Prospective, multi-site study of patient outcomes after implementation of the TREWS machine learning-based early warning system for sepsis.

Early recognition and treatment of sepsis are linked to improved patient outcomes. Machine learning-based early warning systems may reduce the time to recognition, but few systems have undergone clinical evaluation. In this prospective, multi-site cohort study, we examined the association between patient outcomes and provider interaction with a deployed sepsis alert system called the Targeted Real-time Early Warning System (TREWS). During the study, 590,736 patients were monitored by TREWS across five hospitals. We focused our analysis on 6,877 patients with sepsis who were identified by the alert before initiation of antibiotic therapy. Adjusting for patient presentation and severity, patients in this group whose alert was confirmed by a provider within 3 h of the alert had a reduced in-hospital mortality rate (3.3%, confidence interval (CI) 1.7, 5.1%, adjusted absolute reduction, and 18.7%, CI 9.4, 27.0%, adjusted relative reduction), organ failure and length of stay compared with patients whose alert was not confirmed by a provider within 3 h. Improvements in mortality rate (4.5%, CI 0.8, 8.3%, adjusted absolute reduction) and organ failure were larger among those patients who were additionally flagged as high risk. Our findings indicate that early warning systems have the potential to identify sepsis patients early and improve patient outcomes and that sepsis patients who would benefit the most from early treatment can be identified and prioritized at the time of the alert.

Factors driving provider adoption of the TREWS machine learning-based early warning system and its effects on sepsis treatment timing.

Machine learning-based clinical decision support tools for sepsis create opportunities to identify at-risk patients and initiate treatments at early time points, which is critical for improving sepsis outcomes. In view of the increasing use of such systems, better understanding of how they are adopted and used by healthcare providers is needed. Here, we analyzed provider interactions with a sepsis early detection tool (Targeted Real-time Early Warning System), which was deployed at five hospitals over a 2-year period. Among 9,805 retrospectively identified sepsis cases, the early detection tool achieved high sensitivity (82% of sepsis cases were identified) and a high rate of adoption: 89% of all alerts by the system were evaluated by a physician or advanced practice provider and 38% of evaluated alerts were confirmed by a provider. Adjusting for patient presentation and severity, patients with sepsis whose alert was confirmed by a provider within 3 h had a 1.85-h (95% CI 1.66-2.00) reduction in median time to first antibiotic order compared to patients with sepsis whose alert was either dismissed, confirmed more than 3 h after the alert or never addressed in the system. Finally, we found that emergency department providers and providers who had previous interactions with an alert were more likely to interact with alerts, as well as to confirm alerts on retrospectively identified patients with sepsis. Beyond efforts to improve the performance of early warning systems, efforts to improve adoption are essential to their clinical impact and should focus on understanding providers' knowledge of, experience with and attitudes toward such systems.

Prevalence of Different Types of Primary Esophageal Motility Disorders and Their Associated Factors in Patients Referring to Shariati Hospital during 2018-2019.

BACKGROUND: Esophageal motility disorders (EMDs) are common in patients with dysphagia and are effectively diagnosed with high-resolution manometry (HREM). In this study, we aimed to evaluate the prevalence of different types of primary EMDs in patients referred for HREM and to further investigate the factors associated with EMDs. METHODS: In this cross-sectional study, all patients referred to the endoscopy section of Shariati Hospital during 2018-2019 (279 patients) were subjected to HREM and were evaluated according to their diagnosis, and the effect of each factor and each symptom on motility disorders was investigated. RESULTS: 84.5% (235) of the participants were diagnosed with at least one esophageal motility disorder; of them, achalasia was the most common form (52.6%). None of the predictive factors showed a statistically significant correlation with EMDs. However, regarding the symptoms, regurgitation and nocturnal cough were significantly more common in patients with EMD (P=0.001 and 0.009, respectively). CONCLUSION: This study demonstrates the high prevalence of EMDs in patients undergoing manometry. None of the factors studied, such as age, sex, diabetes, hypothyroidism, smoking, and alcohol and opium consumption, had a statistically significant correlation with EMDs.

