Validation of three health literacy screening questions compared with S-TOFHLA in a low-income diverse English- and Spanish-Speaking population.

BACKGROUND: Clinicians need a tool to gauge patients' ability to understand health conditions and treatment options. The Short-form Test of Functional Health Literacy in Adults (S-TOFHLA) is the gold standard for this, but its length is prohibitive for use in clinical settings. This study seeks to validate a novel three-item question set for predicting health literacy. METHODS: This cross-sectional study utilized an in-person questionnaire alongside the S-TOFHLA. The sample included 2027 English- and Spanish-speaking adults (≥18 years) recruited from primary care practices serving a low-income eastern Pennsylvania community. Most patients (57.7%) identified as Hispanic. Diagnostic accuracy of each question and aggregated scores were assessed against the validated survey by calculating the area under the receiver operating characteristic (AUROC) curve. RESULTS: Questions in the 'Problems Learning' and 'Help Reading' domains (AUROC 0.66 for each) performed better than the 'Confident Forms' question (AUROC 0.64). Summing all three scores resulted in an even higher AUROC curve (0.71). Cronbach's alpha of the combined items was 0.696. CONCLUSIONS: Study results suggest that any of the three questions are viable options for screening health literacy levels of diverse patients in primary care clinical settings. However, they perform better as a summed score than when used individually.

Longitudinal Assessment of Empathy and Burnout Across a Single Pharmacy Class Cohort.

OBJECTIVE: This is a final analysis of longitudinal evaluation of burnout and empathy among a cohort of Doctor of Pharmacy students throughout their 4-year enrollment. METHODS: The class of 2021 received sequential Qualtrics (Qualtrics, Provo, UT) surveys containing 2 validated survey instruments, the Jefferson Scale of Empathy and the Maslach Burnout Inventory. Surveys were disseminated at the start of the program (PY1start) and the end of each academic year (PY1end, PY2, PY3, PY4). Linear mixed models accounting for repeated measures, Generalized Estimating Equation, and Cochran's Q statistic were used to evaluate longitudinal change in the Jefferson Scale of Empathy and Maslach Burnout Inventory survey scores, categorized subscales, and burnout. RESULTS: Matched survey responses were included for 91 students (85.8% response rate). Across all years, a decrease in empathy and professional efficacy and an increase in exhaustion and cynicism was seen. High categorical levels of exhaustion and cynicism indicated evidence of burnout throughout the program. Year-to-year analysis indicated statistically significant increases in exhaustion and cynicism between PY1start and all subsequent assessments, a decrease in professional efficacy from PY1start to PY1end and PY2, and a decrease in empathy for PY1start to PY1end. CONCLUSION: Students reported trends of decreasing empathy and professional efficacy, with a simultaneous increase in exhaustion and cynicism. Further evaluation of the impact of COVID-19 on these results, as well as additional methods to support overall student wellness, is needed.

Patient Outcomes in Traumatic Subarachnoid Hemorrhage: A Retrospective Analysis.

INTRODUCTION: Patients with isolated traumatic subarachnoid hemorrhage (itSAH) are often transferred to a Level I or II trauma center for neurosurgical evaluation. Recent literature suggests that some patients, such as those with high Glasgow Coma Scale (GCS) scores, may be safely observed without neurosurgical consultation. The objective of this study was to investigate characteristics of patients with itSAH to determine the clinical utility of neurosurgical evaluation and repeat imaging. MATERIALS AND METHODS: A retrospective chart review of 350 patients aged ≥ 18 y with initial computed tomography head (CTH) showing itSAH and GCS scores of 13-15. Patient demographics, medical history, medications, length of stay, transfer status, injury type and severity, and CTH results were extracted for analysis. Bivariate analyses were conducted to determine whether any factors were associated with a worsening repeat CTH. RESULTS: Most patients were female (57.4%) with blunt injuries (99.1%). The median age was 73 y. Neurosurgery was consulted for 342 (97.7%) patients, with one (0.3%) requiring intervention. Of 311 (88.9%) repeat imaging, 16 (5.1%) showed worsening. Factors with statistically significant associations with worsening CTH included injury severity; neurological deficit; lengths of stay; and a history of congestive heart failure, cirrhosis, or substance use disorder. CONCLUSIONS: The findings suggest that patients with itSAH and high GCS scores may be able to be managed safely without neurosurgical oversight. The factors strongly associated with worsening CTH may be useful in identifying patients who need transfer for intensive care. Further research is needed to confirm these findings and develop appropriate management strategies for patients with itSAH.

