Predictors for emergency readmission in patients with ureteral calculi: a focus on pain management and stone location.

BACKGROUND: The management of patients with ureteral calculi in the emergency department (ED) remains challenging due to high revisit rates. PURPOSE: To identify predictors of revisits among patients with ureteral calculi in the ED. DESIGN, SETTING, AND PARTICIPANTS: Data from patients who presented at a tertiary academic hospital in Seoul, Republic of Korea, between February 2018 and December 2019, were analyzed retrospectively. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Variables, including the respiratory rate (RR), estimated glomerular filtration rate (eGFR), duration of pain, number of analgesic doses, location of ureteral calculi, and ED length of stay (LOS) were examined using logistic regression. We also examined some additional variables included in the STONE and CHOKAI scoring systems to examine their association with revisit. RESULTS: Significant predictors of revisits included the number of analgesic doses and the location of ureteral calculi. Patients who required multiple analgesic doses or those with proximal or mid-ureteral calculi were more likely to revisit the ED. Although the STONE and CHOKAI scores could predict uncomplicated ureteral calculi, we found that the CHOKAI score is a valuable tool for predicting the likelihood of patient revisits (p = 0.021). CONCLUSIONS: Effective pain management and consideration of calculi location are important for predicting patient revisits. More research is required to validate findings, develop precise predictive models, and empower tailored care for high-risk patients. In patients with ureteral calculi in the ED, the number of analgesics given and stone location predict return visits. Proximal ureteral calculi on CT may require early urologic intervention to prevent pain-related revisits.

Emergency department 30-Day emergency department revisits among people with sickle cell disease: Variations in characteristics.

People with sickle cell disease (SCD) often have emergency department (ED) revisits. The characteristics of people with SCD with ED revisits were assessed in this study using Medicaid administrative claims data from California and Georgia, representing 2794 and 3641 individuals with SCD, respectively. In both states, those with 6+ primary care provider (PCP) encounters had the highest percentage of ED revisits. In California, those with 6+ hematology encounters had the lowest percentage of individuals with an ED revisit; in Georgia, those with 1-2 hematology encounters. Increasing access to hematologic care may reduce ED revisits among people with SCD.

Chief complaints and computed tomography results in the emergency department: a three-year retrospective cohort study.

BACKGROUND: Computed tomography (CT) is frequently performed in the patients who admitted to the emergency department (ED), discharged but returned to ED within 72 h. It is unknown whether the main complaints of patients assist physicians to use CT effectively. This study aimed to find the association between chief complaints and the CT results. METHODS: This three-year retrospective cohort study was conducted in the ED of a tertiary medical center. Adult patients who returned to the ED after the index visit were included from 2019 to 2021. Demographics, pre-existing diseases, chief complaints, and CT region were recorded by independent ED physicians. A logistic regression model with an odds ratio (OR) and 95% confidence interval (CI) was used to determine the relationship between chief complaints and positive CT results. RESULTS: In total, 7,699 patients revisited ED after the index visit; 1,202 (15.6%) received CT. The top chief complaints in patients who received CT were abdominal pain, dizziness, and muscle weakness. Patients with abdominal pain or gastrointestinal symptoms had a significantly higher rate of positive abdominopelvic CT than those without it (OR 2.83, 95% CI 1.98-4.05, p < 0.001), while the central nervous system and cardiopulmonary chief complaints were not associated (or negatively associated) with new positive CT findings. CONCLUSION: Chief complaints of patients on revisit to the ED are associated with different yields of new findings when CT scans of the chest, abdomen and head are performed. Physicians should consider these differential likelihoods of new positive findings based on these data.

The association of potentially inappropriate medications, polypharmacy and anticholinergic burden with readmission and emergency room revisit after discharge: A hospital-based retrospective cohort study.

