Palliative Care and Mental Health among Pancreatic Cancer Patients in the United States: An Examination of Service Utilization and Health Outcomes.

INTRODUCTION: Palliative care (PC) utilization remains low among pancreatic cancer patients. This study explores the association of PC with mental health service and pharmacotherapy utilization among pancreatic cancer patients. METHODS: Retrospective analysis was conducted on a sample of patients in the United States with newly diagnosed pancreatic cancer using Electronic Health Record data from Optum's Integrated Claims-Clinical data set. Subsequent diagnoses of anxiety and depression and PC consultation encounters were determined using ICD-9/10 codes. Adjusted associations of mental health treatments with PC and patient characteristics were quantified using multiple logistic regression. RESULTS: Among newly diagnosed pancreatic cancer patients (n = 4029), those with PC consultations exhibited a higher prevalence of anxiety (33.9% vs. 22.8%) and depression (36.2% vs. 23.2%). Mental health service use and pharmacotherapy varied, with the highest utilization among patients having both anxiety and depression. Treatment pattern was also influenced by age (aOR 1.832 for age <55 vs. 65-70 years). Notably, PC consultations showed no significant effect on the likelihood of documented treatment. DISCUSSION: Our study emphasizes underutilization of PC and MH treatment for pancreatic cancer patients. These findings imply a crucial need for further investigation into palliative care's role in addressing mental health concerns among pancreatic cancer patients.

Prevalence and Predictors of Depression in Women with Osteoarthritis: Cross-Sectional Analysis of Nationally Representative Survey Data.

Osteoarthritis (OA) is the most common joint disease in the US and can increase the risk of depression. Both depression and OA disproportionately affect women, yet this study is one of few on depression prevalence, treatment across age groups, and predictors in women with OA. Data were extracted from the 2011-March 2020 National Health and Nutrition Examination Survey (NHANES). Women aged ≥ 45 years with self-reported osteo- or degenerative arthritis were included. Outcomes were depression (assessed with PHQ-9) and treatment (self-reported pharmacotherapy and mental health services). Logistic regression was used to examine associations between age group, covariates, and outcomes. Overall, depression prevalence was 8%, with higher proportions among those 45-64 years old. Aging was associated with reduced odds of depression (Age 65-79: OR 0.68 (95% CI: 0.52-0.89); Age 80+: OR 0.49 (95% CI: 0.33-0.74); vs. Age 45-54). Of those with a positive depression screen, 21.6% documented some form of treatment. Age group was not statistically different between those treated and those not treated. Women aged 45-64 with osteoarthritis may be at increased risk of depression, and most are not treated. As depression is related to increased pain and risk of rehospitalization, future research should prioritize interventions to increase uptake of depression treatment.

Propofol Versus Dexmedetomidine for Procedural Sedation in a Pediatric Population.

OBJECTIVES: Frequently, infants and children require sedation to facilitate noninvasive procedures and imaging studies. Propofol and dexmedetomidine are used to achieve deep procedural sedation in children. The objective of this study was to compare the clinical safety and efficacy of propofol versus dexmedetomidine in pediatric patients undergoing sedation in a pediatric sedation unit. METHODS: A retrospective analysis of patients sedated with either propofol or dexmedetomidine in a pediatric sedation unit by pediatric emergency physicians was performed. Both medications were dosed per protocol with propofol 2 mg/kg induction and 150 µg · kg-1 · min-1 maintenance and dexmedetomidine 3 µg/kg induction for 10 minutes and 2 µg · kg-1 · h-1maintenance. The variables collected included drug dose, sedation time (time that the drug was given to the completion of the procedure), recovery time (end of the study to the return to the presedation sedation score for 15 minutes), need for dose rate changes, airway management, and adverse events. RESULTS: A total of 2432 children were included- 1503 who received propofol and 929 who received dexmedetomidine. Propofol and dexmedetomidine resulted in successful completion of the study in 98.8% and 99.7%, respectively (P = 0.02). The mean recovery time for propofol was 34.3 minutes, compared with 65.6 minutes for dexmedetomidine (P < 0.001). The need for unexpected airway management was 9.7% for propofol and 2.2% for dexmedetomidine (P < 0.001). Adverse events occurred in 8.6% and 6% of patients in the propofol and dexmedetomidine groups, respectively (P = 0.02). CONCLUSIONS: Propofol use led to significantly shorter recovery times, with an increased need for airway management, but rates of bag-mask ventilation (2.3%), airway obstruction (1.1%), and desaturation (1.6%) were low. No patients required intubation. Propofol is a reasonable alternative to dexmedetomidine, with a clinically acceptable safety profile.