Exploring Associations Between Abnormal Weight Classifications and Child Maltreatment Diagnoses.

Child maltreatment poses not only immediate danger, but as a type of toxic stress, it creates higher risk of biologic dysfunction later in life. Pediatricians are in a unique position to diagnose child maltreatment, but they need evidence-based guidance for when to initiate screening when injury is occult. In this retrospective cohort study of 855 pediatric patients diagnosed with child maltreatment, researchers explored whether type or number of diagnoses was associated with abnormal pediatric weight in either direction. Diagnoses and weight assessed at intake were extracted from medical records for analysis. Statistically significant associations were found between weight classification and child maltreatment type as well as diagnosis count. Neglect was most frequently diagnosed, and children with ≥2 diagnoses were more likely to be classified as underweight, overweight, or obese. Findings support abnormal pediatric weight as a biologic signal of adversity that warrants safety screening in the clinical setting.

The Rates of Postmastectomy Immediate Breast Reconstruction during the Initial Months of the COVID-19 Pandemic.

Background: Coronavirus disease 2019 (COVID-19) pandemic-related changes may have led to changes in immediate breast reconstruction (IBR) rates. We aimed to evaluate these changes before, during, and after the initial wave of COVID-19. Methods: We retrospectively reviewed women who underwent mastectomy with or without IBR from January 1 to September 30, 2019 and from January 1 to September 30, 2020, and compared demographic, clinical, and surgical variables between defined time periods. Results: A total of 202 mastectomies were included. Fewer patients underwent IBR during the initial surge of COVID-19 (surge period) compared with the months before (presurge period; 38.46% versus 70.97%, P = 0.0433). When comparing the postsurge period with a year before (postsurge control), fewer patients underwent reconstruction even after the initial surge had passed (53.13% versus 81.25%, P = 0.0007). Those who underwent IBR were older than the year before (59.34 versus 53.06, P = 0.0181). The median number of postoperative visits in the postsurge period was 8.50 (interquartile range: 6-12) compared with 14 (interquartile range: 8-20.50) in the year before (P = 0.0017). The overall incidences of complications and unanticipated resource utilization were also significantly lower in the postsurge period compared with the year before [5.88% versus 30.77% (P = 0.0055), and 14.71% versus 28.85% (P = 0.0103), respectively]. Conclusions: IBR rates were lower even after the initial surge than at the year before. Furthermore, during the pandemic, IBR patients were older, had fewer follow-up visits, and fewer reported complications.

Examining readmissions following outpatient microlaryngeal surgery.

Objective: The objective of this study was to examine readmissions following microlaryngeal surgery. It was hypothesized that airway surgical procedures would have higher rates of readmission. Design: Retrospective review. Methods: Outpatient microlaryngeal surgeries from May 1, 2018 to November 27, 2022 were reviewed. Readmissions related to the original surgery within a 30-day postoperative period were examined. Patient demographics, body mass index, American Society of Anesthesiologist class, comorbidities, type of surgery, ventilation techniques, and operative times were examined and compared. Results: Out of 480 procedures analyzed, 19 (4.0%) resulted in a readmission, 9 (1.9%) of which were for glottic stenosis management. Undergoing an airway procedure was significantly associated with a readmission (p = .002) and increased the odds of readmission by 5.99 (95% confidence interval [CI]: 2.22-16.16, p < .001). Current/former smoking status increased the odds of readmission by 4.50 (95% CI: 1.33-15.19, p = .016). Each additional minute of operating time increased the odds of readmission by 1.03 (95% CI: 1.00-1.05, p = .04). Conclusion: Readmissions from microlaryngeal surgery are seldom reported but nonetheless occur. Identifying factors that may place a procedure at risk for readmission can help improve surgical quality of care. Level of Evidence: 4.