AIMS: While certain drug-use indicators are known to be associated with clinical outcomes, the relationship is unclear for some highly prevalent conditions in in patients aged ≥65 years. We examine correlations between 3 drug-use indicators and postdischarge healthcare services use by older patients according to the presence of dementia, advanced age and frailty. METHODS: This retrospective cohort study analysed data collected from hospital electronic health records between April and December 2017. Potentially inappropriate medications (PIMs) and anticholinergic burden were assessed using the 2015 Beers Criteria and anticholinergic cognitive burden scale (ACBS) score. Minor and major polypharmacy were defined as the use of 5-9 and ≥10 drugs, respectively. Outcomes were set as emergency room revisits and readmissions at 1, 3 and 6 months postdischarge. The correlation between drug-use indicators and outcomes was analysed by multivariable logistic regression. RESULTS: The final cohort included 3061 patients for the analysis, and 2930, 2671 and 2560 patients were followed up to 1, 3 and 6 months after discharge. After controlling for confounders, all 3 drug-use indicators were significantly associated with readmission and emergency room revisits except for the relationship between PIMs and readmission within 6 months. These associations were significantly observed among patients without dementia, aged >80 years and with frailty. CONCLUSION: PIMs, polypharmacy and anticholinergic burden are common at discharge and correlate with future use of healthcare services. In older patients, the absence of dementia, advanced age and frailty should be given extra consideration with regard to medication safety.

Long-acting family planning switching and associated factors among revisit women in Toke Kutaye district of West Shoa Zone, Oromia Region public health facilities, Ethiopia: a mixed methods study.

BACKGROUND: Switching from a long-acting family planning (LAFP) method to another could lead to an unintended pregnancy. However, the proportions of LAFP method switching and predictable factors are not well addressed. Therefore, the aim of this study was to determine the magnitude of LAFP method switching and associated factors among revisit women. The study also explored the reasons for the LAFP method switching among the revisited women. METHOD: A mixed methods study was conducted among 377 reproductive age women attending public health facilities in Toke Kutaye district, West Shoa, Zone, Ethiopia, from 20 May 2021 to 28 July 2021. A systematic random sampling for quantitative and purposive sampling technique for qualitative study was used to select the study participants. A pretested structured questionnaire and in-depth interview were used to determine and explore long-acting family planning switching among revisit women. Data were analysed by Statistical Package for the Social Sciences (SPSS) version 21. Binary logistic regression was conducted to identify the dependent and independent variables at p-value < 0.05 along with 95% Confidence Interval (CI) and Adjusted Odds Ratio (AOR). The qualitative data were analysed using thematic analysis. RESULTS: The magnitude of long-acting family planning method switching was 53.3%. Switching from an implant to other short-acting method was 39.8%, and switching from an intrauterine contraceptive device (IUCD) to other short-acting method was 13.5%. A formal education (AOR, 10.38, 95% CI: 3.48, 30.95), birth spacing (AOR, 5.52, 95% CI: 1.31, 23.33) and perceived infertility (AOR, 11.16, 95% CI: 5.55, 22.45) were factors associated with LAFP switching. The qualitative findings revealed that fear of side effects, lack of adequate information, religion, and misconceptions hinder users from maintaining the LAFP. CONCLUSIONS: The study finds that the proportion of women switching from long-acting family planning was relatively higher than in other studies. The main reasons for LAFP switching were fear of side effects, lack of adequate information specific to LAFP and misconceptions. Therefore, the provision of quality contraceptive counselling by the service providers may mitigate the concern of IUD and implant switching. Furthermore, future prospective research at a larger sample size is needed.

Hyperkalemia in acute heart failure: Short term outcomes from the EAHFE registry.