Emergency Department Diagnosis of Dietl Crisis in a 7-Year-Old Girl With Abdominal Pain.

Children with Dietl crisis often experience a delay in diagnosis, with the clinical entity being underdiagnosed. Pain is caused by compression of an aberrant artery crossing dilated kidney. Pain is often worsened after the consumption of liquids and resolves after fluid reabsorption. There are no clear criteria for evaluating ureter obstruction in childhood abdominal pain in the emergency department setting; however, it has been suggested that ultrasound may aid in the diagnosis. As renal parenchyma is typically preserved, and there is a paucity of associated urological complaints, once properly diagnosed, most patients are well served by a pyeloplasty.

Fever phobia: a survey of caregivers of children seen in a pediatric emergency department.

BACKGROUND: Fever continues to be the most common complaint of children seen in a Pediatric Emergency Department (PED). Previous studies have assessed the prevalence of fever phobia in various populations. This study aims to document the incidence of fever phobia in a PED. METHODS: Through convenience sampling, caregivers of children seen in a PED were surveyed using a research-assistant-administered questionnaire. The survey contained 28 questions pertaining to caregivers' perceptions, attitudes, and behaviors regarding fever in children. RESULTS: In all, 230 caregivers were surveyed. The median temperature considered to be a fever was 37.8 degrees C (100.0 degrees F), with a range of 36.1 degrees C (97 degrees F) to 40.6 degrees C (105 degrees F), whereas the median temperature considered to result in harmful consequences was 40.6 degrees C (105 degrees F), with a range of 37.8 degrees C (100 degrees F) to 43.3 degrees C (110 degrees F). The median temperature at which antipyretics would be administered was 37.8 degrees C (100 degrees F), with a range of 36.1 degrees C (97 degrees F) to 39.4 degrees C (103 degrees F). More than one third of caregivers reported that they would administer antipyretics inappropriately. The median temperature at which a child would be taken to the PED was 39.4 degrees C (103 degrees F), with a range of 36.7 degrees C (98 degrees F) to 40.8 degrees C (105.4 degrees F). There was also a relationship between level of education and level of fever concern. CONCLUSION: Fever phobia and inappropriate treatment for febrile children is present among caregivers of patients seen in a PED. Level of education may be a factor in fever knowledge and practices. Overly zealous, potentially harmful home practices and unnecessary PED visits for the assessment and treatment of fever in children is widespread among caregivers surveyed in the PED.

Biologic and chemical terrorism in children: an assessment of residents' knowledge.

This study was conducted to determine the baseline fund of knowledge of pediatric and emergency medicine residents at a single institution in the medical management of pediatric victims of biologic and chemical terrorism. A test covering essential content was developed and validated by experts. The test was given anonymously to volunteer pediatric and emergency medicine residents at a single institution. The test was readministered 5 months after a lecture on the content. The 34 pediatric residents and 15 emergency medicine residents scored a median of 65% and 73%, respectively (P = .03). Residents from both specialties combined scored a median of 70% correct versus those residents who did not attend the lecture. Pediatric and emergency medicine residents are significantly unprepared to manage pediatric victims of biologic and chemical terrorism. Education curriculums on this topic must be incorporated into these residencies. The traditional lecture format may not be the most effective technique.

Prudent layperson definition of an emergent pediatric medical condition.

This study was designed to assess how well parents rated pediatric medical conditions based on their perceived degree of urgency so as to determine if the "Prudent Layperson Standard'' is reasonable. A self-administered, supervised survey was given to a convenience sample of 340 caregivers in the emergency department of an urban children's hospital. Respondents were asked to rank the urgency of 15 scenarios. A caregiver response within 1 point of the physician score was considered concordant with medical opinion. A 2-week-old infant with a rectal temperature of 103.7 degrees F was the only emergent scenario underestimated by caregivers. A 1 1/2-yr-old child with an upper respiratory tract infection, a 7-year-old child with ringworm, an 8-month-old infant with a simple forehead contusion, and a 4-year-old child with conjunctivitis were the non-urgent scenarios overestimated by caregivers. Laypeople are able to identify cases constructed to represent obvious pediatric medical emergencies. Several patient subgroups frequently overestimate medical urgency.

Near strangulation as a result of hair tourniquet syndrome.