Incidence of Complications Associated With Lipectomy Techniques and Patient Body Mass Index: An Institutional and National Analysis Using the Tracking Operations and Outcomes for Plastic Surgeons.

INTRODUCTION: An evaluation of complication rates in different abdominal lipectomy techniques with relationship to body mass index (BMI) and other risk factors. METHODS: We identified patients who underwent an abdominal lipectomy at our institution from January 2015 to July 2020. Those with concurrent hernia repair were excluded. Patients were classified into 2 groups: (1) horizontal lipectomy with or without umbilical translocation and (2) inverted-T lipectomy with translocation. Demographics, operative details, and postoperative complications were collected for 1 year postoperatively. Bivariate analyses were conducted to determine factors associated with type of procedure and complications. Crude and stratum-specific (based on BMI) odds ratios for complications were calculated for the inverted T as compared with the horizontal group. A replicate analysis using the national Tracking Operations and Outcomes for Plastic Surgeons (TOPS) as a single cohort was performed. RESULTS: At our institution, 362 patients (group 1 = 196, group 2 = 166) were included. A total of 40.9% of patients experienced at least one complication at 1 year postoperatively with the complication rate decreasing to 28.0% when analyzed at the 30-day postoperative period. Specifically, wound disruption rates were highest in group 2 (39.8%) compared with group 1 (15.6%; P < 0.0001). The odds of experiencing a complication were greater in the inverted-T group overall and within each stratum of BMI. When dividing the cohort based on BMI class (normal weight, overweight, class I, class II, and class III obesity), the incidence of wound disruption increased as did BMI (2.6%, 22.2%, 27.2%, 48.2%, and 56.3%, respectively; P < 0.0001). The TOPS data set included 23,067 patients and showed an overall complication rate of 13.1% at 30-day postop. Overall, wound disruption rate was 4.6%. Compared with normal weight patients, the odds of experiencing a complication trended higher with each stratum of BMI. Other factors associated with complications included BMI, tobacco use, diabetes, American Society of Anesthesiology, prior massive weight loss, and LOS. CONCLUSIONS: The increasing complication rate within each BMI stratum of the large sample size of the TOPS patient cohort, in addition to our similar institutional trends, suggests that a staged procedure may be more appropriate for higher BMI patients. Surgical technique modification with limited flap undermining in patients undergoing inverted-T lipectomy to preserve flap perfusion may also decrease overall complication rates.

Risk Factors Associated With Neurosurgical Intervention in Patients With Mild Traumatic Intracranial Hemorrhage.

INTRODUCTION: Community centers commonly transfer patients with traumatic intracranial hemorrhage (ICH) to level 1 and 2 trauma centers for neurosurgical evaluation regardless of the degree of injury. Determining risk factors leading to neurosurgical intervention (NSI) may reduce morbidity and mortality of traumatic ICH and the transfer of patients with lower risk of NSI. METHODS: A retrospective chart review was performed on patients admitted or transferred to a level 1 trauma center from October 2015 to September 2019 with Glassgow Coma Scale score 13-15 and traumatic ICH on initial head computerized tomography (CTH) scan. Bivariate analyses and multivariable regression were used to identify factors associated with progression to NSI. RESULTS: Of 1542 included patients, 8.2% required NSI. A greater proportion were male (69.1% versus 52.3%, P = 0.0003), on warfarin (37.7% versus 21.6%, P = 0.0023), presented with subdural hemorrhage (98.4% versus 63.3%, P < 0.0001, larger subdural hemorrhage size (median 19 mm [interquartile range {IQR}: 14-25] versus 5 mm [IQR: 3-8], P < 0.0001), and had a worsening repeat CTH (24.4% versus 13%, P < 0.0001). On physical examination, more patients had confusion (40.5% versus 31.4%, P = 0.0495) and hemiparesis (16.2% versus 2.6%, P < 0.0001). CTH findings of midline shift (80.2% versus 10.8%, P < 0.0001) and shift size (median 8.0 mm [IQR: 5.0-12.0] versus 4 mm [IQR: 3-5], P < 0.0001) were significantly associated with NSI. CONCLUSIONS: Clinical factors and patient characteristics can be used to infer a greater risk of requiring NSI. These factors could reduce unnecessary transfers and hasten the transfer of patients more likely to progress to NSI.

