Prevalence, Trends, and Outcomes of Pulmonary Embolism Treated with Mechanical and Surgical Thrombectomy from a Nationwide Inpatient Sample.

Pulmonary embolism (PE) is the third most common vascular disease in the US, a frequently underdiagnosed and potentially fatal condition where embolic material blocks one or more pulmonary arteries impairing blood flow. In this study, we aim to describe the prevalence, outcomes, and predictors of mortality of PE patients treated with mechanical (MT) and surgical thrombectomy (ST). This is a retrospective study using the Agency for Healthcare Research and Quality's HCUP NIS data from 2010−2018. We used the ninth and tenth revisions of the International Classification of Diseases clinical modification codes (ICD-9-CM and ICD-10-CM) to identify patients admitted with a primary diagnosis of PE (ICD-10-CM codes I26.02, I26.09, I26.92, I26.93, I26.94, and I26.99; ICD-9-CM codes 415.11, 415.13, and 415.19). We extracted demographics, hospital-level, and patient-level characteristics, and defined the severity of comorbid conditions using Deyo modification of the Elixhauser Comorbidity Index. The primary outcomes of interest were the utilization trends of PE (treated with MT and ST); the secondary outcomes were mortality, discharge to facility, peri-procedural complications, and length of hospital (LOS) stay; the tertiary outcome was to identify the predictors of in-hospital mortality. From 2010−2018, there were 1,627,718 hospitalizations for PE, of which 6531 (0.39%) underwent MT and 3465 (0.21%) underwent ST. The utilization trend of MT increased from 336 (0.20%) in 2010 to 1655 (0.87%) in 2018; the utilization trend of ST was 260 (0.15%) in 2010 and 430 (0.23%) in 2018. The unadjusted in-hospital mortality for MT was 9.1% with the mean LOS being 7(±0.3) days; for ST, mortality was 13.9% with a mean LOS of 13(±0.4) days. The occurrences of periprocedural complications for MT and ST were as follows: invasive mechanical ventilation was 13.8% and 32%; cardiopulmonary bypass was 3.3% and 68.3%; pulmonary embolectomy surgery was 1.7%; and bleeding complications were 1.4% and 3.4%. Predictors associated with in-hospital mortality for MT were: increasing age (OR 1.2, 95% CI 1.0−1.3, p < 0.026), female sex (OR 1.9, 95% CI 1.2−2.8, p < 0.004), large hospitals (OR 2.2, 95% 1.4−3.5, p < 0.001), and teaching hospitals (OR 1.8, 95% CI 1.1−3.1, p < 0.023). The predictor of in-hospital mortality for ST was increasing age (OR 1.2, 95% CI 1.0−1.4, p < 0.046). The number of MT procedures performed has rapidly increased over the past decade. Further studies are warranted to determine their rise and therapeutic use.

Geographic information system-based mapping of air pollution & emergency room visits of patients for acute respiratory symptoms in Delhi, India (March 2018-February 2019).

Background & objectives: Studies assessing the spatial and temporal association of ambient air pollution with emergency room visits of patients having acute respiratory symptoms in Delhi are lacking. Therefore, the present study explored the relationship between spatio-temporal variation of particulate matter (PM)2.5 concentrations and air quality index (AQI) with emergency room (ER) visits of patients having acute respiratory symptoms in Delhi using the geographic information system (GIS) approach. Methods: The daily number of ER visits of patients having acute respiratory symptoms (less than or equal to two weeks) was recorded from the ER of four hospitals of Delhi from March 2018 to February 2019. Daily outdoor PM2.5 concentrations and air quality index (AQI) were obtained from the Delhi Pollution Control Committee. Spatial distribution of patients with acute respiratory symptoms visiting ER, PM2.5 concentrations and AQI were mapped for three seasons of Delhi using ArcGIS software. Results: Of the 70,594 patients screened from ER, 18,063 eligible patients were enrolled in the study. Winter days had poor AQI compared to moderate and satisfactory AQI during summer and monsoon days, respectively. None of the days reported good AQI (<50). During winters, an increase in acute respiratory ER visits of patients was associated with higher PM2.5 concentrations in the highly polluted northwest region of Delhi. In contrast, a lower number of acute respiratory ER visits of patients were seen from the 'moderately polluted' south-west region of Delhi with relatively lower PM2.5 concentrations. Interpretation & conclusions: Acute respiratory ER visits of patients were related to regional PM2.5 concentrations and AQI that differed during the three seasons of Delhi. The present study provides support for identifying the hotspots and implementation of focused, intensive decentralized strategies to control ambient air pollution in worst-affected areas, in addition to the general city-wise strategies.