OBJECTIVE: Both hyperkalemia (HK) and Acute Heart Failure (AHF) are associated with increased short-term mortality, and the management of either may exacerbate the other. As the relationship between HK and AHF is poorly described, our purpose was to determine the relationship between HK and short-term outcomes in Emergency Department (ED) AHF. METHODS: The EAHFE Registry enrolls all ED AHF patients from 45 Spanish ED and records in-hospital and post-discharge outcomes. Our primary outcome was all-cause in-hospital death, with secondary outcomes of prolonged hospitalization (>7 days) and 7-day post-discharge adverse events (ED revisit, hospitalization, or death). Associations between serum potassium (sK) and outcomes were explored using logistic regression by restricted cubic spline (RCS) curves, with sK =4.0 mEq/L as the reference, adjusting by age, sex, comorbidities, patient baseline status and chronic treatments. Interaction analyses were performed for the primary outcome. RESULTS: Of 13,606 ED AHF patients, the median (IQR) age was 83 (76-88) years, 54% were women, and the median (IQR) sK was 4.5 mEq/L (4.3-4.9) with a range of 4.0-9.9 mEq/L. In-hospital mortality was 7.7%, with prolonged hospitalization in 35.9%, and a 7-day post-discharge adverse event rate of 8.7%. Adjusted in-hospital mortality increased steadily from sK ≥4.8 (OR = 1.35, 95% CI = 1.01-1.80) to sK = 9.9 (8.41, 3.60-19.6). Non-diabetics with elevated sK had higher odds of death, while chronic treatment with mineralocorticoid-receptor antagonists exhibited a mixed effect. Neither prolonged hospitalization nor post-discharge adverse events was associated with sK. CONCLUSION: In ED AHF, initial sK >4.8 mEq/L was independently associated with in-hospital mortality, suggesting that this cohort may benefit from aggressive HK treatment.

Patients' experiences and reasons for unplanned return visits to the emergency department: A qualitative study.

AIMS: The aim of this study was to explore the reasons for and experiences of patients who make an unplanned return visit to the emergency department. DESIGN: This study forms the qualitative phase of a larger explanatory sequential mixed methods study and is informed by interpretive description. The paper was prepared using the consolidated criteria for reporting qualitative research. METHODS: Semi-structured patient interviews were conducted over a 3-month period (July-September 2021). Data were analysed using reflexive thematic analysis. RESULTS: Interviews from 13 participants generated findings related to experiences at and following their initial visit that contributed to their decision to return to the emergency department. Four themes were developed: (1) Patients experience barriers to feeling heard and having their concerns addressed; (2) Patients have little choice but to place their trust in clinicians; (3) Patients unexpectedly experience persistent symptoms which cannot be managed at home; and (4) Patients develop a sense of urgency about having their condition treated. CONCLUSION: A negative experience at the initial ED visit may have dual conflicting impacts. It can contribute to patients' perceived need for a return visit because they are ill-equipped to manage their condition at home, and it can also contribute to their initial reluctance to return to the ED when symptoms persist. Nurses and other clinicians working in ED need to actively build patient's experiential trust through clear communication, timely consultation and shared decision-making at discharge, which in turn can increase patient's confidence and capability to self-manage their condition. This study adds to the current body of literature about return visits by highlighting that a more positive experience of ED may assist patients to make better-informed decisions about when and how to seek treatment and minimize unnecessary and unplanned return visits. Whilst not an intended topic for exploration in this study, the COVID-19 pandemic influenced patients' experiences at both initial and return ED visits and limited their ability to access primary healthcare options. These experiences contributed to patients' decisions to make a return visit.

Differences in the characteristics and patterns of adult emergency department return visits before and after the coronavirus disease 2019 outbreak.

BACKGROUND: Data about changes in the characteristics of ED return visits before and after the COVID-19 outbreak are limited. This study aimed to report the differences on utility in ED return visits after the COVID-19 outbreak. METHODS: This retrospective cohort study was conducted from 2019 to 2020. Adult patients with ED return visits were included in the analysis. Variables including demographic characteristics, pre-comorbidities, triage levels, vital signs, chief complaints, management, and diagnosis were recorded and confirmed via a manual assessment. RESULTS: The proportion of patients with ED visits decreased by 23%. Hence, that of patients with ED return visits also reduced from 2580 to 2020 patients (22%) after the COVID-19 outbreak. The average age (60-57.8 years) of patients with return visits was significantly younger, and the proportion of female patients decreased remarkably. Further, the proportion of patients with chronic pre-existing diseases at the return visit significantly differed after the COVID-19 outbreak. The proportion of patients with chief complaints including dizziness, dyspnea, cough, vomiting, diarrhea, and chills during the return visits significantly differed before and after the COVID-19 pandemic. In the multivariable logistic regression model, age, high triage level were significantly associated with unfavorable outcome return visit. CONCLUSION: The use of services in the ED has changed since the COVID-19 outbreak. Hence, the proportion of patients with unplanned return visits within 72 h decreased. After the COVID-19 outbreak, people are now cautious whether they should return to the ED, as in the pre-pandemic situation, or just treat conservatively at home.