Characterizing styles of clinical note production and relationship to clinical work hours among first-year residents.

OBJECTIVE: To characterize variation in clinical documentation production patterns, how this variation relates to individual resident behavior preferences, and how these choices relate to work hours. MATERIALS AND METHODS: We used unsupervised machine learning with clinical note metadata for 1265 progress notes written for 279 patient encounters by 50 first-year residents on the Hospital Medicine service in 2018 to uncover distinct note-level and user-level production patterns. We examined average and 95% confidence intervals of median user daily work hours measured from audit log data for each user-level production pattern. RESULTS: Our analysis revealed 10 distinct note-level and 5 distinct user-level production patterns (user styles). Note production patterns varied in when writing occurred and in how dispersed writing was through the day. User styles varied in which note production pattern(s) dominated. We observed suggestive trends in work hours for different user styles: residents who preferred producing notes in dispersed sessions had higher median daily hours worked while residents who preferred producing notes in the morning or in a single uninterrupted session had lower median daily hours worked. DISCUSSION: These relationships suggest that note writing behaviors should be further investigated to understand what practices could be targeted to reduce documentation burden and derivative outcomes such as resident work hour violations. CONCLUSION: Clinical note documentation is a time-consuming activity for physicians; we identify substantial variation in how first-year residents choose to do this work and suggestive trends between user preferences and work hours.

Estimation of Surgical Resident Duty Hours and Workload in Real Time Using Electronic Health Record Data.

OBJECTIVE: To explore the use of electronic health record (EHR) data to estimate surgery resident duty hours and monitor real time workload. DESIGN: Retrospective analysis of resident duty hours logged using a voluntary global positioning system (GPS)-based smartphone application compared to duty hour estimates by an EHR-based algorithm. The algorithm estimated duty hours using EHR activity data and operating room logs. A dashboard was developed through Plan-Do-Study-Act cycles for real-time monitoring of workload. SETTING: Single tertiary/quaternary medical center general surgery residency program with approximately 90 categorical, preliminary, and integrated residents at eight clinical sites. PARTICIPANTS: Categorical, preliminary, and integrated surgery residents of all clinical years who volunteered to pilot a GPS application to track duty hours. RESULTS: Of 2,623 work periods by 59 residents were logged with both methods. EHR-estimated work periods started later than GPS logs (median 0.3 hours, interquartile range [IQR] -0.1 - 0.3); EHR-estimated work periods ended earlier than GPS logs (median 0.1 hours, IQR -0.7 - 0.3); and EHR-estimated duty hour totals were less than totals logged by GPS (median -0.3 hours, IQR -0.8 - +0.1). Overall correlation between weekly duty hours logged by EHR and GPS was 0.79. Correlations between the 2 systems stratified from PGY-1 through PGY-5 were 0.76, 0.64, 0.82, 0.87, and 0.83, respectively. The algorithm identified six 80-hour workweek violations (averaged over 4 weeks), while GPS logs identified 8. EHR-based duty hours and operational data were integrated into a dashboard to enable real time monitoring of resident workloads. CONCLUSIONS: EHR-based estimation of surgical resident duty hours has good correlation with GPS-based assessment of duty hours and identifies most workweek duty hour violations. This approach allows for dynamic workload monitoring and may be combined with operational data to anticipate and prevent duty hour violations, thereby optimizing learning.

Cross-cultural adaptation, validity, and reliability of the Wexner questionnaire in patients with functional constipation in an Iranian population.