Effects of ambient air pollution on emergency room visits of children for acute respiratory symptoms in Delhi, India.

The present study explored the association between daily ambient air pollution and daily emergency room (ER) visits due to acute respiratory symptoms in children of Delhi. The daily counts of ER visits (ERV) of children (≤15 years) having acute respiratory symptoms were obtained from two hospitals of Delhi for 21 months. Simultaneously, data on daily concentrations of particulate matter (PM10 and PM2.5), nitrogen dioxide (NO2), sulfur dioxide (SO2), carbon monoxide (CO), and ozone (O3) and weather variables were provided by the Delhi Pollution Control Committee. K-means clustering with time-series approach and multi-pollutant generalized additive models with Poisson link function was used to estimate the 0-6-day lagged change in daily ER visits with the change in multiple pollutants levels. Out of 1,32,029 children screened, 19,120 eligible children having acute respiratory symptoms for ≤2 weeks and residing in Delhi for the past 4 weeks were enrolled. There was a 29% and 21% increase in ERVs among children on high and moderate level pollution cluster days, respectively, compared to low pollution cluster days on the same day and previous 1-6 days of exposure to air pollutants. There was percentage increase (95% CI) 1.50% (0.76, 2.25) in ERVs for acute respiratory symptoms for 10 µg/m3 increase of NO2 on previous day 1, 46.78% (21.01, 78.05) for 10 µg/m3 of CO on previous day 3, and 13.15% (9.95, 16.45) for 10 µg/m3 of SO2 on same day of exposure. An increase in the daily ER visits of children for acute respiratory symptoms was observed after increase in daily ambient air pollution levels in Delhi.

Characterization of PM2.5 in Delhi: role and impact of secondary aerosol, burning of biomass, and municipal solid waste and crustal matter.

Delhi is one among the highly air polluted cities in the world. Absence of causal relationship between emitting sources of PM2.5 and their impact has resulted in inadequate actions. This research combines a set of innovative and state-of-the-art analytical techniques to establish relative predominance of PM2.5 sources. Air quality sampling at six sites in summer and winter for 40 days (at each site) showed alarmingly high PM2.5 concentrations (340 ± 135 µg/m3). The collected PM2.5 was subjected to chemical speciation including ions, metals, organic and elemental carbons which followed application of chemical mass balance technique for source apportionment. The source apportionment results showed that secondary aerosols, biomass burning (BMB), vehicles, fugitive dust, coal and fly ash, and municipal solid waste burning were the important sources. It was observed that secondary aerosol and crustal matter accounted for over 50% of mass. The PM2.5 levels were not solely result of emissions from Delhi; it is a larger regional problem caused by contiguous urban agglomerations. It was argued that emission reduction of precursors of secondary aerosol, SO2, NOx, and volatile organic compounds, which are unabated, is essential. A substantial reduction in BMB and suspension of crustal dust is equally important to ensure compliance with air quality standards.

Consensus statement on the use of intramuscular aripiprazole for the rapid control of agitation in bipolar mania and schizophrenia.

As much as the ideal treatment goal for severe mental illnesses such as bipolar disorder and schizophrenia is to prevent or delay the recurrence or relapse of acute episodes, when the patient presents with an acute episode, the goal should be to manage behavioural symptoms, and return to prior levels of symptomatic control. In a serious mental illness, the management of the acutely agitated state may require rapid tranquillisation (RT) to control violent and/or disturbed behaviour when all other methods of de-escalation have failed. Current clinical practice guidelines for emergency interventions in the case of acutely disturbed behaviours favour calming the patient by reducing agitation with mild sedation, but not sleep, to allow continued interaction with the patient, to ensure an accurate diagnosis, and to enable patients to be actively engaged in treatment decisions. Pharmacotherapy is an essential element in RT and the available agents used may be unique and separate from the patient's regular course of treatment, primarily because agents used in RT may not be suitable for long-term treatment due to an unfavourable efficacy and safety profile. Therefore, the choice of pharmacotherapy is essential to achieve an effective RT and a smooth transition to standard care and routine daily life for the patient. Of the available agents for RT, aripiprazole demonstrated a favourable efficacy and safety profile both over the short-term - including in its intramuscular form (IM) - and in the long-term treatment of bipolar I disorder and schizophrenia. The objective of this article is to assess the available clinical data on IM aripiprazole as a treatment option for the rapid control of agitation and disturbed behaviours in these conditions and to provide a consensus statement based on the expertise of UK healthcare practitioners in acute treatment units.