The role of carotid ultrasound in patients with non-lateralizing neurological complaints.

OBJECTIVES: In the United States, approximately 18-25% of carotid duplex ultrasound (CUS) studies are ordered to assess patients with non-lateralizing neurological complaints such as syncope, blurry vision, lightheadedness, headache, and altered mental status. The purpose of this study is to evaluate the benefit of CUS in the evaluation of patients presenting with non-lateralizing signs or symptoms. MATERIALS AND METHODS: We conducted a retrospective analysis to assess the degree and laterality of carotid stenosis among patients with non-lateralizing neurological complaints who underwent CUS interpreted by certified vascular neurologists over a period of 3 years. The primary endpoint was to identify the prevalence of moderate-to-severe carotid artery stenosis among 280 patients who met inclusion criteria. RESULTS: A total of 17.7% of CUS studies were ordered for non-lateralizing symptoms. Two hundred and sixty-one patients (93.21%) had either normal imaging or mild carotid stenosis of <50%. Nineteen patients (6.79%) were found to have stenosis of ≥50%. In this subgroup, age and known preexisting carotid artery atherosclerotic disease were the only variables found to have a statistically significant association with the level of stenosis found on CUS. Two patients with asymptomatic stenosis of >70% underwent a revascularization procedure. CONCLUSION: At least 17.7% of CUS studies were completed for non-lateralizing symptoms. The study is of low-yield with the prevalence of moderate-to-severe stenosis being comparable to that in the general asymptomatic population. We conclude that there is minimal clinical value in the use of CUS to investigate non-lateralizing neurological complaints, resulting in unnecessary healthcare costs.

The Utility of Cannabis-Based Medicine in Chronic Pain Management: A Case Report.

Chronic pain is a common diagnosis that patients may face, resulting in increased morbidity and mortality and affecting the overall quality of life. In addition to established multidisciplinary pain management, medical cannabis may offer an approach to improving pain outcomes and functionality. This case involves a 72-year-old female patient, with chronic neck, lower back, and diffuse arthritic pain due to comorbid osteoarthritis (OA), scleroderma, and scoliosis. Medical cannabis therapy was certified based on the goals of improving pain control and simultaneously reducing the patient's chronic opioid medication dose. Using potential opioid alternatives, such as medical cannabis, may prove beneficial to clinicians looking to improve pain management and reduce opioid therapy in patients.

Incidence of Secondary Hemophagocytic Lymphohistiocytosis in Critically-Ill COVID-19 Patients.

Objective Coronavirus disease 2019 (COVID-19) is associated with diffuse lung injury that can progress to acute respiratory distress syndrome, multisystem-organ failure, and death. The inflammatory storm seen in many COVID-19 patients closely resembles secondary hemophagocytic lymphohistiocytosis (sHLH) which has been described in other virus-associated severe sepsis. We sought to describe the incidence of sHLH in COVID-19 infected patients. Design In this retrospective study, we reviewed the records of critically ill COVID-19 positive patients to determine the incidence of sHLH. An H-score for sHLH diagnosis was determined for each study participant, with a score greater than 169 points needed for diagnosis. Setting A quaternary referral center in suburban Pennsylvania, USA. Patients All study participants had a positive COVID-19 test, and were deemed critically ill defined as receiving invasive mechanical ventilation and/or who expired. Measurements and Main Results Of the 246 records identified, 242 records met inclusion criteria and were reviewed. Eighty five patients were excluded from analysis due to missing H-score data parameters. Overall, 32 of 157 (20.38%, 95% CI:14.38-27.54%) patients met diagnostic criteria for sHLH. The average age was 69.42 years (standard deviation (SD) 14.81). Patients diagnosed with sHLH were more likely to be younger (61.09 years vs 69.38 years, P = 0.0036), male (71.88% vs 52.00%, P = 0.0433), and require mechanical ventilation (96.88% vs 72.80%, P = 0.0035). Conclusions Among critically ill COVID-19 positive patients, the incidence of sHLH is higher than previously reported in patients with non-COVID-19 related sepsis. Clinicians caring for COVID-19 patients should consider this secondary diagnosis and subsequent appropriate treatments, especially in those requiring mechanical ventilation.