AIM: The present study aimed to cross-culturally adapt and assess the validity and reliability of the English version of the Wexner questionnaire translated into the Persian language in Iranian patients. BACKGROUND: Constipation is one of the most common gastrointestinal disorders; therefore, it is necessary to utilize an index for both the clinic and research studies. METHODS: In the first phase, the English version of the Wexner questionnaire was translated into the Persian language. In the second phase, the Persian version was assessed to evaluate the psychometric properties in 136 patients with functional constipation who referred to gastrointestinal and physical medicine clinics. Content validity was assessed by face validity. Construct validity was tested based on hypothesis testing and structural validity. The correlation of the total scores of the Wexner questionnaire and the Patient Assessment Constipation Quality Of Life (PAC-QOL) questionnaire was used for concurrent criterion validity. Internal consistency and test-retest reliability were calculated using Cronbach's α and intraclass correlation coefficient (ICC).The floor/ceiling effect of the questionnaire was also evaluated. RESULTS: The content validity of the Persian version of Wexner's questionnaire was acceptable. The construct and concurrent criteria validity showed moderate correlation. The internal consistency and intrarater reliability were moderate (0.51) and excellent (rp = 0.97, p-value <0.001), respectively. No floor/ceiling effect was seen. CONCLUSION: The Persian version of the Wexner questionnaire showed good validity and reliability in Iranian patients and can therefore be applied in clinics as well as in research for Persian-speaking countries.

Automating Measurement of Trainee Work Hours.

BACKGROUND: Medical training programs across the country are bound to a set of work hour regulations, generally monitored via self-report. OBJECTIVE: We developed a computational method to automate measurement of intern and resident work hours, which we validated against self-report. DESIGN, SETTING, AND PARTICIPANTS: We included all electronic health record (EHR) access log data between July 1, 2018, and June 30, 2019, for trainees enrolled in the internal medicine training program. We inferred the duration of continuous in-hospital work hours by linking EHR sessions that occurred within 5 hours as "on-campus" work and further accounted for "out-of-hospital" work which might be taking place at home. MAIN OUTCOMES AND MEASURES: We compared daily work hours estimated through the computational method with self-report and calculated the mean absolute error between the two groups. We used the computational method to estimate average weekly work hours across the rotation and the percentage of rotations where average work hours exceed the 80-hour workweek. RESULTS: The mean absolute error between self-reported and EHR-derived daily work hours for first- (PGY-1), second- (PGY-2), and third- (PGY-3) year trainees were 1.27, 1.51, and 1.51 hours, respectively. Using this computational method, we estimated average (SD) weekly work hours of 57.0 (21.7), 69.9 (12.2), and 64.1 (16.3) for PGY-1, PGY-2, and PGY-3 residents. CONCLUSION: EHR log data can be used to accurately approximate self-report of work hours, accounting for both in-hospital and out-of-hospital work. Automation will reduce trainees' clerical work, improve consistency and comparability of data, and provide more complete and timely data that training programs need.

Deep neural network-based automatic metasurface design with a wide frequency range.

Beyond the scope of conventional metasurface, which necessitates plenty of computational resources and time, an inverse design approach using machine learning algorithms promises an effective way for metasurface design. In this paper, benefiting from Deep Neural Network (DNN), an inverse design procedure of a metasurface in an ultra-wide working frequency band is presented in which the output unit cell structure can be directly computed by a specified design target. To reach the highest working frequency for training the DNN, we consider 8 ring-shaped patterns to generate resonant notches at a wide range of working frequencies from 4 to 45 GHz. We propose two network architectures. In one architecture, we restrict the output of the DNN, so the network can only generate the metasurface structure from the input of 8 ring-shaped patterns. This approach drastically reduces the computational time, while keeping the network's accuracy above 91%. We show that our model based on DNN can satisfactorily generate the output metasurface structure with an average accuracy of over 90% in both network architectures. Determination of the metasurface structure directly without time-consuming optimization procedures, an ultra-wide working frequency, and high average accuracy equip an inspiring platform for engineering projects without the need for complex electromagnetic theory.

Safety and Efficacy of Graded Gradual Pneumatic Balloon Dilation in Idiopathic Achalasia Patients: A 24-Year Single-Center Experience.