Hair tourniquet syndrome has been a recognized clinical entity for many decades. In this syndrome, hair becomes tightly wrapped around an appendage, usually that of an infant. Body parts involved include the finger, toe, penis, clitoris, and uvula. The end result of necrosis is also well documented. In this report, an 11-month-old girl with hair tourniquet syndrome causing signs and symptoms of an acute strangulation is presented.

A prospective study of the "two-bag system'' in diabetic ketoacidosis management.

The "two-bag'' system, an adaptation of the euglycemic clamp technique, consists of simultaneous administration of 2 intravenous (IV) fluid bags of differing dextrose concentrations. Individualized therapy is dictated by adjustment of the infusion rate of each bag. We sought to assess the benefits of the two-bag system in the initial acute emergency department management of children in diabetic ketoacidosis (DKA). Thirty-three children presenting to an urban pediatric emergency department in DKA were randomized into 2 groups: patients managed with the two-bag system and patients managed with the traditional "one-bag'' system. Other aspects of the management were standardized. Outcome measures included rate of decline in serum glucose, rate of bicarbonate correction, time on IV insulin therapy, and response time for IV fluid changes. Study period was defined as time on IV insulin therapy. There were no differences between the 2 groups in demographic parameters, initial baseline metabolic parameters, or total time on IV insulin therapy. There were no differences between the groups in average rates of serum glucose decline: two-bag 33.1 mg/dL/hr (s.e. 5.57, 95% CI 22.2, 44), one-bag 30.2 mg/dL/hr (s.e. 5.72, 95% CI 19, 41.4); average rate of serum bicarbonate correction: two-bag 1.19 mEq/L/hr, one-bag 1.27 mEq/L/hr; or the average number of IV fluid bags used: two-bag 4.1 bags, one-bag 3.2 bags. However, there was a difference between the groups in regard to elapsed total time to make changes in the IV fluids: two-bag 1 minute, one-bag 42 minutes, (p < 0.001). The "two-bag'' system enables a faster response time in making IV fluid therapy changes. This efficiency makes this system ideal for use in the emergency department.

Factors used by pediatric emergency medicine program directors to select their fellows.

BACKGROUND: Pediatric emergency medicine (PEM) recently has become a highly competitive subspecialty with twice the number of applicants for positions available. Little information exists on the characteristics that PEM programs desire in their applicants. We sought to assess the factors used by PEM program directors when ranking PEM fellow applicants in the National Resident Match Program (NRMP). METHODS: A 47-item questionnaire (adapted from a previously published questionnaire) was designed to assess the relative importance of various factors in the ranking of PEM fellow applicants in the NRMP. The questionnaire was mailed to all 43 PEM program directors that participated in the 2001 NRMP. The program directors were asked to grade selection factors based on a five-point Likert scale: 1, unimportant; 2, somewhat important; 3, important; 4, very important; 5, critical. The factors addressed in the questionnaire included academic criteria, letters of recommendation, applicant characteristics, and aspects of the interview. In addition, we asked 10 yes-or-no questions pertaining to specific aspects of each program. Responses were tabulated and means and standard deviations reported. RESULTS: A program response rate of 93% (40/43) was obtained. The most important factors in granting an interview were recommendations from colleagues in PEM (4.21 +/- 0.78), research potential (3.81 +/- 1.10), and reputation of the applicant's pediatric program (3.51 +/- 0.91). The least important factors in granting an interview were reputation of the applicant's undergraduate institution (1.76 +/- 0.86), medical school grades (1.83 +/- 0.87), and board scores (2.11 +/- 0.91). Letters from division chiefs of PEM (4.15 +/- 0.78) and clinical faculty in PEM (4.06 +/- 0.82) were considered the most important letters of recommendation, whereas letters from basic science faculty were considered the least important (1.89 +/- 0.96). Ability to work with a team (4.66 +/- 0.42), compatibility with the program (4.65 +/- 0.35), commitment to hard work (4.55 +/- 0.45), ability to grow in knowledge (4.41 +/- 0.58), ability to solve problems (4.36 +/- 0.63), ability to listen (4.34 +/- 0.65), and ability to articulate thoughts (4.32 +/- 0.59) were the most important characteristics in the final ranking of candidates. Thirty percent (12/40) of the program directors stated that it was important for the program to "match" its top choice. The majority of programs have a selection committee that contributes to the final ranking of applicants. CONCLUSIONS: The results of this study suggest that a rather subjective but uniform prioritization of criteria is used in evaluating PEM program applicants. Awareness of these factors would enable applicants to make a critical self-analysis of their strengths and weaknesses prior to the submission of their applications.