Relationship Between Vaccination Status and Biopsychosocial Characteristics in Sheltered Adolescents.

Introduction Homeless youth are a vulnerable population. A volunteer clinic supported by medical students in northeastern Pennsylvania provides shelter and healthcare to adolescents seeking refuge. We set out to determine the immunization status of youth in the shelter and evaluate for associations of immunization deficiency with demographics or biopsychosocial factors. Methods After IRB approval, a retrospective cohort study was performed from existing clinical records at the shelter 2/2015-9/2019. Chart abstraction included variables such as demographics (including age, sex, and race/ethnicity), biopsychosocial factors (including childhood trauma/abuse history, substance abuse history, and sexual activity), and immunization history. Results A total of 440 charts were analyzed. When comparing demographics of patients that had complete vaccine regimens versus those who did not, the race was statistically significant (p=.006). The most prominent difference in race was seen for Black/African American patients; only 19.57% had a completed vaccine regimen documented. Regarding immunization history, vaccine schedules of hepatitis B, measles mumps rubella (MMR), inactivated polio vaccine (IPV), and varicella were most likely to be complete; pneumococcal conjugate vaccine (PCV) 13, rotavirus, influenza, and human papillomavirus vaccine (HPV) were least likely. There was no association found between a completed vaccine regimen and biopsychosocial variables. A larger portion of females (37.35%) completed the HPV vaccine compared to males (23.14%) (p=.009). Conclusions In this single-site study, this vulnerable, at-risk population of sheltered adolescents lacked the vaccinations recommended by the Centers for Disease Control and Prevention. Racial disparities further compounded this vulnerability for Black/African American teens. Additionally, a significantly greater number of female patients received the HPV vaccine compared to males.

Characteristics of Transgender Patient Cases Managed by a Toxicologist: an Analysis of the Toxicology Investigator's Consortium (ToxIC) Registry: January 2017-June 2019.

INTRODUCTION: The Toxicology Investigators Consortium (ToxIC) database, created in 2010 by the American College of Medical Toxicology (ACMT), compiles data recorded by medical toxicologists. In January 2017, the data field for transgender (and if transgender, male-to-female or female-to-male) was added to the ToxIC form. Little is known regarding trends in poisonings among transgender patients. We sought to review consultations managed by a bedside toxicologist and provide descriptive data in trends among types of exposures within the transgender demographic. METHODS: A retrospective ToxIC database evaluation of cases in which the patient identified as transgender were reviewed from January 2017-June 2019 and descriptive demographics reported. RESULTS: The registry contained 113 cases that involved transgender patients. Of those with complete data, 41 (36.6%) were male-to-female, 68 (60.7%) were female-to-male, and 3 (2.7%) identified as gender non-conforming. Of those with complete data, the most common reason for encounter was intentional use of a pharmaceutical drug (N = 97, 85.8%), of which 85 (87.6%) were classified as intentional pharmaceutical use intended for self-harm. Analgesics were the most common class of drugs used out of those reported (N = 24, 22%). Forty-six (90.2%) patients aged 13-18 with complete data were identified as encounters due to self-harm. Attempt at self-harm was the most common reason for intentional pharmaceutical encounter among the sample of transgender patients with complete data (N = 85, 87.6%); with female-to-male patients having an N = 53 (77.9%). CONCLUSION: Among transgender patients in the ToxIC registry, the most common primary reason for the encounter was intentional use of a pharmaceutical drug intended for self-harm. In this small cohort, there were some age and transition differences in prevalence. These findings may inform poisoning prevention practices as well as sex- and gender-based management of patients in this vulnerable population.