[Validation of the COVID-19-12O score for predicting readmissions/revisits in patients with SARS-CoV-2 pneumonia discharged from the emergency department]. / Validación de la escala COVID-19-12O para predecir reingreso/revisita en pacientes con neumonía por SARS-CoV-2 dados de alta desde Urgencias.

Objective: The COVID-19-12O score has been validated for determining the risk of respiratory failure in patients hospitalized due to COVID-19. This study aims to assess whether the score is effective for predicting readmissions and revisits in patients with SARS-CoV-2 pneumonia discharged from a hospital emergency department (HED). Method: This work is a retrospective cohort of consecutive patients with SARS-CoV-2 pneumonia discharged from the HED of a tertiary hospital from January 7 to February 17, 2021. The COVID-19-12O score with a cut-off point of nine points was used to define the risk of admissions or revisits. The primary outcome variable was a revisit with or without hospital readmission after 30 days of discharge from the HED. Results: Seventy-seven patients were included. The median age was 59 years, 63.6% were men, and the Charlson Comorbidity Index was 2. A total of 9.1% had an emergency room revisit and 15.3% had a deferred hospital admission. The relative risk (RR) for an HED revisit was 0.46 (0.04-4.62, 95% CI p = 0.452) and the RR for hospital readmission was 6.88 (1.20-39.49, 95% CI, p < 0.005). Conclusions: The COVID-19-12O score is effective in determining the risk of hospital readmission in patients discharged from an HED with SARS-CoV-2 pneumonia, but is not useful for assessing the risk of revisit.

Secondary asthma prevention measures are not adequately addressed prior to emergency department discharge!

BACKGROUND: Exacerbations of acute asthma are frequent presentations to the Emergency Department (ED) and contribute to ED overcrowding and healthcare cost. The purpose of this study was to evaluate whether ED clinicians are implementing secondary asthma prevention measures prior to discharging patients after an acute asthma exacerbation and also to determine whether ED clinicians are able to correctly demonstrate how to use an asthma metered dose inhaler (MDI) device. METHODS: Consenting doctors employed at four EDs situated in the Gauteng province of South Africa were asked to complete a questionnaire and thereafter demonstrate the technique of using an MDI device. Collected data was presented using descriptive statistics. RESULTS: Eighty-six doctors were included in the study. Of these, 18 (20.9%) routinely checked that inhaler technique was correct, 50 (58.1%) routinely enquired regarding adherence to their asthma treatment, 8 (9.3%) routinely informed patients of the side effects of asthma medication, 16 (18.6%) routinely provided patients with a written asthma action plan, 7 (8.1%) routinely evaluated for the presence of concurrent allergic rhinitis and 53 (61.6%) routinely counselled patients regarding smoking cessation. With regards to correctly demonstrating how to use an MDI device, only 23 (26.74%) physician participants performed all eight steps correctly. CONCLUSION: This study indicates that secondary asthma prevention measures are not adequately addressed by clinicians prior to discharging patients from the ED after an acute asthma attack. It is recommended that ED clinicians are educated with regards to the importance of these measures.

Impact of low health literacy on patients' health outcomes: a multicenter cohort study.