A UK panel consensus on the initiation of aripiprazole for the treatment of bipolar mania.

OBJECTIVE: The objective of this consensus paper is to provide practical guidance on why and how aripiprazole, with its distinct pharmacological and side effect profile, should be used for treatment of acute bipolar mania. METHODS: An advisory panel of UK healthcare professionals, with extensive experience of prescribing aripiprazole for acute bipolar mania, met to discuss its use in this setting. RESULTS: The panel agreed that aripiprazole is effective in treating bipolar mania when prescribed and dosed appropriately, in both the short and long term, as monotherapy or in combination with a mood stabilizer. Unlike other atypical agents, aripiprazole has antimanic effects that are not associated with sedation, which is beneficial for patients, particularly in the long term. If rapid tranquillization is required when initiating aripiprazole in acutely disturbed patients, short-term coprescription of a benzodiazepine is recommended. Most side effects associated with aripiprazole occur within the first 1-3 weeks and are usually transient and easily treatable. Aripiprazole poses low risk of metabolic side effects, sexual dysfunction, and anhedonia, which can facilitate treatment adherence and help improve clinical outcomes. CONCLUSIONS: Aripiprazole is an effective first-line treatment for acute bipolar mania with a favorable safety/tolerability profile.

Diabetic control and atypical antipsychotics: a case report.

INTRODUCTION: People with schizophrenia are at increased risk of developing metabolic disturbances. This risk may be further exacerbated by the use of antipsychotic agents. Research is still ongoing to determine the metabolic impact of antipsychotics on glucose regulation. In this case report we review some of the possible mechanisms of action of antipsychotic medication on glucose regulation. CASE PRESENTATION: We present the case of a 50-year-old man diagnosed with paranoid schizophrenia who developed type 2 diabetes mellitus whilst on treatment with second generation antipsychotics (SGA). His diabetes was controlled by a combination of antidiabetic drugs that were associated with his psychotropic treatment. Due to deterioration in his mental state, the patient was admitted on two occasions to a psychiatric unit during which his prescribed medication (olanzapine and risperidone) was discontinued and changed to aripiprazole. On both occasions, the patient suffered hypoglycaemic episodes and his antidiabetic treatment had to be adjusted accordingly. The patient did not require any antidiabetic treatment whilst on aripiprazole during the follow up period. CONCLUSION: Clinicians face regular dilemmas in trying to find the right balance between achieving control over a patient's mental illness and reducing any adverse effects associated with the prescribed medication. In patients receiving concomitant antidiabetic therapy, caution should be exercised when changing from one SGA to another. Whilst more longitudinal data are required, a trial of alternative SGAs, including aripiprazole in those developing type 2 diabetes and impaired glucose tolerance may be a worthwhile therapeutic option.

Insight, social knowledge and working memory in schizophrenia.

BACKGROUND: There is evidence that insight and social judgements are impaired in schizophrenia. The influence of these factors on the decision to treat compulsorily in schizophrenia is poorly understood. AIMS: To investigate the contribution of insight, social knowledge, and working memory to the determination to treat coercively in schizophrenia. METHOD: Insight rating scale, social knowledge questionnaire and working memory tests were administered to detained patients with schizophrenia. Results were compared with those of a control group of voluntary in-patients with schizophrenia. RESULTS: Detained patients scored worse on insight and social knowledge, yet there was no significant correlation between these scores. There was no significant difference in severity of psychopathology between the experimental and control groups. Results for working memory were inconclusive. CONCLUSION: Insight and social knowledge are significantly, but independently, associated with the determination to treat coercively in schizophrenia. This suggests that insight and social knowledge are distinct skills. The contribution of working memory remains unclear.