The Modified Fisher Scale Lacks Interrater Reliability.

BACKGROUND: The modified Fisher scale (mFS) is a critical clinical and research tool for risk stratification of cerebral vasospasm. As such, the mFS is included as a common data element by the National Institute of Neurological Disorders and Stroke SAH Working Group. There are few studies assessing the interrater reliability of the mFS. METHODS: We distributed a survey to a convenience sample with snowball sampling of practicing neurointensivists and through the research survey portion of the Neurocritical Care Society Web site. The survey consisted of 15 scrollable CT scans of patients with SAH for mFS grading, two questions regarding the definitions of the scale criteria and demographics of the responding physician. Kendall's coefficient of concordance was used to determine the interrater reliability of mFS grading. RESULTS: Forty-six participants (97.8% neurocritical care fellowship trained, 78% UCNS-certified in neurocritical care, median 5 years (IQR 3-6.3) in practice, treating median of 80 patients (IQR 50-100) with SAH annually from 32 institutions) completed the survey. By mFS criteria, 30% correctly identified that there is no clear measurement of thin versus thick blood, and 42% correctly identified that blood in any ventricle is scored as "intraventricular blood." The overall interrater reliability by Kendall's coefficient of concordance for the mFS was moderate (W = 0.586, p < 0.0005). CONCLUSIONS: Agreement among raters in grading the mFS is only moderate. Online training tools could be developed to improve mFS reliability and standardize research in SAH.

Sex Differences in Substance Use and Misuse: A Toxicology Investigators' Consortium (ToxIC) Registry Analysis.

BACKGROUND: Variations between male and female populations are previously reported in classes of harmfully used/misused drugs, severity of substance use disorder and risk of relapse. The aim of this study was to provide a review of bedside medical toxicologist managed, sex-specific poisonings in adults that present with harmful drug use/misuse. METHODS: ToxIC Registry cases ≥19 and ≤65 years old, with harmful drug use or misuse during the timeframe June 2010-December 2016, were studied. Demographics, primary agents of toxic exposure, administration route and complications were analyzed. Descriptive methods were used in the analysis. RESULTS: The database included 51,440 cases. Of these, 3426 cases were analyzed in which the primary reason for the encounter was harmful substance use/misuse. Females were found to harmfully use/misuse pharmaceutical drugs (N=806, 65.6%) more than nonpharmaceutical drugs (N=423, 34.4%). Males more frequently used nonpharmaceutical drugs (N=1189, 54.1%) than pharmaceutical drugs (1008, 45.9%). Analgesics were used by females (N= 215, 18.2%) and males (N=137, 6.6%). Sedative hypnotics were used by females (N=165, 14%) and males (N=160, 7.8%). Psychoactive agents were used by males (N=325, 15.8%) and females (N=67, 5.7%). Sympathomimetics were used by males (N=381, 18.5%) and females (N=151, 12.8%). The majority of both male and female participants, 1712 (57.9%), utilized an oral route of administration. However, 312 (16.5%) of males utilized inhalation vs 73 (6.8%) of females inhaled their substance. CONCLUSION: There were sex-specific differences among patients evaluated for harmful substance use/misuse by toxicologists. Considering these differences in regards to management and preventive approaches may be indicated.

Sex Differences in Pediatric Poisonings by Age Group: a Toxicology Investigators' Consortium (ToxIC) Analysis (2010-2016).