BACKGROUND: This study aims to assess the health literacy of medical patients admitted to hospitals and examine its correlation with patients' emergency department visits, hospital readmissions, and durations of hospital stay. METHODS: This prospective cohort study recruited patients admitted to the general internal medicine units at the two urban tertiary care hospitals. Health literacy was measured using the full-length Test of Functional Health Literacy in Adults. Logistic regression analyses were performed to examine the correlation between health literacy and the desired outcomes. The primary outcome of interest of this study was to determine the correlation between health literacy and emergency department revisit within 90 days of discharge. The secondary outcomes of interest were to assess the correlation between health literacy and length of stay and hospital readmission within 90 days of discharge. RESULTS: We found that 50% had adequate health literacy, 32% had inadequate, and 18% of patients had marginal health literacy. Patients with inadequate health literacy were more likely to revisit the emergency department as compared to patients with adequate health literacy (odds ratio: 3.0; 95% Confidence Interval: 1.3-6.9, p = 0.01). In patients with inadequate health literacy, the mean predicted probability of emergency department revisits was 0.22 ± 0.11 if their education level was some high school or less and 0.57 ± 0.18 if they had completed college. No significant correlation was noted between health literacy and duration of hospital stay or readmission. CONCLUSIONS: Only half of the patients admitted to the general internal medicine unit had adequate health literacy. Patients with low health literacy, but high education, had a higher probability of emergency department revisits.

Safety and Revisit Related to Discharge the Sixty-one Spanish Emergency Department Medical Centers Without Hospitalization in Patients with COVID-19 Pneumonia. A Prospective Cohort Study UMC-Pneumonia COVID-19.

BACKGROUND: Information is needed on the safety and efficacy of direct discharge from the emergency department (ED) of patients with COVID-19 pneumonia. OBJECTIVES: The objectives of the study were to study the variables associated with discharge from the ED in patients presenting with COVID-19 pneumonia, and study ED revisits related to COVID-19 at 30 days (EDR30d). METHODS: Multicenter study of the SIESTA cohort including 1198 randomly selected COVID patients in 61 EDs of Spanish medical centers from March 1, 2020, to April 30, 2020. We collected baseline and related characteristics of the acute episode and calculated the adjusted odds ratios (aOR) for ED discharge. In addition, we analyzed the variables related to EDR30d in discharged patients. RESULTS: We analyzed 859 patients presenting with COVID-19 pneumonia, 84 (9.8%) of whom weredischarged from the ED. The variables independently associated with discharge were being a woman (aOR 1.890; 95%CI 1.176 3.037), age < 60 years (aOR 2.324; 95%CI 1.353-3.990), and lymphocyte count > 1200/mm3 (aOR 4.667; 95%CI 1.045-20.839). The EDR30d of the ED discharged group was 40.0%, being lower in women (aOR 0.368; 95%CI 0.142-0.953). A totalof 130 hospitalized patients died (16.8%) as did two in the group discharged from the ED (2.4%) (OR 0.121; 95%CI 0.029-0.498). CONCLUSION: Discharge from the ED in patients with COVID-19 pneumonia was infrequent and was associated with few variables of the episode. The EDR30d was high, albeit with a low mortality.

Saving the hotel industry: Strategic response to the COVID-19 pandemic, hotel selection analysis, and customer retention.

This study investigates the effect of the COVID-19 pandemic on the hotel selection attributes and customer post-purchase behaviors. Qualitative and quantitative processes comprising an importance-performance analysis are used. This mixed-methods approach successfully (1) explores the hotel selection attributes after the COVID-19 pandemic, (2) uncovers the change of importance of these attributes before and after the outbreak of COVID-19, (3) identifies the importance and the performance level of the hotel selection attributes, and (4) explores the roles of the hotel selection attributes that form the overall image of a hotel and the subsequent intentions to revisit a hotel. This study includes a high degree of value, and this is the first empirical research that explores the guests' hotel choice behaviors before and after the pandemic, which can be helpful for the subsequent guest-behavior studies in the post-pandemic era.

The effect of COVID-19 on tourists' intention to resume hotel consumption: The role of resilience.

This study aims to better understand how one particular personal capacity-psychological resilience-may help consumers adapt to the 'new normal' provoked by the COVID-19 pandemic in the hotel context, which is characterized by high uncertainty. We conducted a quantitative empirical study among consumers of hotel services, which showed that their psychological resilience has a negative effect on their perceived health risk and emotional risk. This negative effect on risk helps increase tourist intention to return to consuming hotel services despite the on-going pandemic. The findings are of value to the literature and the professional sector alike, as they demonstrate both relationships jointly for the first time. The work can help hotel firms to design more effective strategies for approaching customers in the 'new normal'.

