 2) severe hypoglycemia, 3) admissions for diabetic ketoacidosis (DKA) or ER visits, and 4) healthcare cost. RESULTS: 152 patients with new-onset T1DM from September 2007-August 2009. There were no differences between outpatient group (OG) and inpatient group (IG) in mean HbA1c levels at 1, 2 and 3 years post-diagnosis (OG 8%, 8.5%, 9.3%; IG 8.3%, 8.9%, 9%, p=0.51). Episodes of severe hypoglycemia, DKA, and ER visits were not different between the two groups. Mean total hospital costs for OG and pure OG were significantly less than IG (OG: $2886 vs. IG: $4925, p<0.001), (pure OG: $1044 vs. IG: $4925, p<0.0001). CONCLUSION: Our study demonstrates that outpatient- based pediatric diabetes education lowers healthcare cost without compromising medical outcomes. [Full article available at http://rimed.org/rimedicaljournal-2017-02.asp].