OBJECTIVE: To review pediatric poisonings evaluated at the bedside by medical toxicologists and reported in the ToxIC registry, by sex and age group. METHODS: Pediatric poisoning cases age ≤18 years, reported between January 2010 and December 2016, were reviewed. Descriptive statistics were used to describe study variables by age group and sex. RESULTS: A total of 12,699 cases were analyzed. There were 7517 females and 5182 males. Those < 2 years old represented 12.5% of the study group (n = 1584), 17.2% were 2-6 years old (n = 2178), 8.6% were 7-12 years old (n = 1097), and 61.7% were 13-18 years old (n = 7840). The most common primary reasons for encounter were intentional pharmaceutical with 4900 females and 1836 males; intentional non-pharmaceutical with 952 females and 1213 males; unintentional pharmaceutical with 539 females and 644 males; and unintentional non-pharmaceutical with 435 females and 593 males. Overall, pharmaceuticals were the most commonly involved agents, including analgesics (20.9% of cases) and antidepressants (11% of cases): 27.8% of females and 10.7% of males were reportedly exposed to an analgesic.13.7% of females and 7.0% of males were reportedly exposed to an antidepressant. Among 1584 cases under 2 years, there were 747 females and 837 males; among 2178 cases aged 2-6 years, there were 954 females and 1224 males; among 1097 cases aged 7-12 years, there were 555 females and 542 males; and among 7840 cases aged 13-18 years, there were 5261 females and 2579 males. Death was reported in 0.7% of the cases: 20 females and 18 males. 6.1% of cases were managed with intubation: 421 females and 351 males. CONCLUSIONS: Sex-based characteristics of poisonings varied by age group among pediatric poisoning presentations reported to the ToxIC registry and further research is needed to determine implications for education and prevention efforts.

Impact of Palliative Care on Resource Utilization and Quality in the Care of Patients Undergoing Therapeutic Hypothermia.

Few studies have been done assessing the impact of palliative care on patients suffering cardiac arrest and requiring therapeutic hypothermia (TH). We conducted a retrospective cohort study to compare resource utilization and quality indicators among patients undergoing TH with and without palliative care consultation. Data were collected, over a two-year period, from the institutional international cardiac arrest registry database and electronic medical record review. One hundred twenty-nine patients were screened, 102 met inclusion criteria. Sixty-four patients (63%) had a palliative care consult. None of the differences between the groups' prehospital clinical characteristics were significant (functional status p = 0.29; cerebral performance (CPC) score p = 0.16). The overall mortality rate of participants was 53%, with a rate of 47% for the nonpalliative care group and 56% of the palliative care group (p = 0.38). There was a decrease in resource utilization in the palliative care group, with discontinuation in lab tests showing significance (p = 0.04). All quality indicators were addressed more frequently in the palliative care group (p = < 0.0001). More patients in the palliative care group (56%) than in the nonpalliative care group (39%) had a do not resuscitate order placed (p = 0.10). Our results show reduced resource utilization and improved quality of care in patients undergoing TH treatment when palliative care is involved. These findings suggest that palliative care should be an integral part of the treatment guidelines for this patient population.

A Retrospective Cohort Study to Assess the Impact of an Inpatient Infectious Disease Telemedicine Consultation Service on Hospital and Patient Outcomes.

BACKGROUND: Here, we review our experience of providing inpatient infectious disease (ID) consultations using real-time interactive telemedicine assessments. We sought to obtain a baseline and document trends regarding the use of telemedicine ID (teleID) consults as an adjunct to the standard of care through the time period in which teleID consultations were introduced. METHODS: Data were pulled via manual, retrospective chart reviews of the electronic medical record. Primary outcomes included lengths of stay (LOS), antibiotic usage, and relapse incidences. RESULTS: There were a total of 244 patients at 1 remote hospital site who were provided with ID consultations, either in person, via teleID, or both. Before the availability of teleID (pre-teleID), there were 73 patients transferred for ID consults, while 171 patients were seen via teleID once available. While all 73 patients in the pre-teleID group were transferred from the remote hospital to the hub hospital, only 14 (8.2%) of all remote hospital patients assessed by teleID were transferred. Patient LOS across both facilities decreased when patients were seen via teleID, compared to pre-teleID (P = .0001). The median number of days that patients received antibiotics decreased in the teleID group (median 15, interquartile range [IQR] 9-25), compared to the pre-teleID group (median 19, IQR 11-28), but this decrease was not statistically significant (P = .0770). There was no statistically significant difference in relapse rates, although data were lacking because of patients being lost to follow-up. CONCLUSIONS: ID telemedicine practice directed at inpatients appears to be a promising route of care.