Perceived hygiene attributes in the hotel industry: customer retention amid the COVID-19 crisis.

The COVID-19 pandemic has caused a crisis in the hotel industry worldwide, but few studies have suggested methods to retain customers. This study proposes hygiene management as a means to minimize the indirect damage from COVID-19 to the hotel industry. It identifies perceived hygiene attributes and explores their influence on hotel image, word of mouth, and revisit intentions. This study identifies and validates three types of perceived hygiene attributes through qualitative and quantitative methods. It uses structural equation modeling to validate hypotheses and concludes that there are significant relationships of influence between the proposed variables. This study provides important and meaningful insights into hotel image and customer behavior through perceived hygiene attributes.

Association between Age and Umbilical Hernia Repair Outcomes in Children: A Multistate Population-Based Cohort Study.

OBJECTIVE: To evaluate whether patient age or other sociodemographic and clinical characteristics are associated with recurrence or unplanned related hospital revisits after pediatric umbilical hernia repair. STUDY DESIGN: We performed a retrospective cohort study using the Healthcare Cost and Utilization Project State Inpatient, Emergency Department, and Ambulatory Surgery and Services Databases of 7 states. Pediatric umbilical hernia repairs performed at any hospital or surgery center in 2010-2014 were included. Hernia recurrences and occurrences of unplanned and related hospital revisits within 30 days were evaluated. RESULTS: Of 9809 included patients, 52.0% were female and 50.5% were black. The 3-year hernia recurrence rate was 0.57% (95% CI 0.42, 0.73). In multivariable analysis, the recurrence rate was higher in children <4 years of age than in children 4-10 years of age (hazard ratio [HR] 1.93, 95% CI 1.09, 3.44). Unplanned related hospital revisits within 30 days occurred in 2.5% of patients. Patient characteristics associated with the risk of an unplanned related hospital revisit included age <4 years (HR 2.17, 95% CI 1.70, 2.77) or >10 years (HR 2.11, 95% CI 1.46, 3.05), public insurance (HR 2.10, 95% CI 1.58, 2.79), asthma (HR 1.74, 95% CI 1.32, 2.29), and initial presentation to the emergency department (HR 2.46, 95% CI 1.08, 5.61). CONCLUSIONS: Rates of recurrence and unplanned related hospital revisits following pediatric umbilical hernia repair are higher in children younger than 4 years of age. These findings support delaying the repair of asymptomatic umbilical hernia in children until 4 years of age.

Data mining techniques utilizing latent class models to evaluate emergency department revisits.

BACKGROUND: The use of machine learning techniques is especially pertinent to the composite and challenging conditions of emergency departments (EDs). Repeat ED visits (i.e. revisits) are an example of potentially inappropriate utilization of resources that can be forecasted by these techniques. OBJECTIVE: To track the ED revisit risk over time using the hidden Markov model (HMM) as a major latent class model. Given the HMM states, we carried out forecasting of future ED revisits with various data mining models. METHODS: Information integrated from four distributed sources (e.g. electronic health records and health information exchange) was integrated into four HMMs which capture the relationships between an observed and a hidden progression that shift over time through a series of hidden states in an adult patient population. RESULTS: Assimilating a pre-analysis of the various patients by applying latent class models and directing them to well-known classifiers functioned well. The performance was significantly better than without utilizing pre-analysis of HMM for all prediction models (classifiers(. CONCLUSIONS: These findings suggest that one prospective approach to advanced risk prediction is to leverage the longitudinal nature of health care data by exploiting patients' between state variation.

Impact of wait time during a first pediatric emergency room visit on likelihood of revisit in the next year.