Sex differences in patients with suicidal intent that are managed by toxicologists: An analysis of the Toxicology Investigators' Consortium (ToxIC) Registry.

INTRODUCTION: The Toxicology Investigator's Consortium (ToxIC) maintains a prospective case registry of all patients that have been managed at the bedside by medical toxicologists. We set out to characterize the differences in toxicological suicide attempts between men and women among adult patients with poisonings managed by medical toxicologists. METHODS: ToxIC database consults for adults aged 19-65 whose primary reasons for encounter were classified as suicide attempt were used for this study (1/2010-12/2016). Data used for analysis included primary agents of toxic exposure, routes of administration, and complications. The statistical analysis was limited to descriptive methods. RESULTS: Out of 51,440 registry cases, 33,259 cases remained for analysis after applying the ages 19-65 and removing those without complete data. Of these, there were 4827 suicide attempts (14.5% of toxicological exposures) which were sub classified by gender. There were more females (F) than males (M) whose toxicology consults were due to suicidal attempts (57.6% versus 42.4%). We also found that more males used alcohol as their primary agent (2.8%M v 1.5%F) or a nonpharmaceutical (%7.4 M v %2.3 F). CONCLUSIONS: In our study, we found that there were more females than males who attempted suicide by self-poisoning; and more of them used pharmaceuticals than males. In contrast, a greater number of males used nonpharmaceuticals such as alcohol. We did not find large sex-differences in suicide completion rates, routes of administration, or subsequent symptomologies. In summary, sex-based differences were observed between adult patients with suicidal-intent exposures/ingestions managed at the bedside by medical toxicologists.

The Effect of Regional Anesthetic Sphenopalatine Ganglion Block on Self-Reported Pain in Patients With Status Migrainosus.

BACKGROUND: Status migrainosus (SM) is defined as a debilitating migraine attack lasting more than 72 hours in patients previously known to suffer from migraine headache. Typically, these attacks fail to respond to over the counter and abortive medications. The sphenopalatine ganglion (SPG) plays a critical role in propagating both pain and the autonomic symptoms commonly associated with migraines. SPG block via transnasal lidocaine is moderately effective in reducing migraine symptoms, but this approach is often poorly tolerated and the results are inconsistent. We proposed that an SPG block using a suprazygomatic injection approach would be a safe and effective option to abort or alleviate pain and autonomic symptoms of SM. METHODS: Through a retrospective records review, we identified patients with a well-established diagnosis of migraine, based on the International Headache Society criteria. Patients selected for study inclusion were diagnosed with SM, had failed to respond to 2 or more abortive medications, and had received a suprazygomatic SPG block. Patients had also been asked to rate their pain on a 1-10 Likert scale, both before and 30 minutes after the injection. RESULTS: Eighty-eight consecutive patients (20 men and 68 women) received a total of 252 suprazygomatic SPG block procedures in the outpatient headache clinic after traditional medications failed to abort their SM. At 30 minutes following the injections, there was a 67.2% (±26.6%) reduction in pain severity with a median reduction of 5 points (IQR= -6 to -3) on the Likert scale (ranging from 1 to 10). Overall, patients experienced a statistically significant reduction in pain severity (P < .0001). CONCLUSION: The SPG is known to play an integral role in the pathophysiology of facial pain and the trigeminal autonomic cephalalgias, although its exact role in the generation and maintenance of migraine headache remains unclear. Regional anesthetic suprazygomatic SPG block is potentially effective for immediate relief of SM. We believe the procedure is simple to perform and has minimal risk.