OBJECTIVE: Pediatric emergency departments (ED) develop strategies to decrease wait time. Yet, lowering wait times may incite patients to come back, and increase patient volume. We aim to determine if wait time in a first visit influenced the likelihood of a revisit to the same setting. METHODS: We performed a retrospective cohort study of children with a first visit to a single pediatric ED between November 1st 2016, and October 31st 2017. First visit was defined as no visit in the same ED in the previous 12 months. The primary outcome was the occurrence of a revisit at the same ED within 12 months of the first visit. Our main predictor was the wait time at the first visit for primary evaluation by a physician. We used multivariable logistic regression models to adjust for potential risk factors (age, triage level, day of visit and disposition). RESULTS: Among 85,844 ED visits during the study period, 36,844 were first visits and fulfilled inclusion/exclusion criteria. Median wait time was 101 min (interquartile range: 56-177 min). Among those with a first visit, 11,351 (30.8%) had a revisit within 12 months. In multivariable analysis, each one hour increase in wait time was associated with a lower probability of revisit (OR: 0.92; 95% CI: 0.91-0.94). CONCLUSIONS: Shorter wait time was associated with higher likelihood of a revisit to the same ED in the following 12 months. Strategies to reduce wait times should take into consideration possible concomitant increase in patient volume.

Ecological correlates of space use patterns in wild western lowland gorillas.

The distribution of resources is a crucial determinant of animals' space use (e.g., daily travel distance, monthly home range size, and revisitation patterns). We examined how variation in ecological parameters affected variability in space use patterns of western lowland gorillas, Gorilla gorilla gorilla. They are an interesting species for investigating this topic because key components of their diet are nonfruit items (herbaceous vegetation and tree leaves) that occur at low density and are sparsely distributed, and fruits, which show high spatiotemporal variation in availability. We estimated how availability of nonfruit foods and fruit, frugivory (proportion of feeding time consuming fruit), and swamps in areas used by the gorillas influenced daily travel distance, monthly home range size, and revisit frequency to grid cells in the home range of one habituated gorilla group in Loango National Park, Gabon. Using location data from 2015 to 2018, we found that the gorillas decreased their daily travel distance as both the density of nonfruit foods and the proportion of swamps in areas used increased. Daily travel distances were shorter when both frugivory and availability of fruit were higher, yet, daily travel distances were longer when availability of fruit was low but frugivory was still high. Furthermore, monthly home range size increased as frugivory increased and monthly revisit frequencies to an area increased as fruit availability of an area increased. In conclusion, the availability of both nonfruit and fruit influenced the gorillas' space use patterns. Gorillas decreased foraging effort when food availability was high but were willing to incur increasing foraging costs to feed on fruit when availability was low. This study highlights how animals have to adjust their space use with changing resource availability and it emphasizes the value of examining multiple parameters of space use.

Methamphetamine, Amphetamine, and MDMA Use and Emergency Department Recidivism.

BACKGROUND: Emergency department (ED) recidivism and the use of amphetamine and associated derivatives such as methamphetamine and MDMA (MAE), are intersecting public health concerns. OBJECTIVE: This study aims to determine the frequency of ED recidivism of patients who use MAE and associated factors. METHODS: The study was a retrospective 6-year electronic medical record review of patients with MAE-positive toxicology screens and single and multiple ED visits in the span of 12 months. RESULTS: There were 7844 ED visits by 5568 MAE-positive patients. Average age was 42 ± 13 years. The majority were male (65%), white (46%), tobacco smokers (55%), and in the psychiatric discharge diagnostic-related group (41%), followed by blunt trauma (20%). Admission rate was 35%, with another 17% transferred to inpatient psychiatric treatment facilities. Occasional (2-5 visits/year), heavy (6-11 visits/year), and super users (≥12 visits/year) altogether accounted for 20% of patients and 43% of visits. Heavy and super users combined represented 2% of patients and 10% of visits, with significant differences for race/ethnicity, health insurance, tobacco smoking, and psychiatric/cardiovascular/trauma discharge diagnostic-related groups. Heavy and super users were less likely to be admitted and more likely to be discharged to an inpatient psychiatric treatment facility. Regression analysis revealed racial/ethnic differences, female gender, and tobacco smoking to be associated with super and heavy use. Heavy users were more likely to have cardiovascular-related discharge diagnoses. CONCLUSIONS: The prevalence of ED recidivism in patients who use MAE is similar to published ranges for general ED users. Significant differences in demographics, discharge diagnoses, insurance, smoking, and disposition exist between nonfrequent and frequent ED users.