BACKGROUND: Pneumatic balloon dilation (PBD) is a first line treatment for idiopathic achalasia. Here we report the safety and efficacy of graded gradual PBD on short and long-term follow-up. METHODS: We evaluated 1370 idiopathic achalasia patients over a period of 24 years (1994-2018), prospectively. 216 patients did not undergo PBD due to comorbid diseases. Ultimately, 1092 achalasia patients were enrolled. All patients underwent graded gradual PBD, with repeat dilation if symptoms relapsed. Response to treatment was evaluated by Vantrappen scoring system. RESULTS: Of 1092 achalasia patients, 937 patients were treated by PBD and 155 patients were treated by combined therapy (PBD 1 month after Botulinum toxin injection). In short-term follow-up, 728 of 1092 patients underwent one PBD and 77.3% of them had excellent or good response (responders), 163 patients (58.6%) who underwent two PBDs were responders, and 44 (51.2%) patients who underwent three PBDs were responders. Overall, 2193 balloon dilations were performed on 1092 patients (mean 2 PBDs/patient). Of 786 patients with long-term follow-up, 259 patients had excellent or good response with one PBD. The responders with two, three, and four or more dilations were 149, 67, and 67, respectively. The overall response rate was 69%. No any serious complications were noted by using the graded gradual method. CONCLUSION: Our results show that graded gradual PBD is a safe and effective method for treatment of achalasia patients, and achieves sufficient short and long-term symptomatic remission with high cumulative success rate.

Comparison of Treatment Response in Different Types of Achalasia: A Long-Term Study.

BACKGROUND Three manometric patterns are seen in high-resolution manometry (HRM). Response to treatment has been reported to be different in these subtypes. We aimed to investigate the frequency and response to treatment in subtypes of achalasia. METHODS 306 patients between 15 to 60 years old, naïve to treatment with idiopathic achalasia (IA) were evaluated prospectively in a cohort study for 8 years. The patients were treated with pneumatic balloon dilation (PBD), and evaluated before and one month after PBD with Achalasia Symptom Score (ASS) and timed barium esophagogram (TBE) and then every 6 months with ASS. The primary study outcome was defined as a reduction in ASS (equal to or less than 4) and a reduction greater than 80% in the volume of barium in TBE at 1 month after PBD compared with baseline values. RESULTS According to HRM, 57 were classified as type I (18.62%), 223 as type II (72.9%), and 26 as type III (8.5%). The mean lower esophageal sphincter (LES) residual pressures before treatment were 34.05 ± 31.55, 32.99 ± 17.90, and 37.47 ± 14.07 mmHg in types I, II, and III, respectively (p = 0.18). The mean ASS values before treatment were 12.23, 11.50, and 11.50, for types I, II, and III, respectively (p = 0.29). The ASS dropped to 2.50 in type I, 2.40 in type II, and 2.12 in type III at 1 month after treatment (p = 0.83). Eventually, at the end of follow-up, 24 patients with type I (83%), 82 patients with type II (67%), and five patients with type III (83%) showed sustained good responses (p = 0.528). CONCLUSION Manometric subtypes of achalasia did not have an important role in clinical success in the long term. Achalasia has no definite cure, but with current treatment modalities, palliation of symptoms is possible in over 90% of patients.

Is COPD associated with alterations in hearing? A systematic review and meta-analysis.

BACKGROUND AND AIMS: COPD is an irreversible or persistent airflow obstruction, which affects up to 600 million people globally. The primary purpose of this systematic review was to explore the COPD-based alteration in the auditory system function by conducting a quantitative analysis of presently published data. MATERIALS AND METHODS: We systematically searched seven diverse electronic databases and manual searching of references to identify relevant studies. Data from the selected studies were rated by two investigators independently in a blinded fashion. Meta-analysis was done on pooled data using Cochrane's Review Manager 5.3. RESULTS: Sixteen articles received suitable scores and were thus included for further processes. Hearing loss (HL) was defined as a change in pure tone audiometry (PTA) thresholds, auditory brainstem response (ABR), and auditory P300 parameters. ABR wave was significantly elongated in patients with COPD than in controls (standardized mean difference [SMD]=0.27, 95% CI: 0.05-0.48, P=0.02). PTA was significantly higher in patients with COPD when compared with controls (SMD=1.76, 95% CI: 0.43-3.08, P=0.0004). We found that patients with COPD had a significantly higher latency than controls (SMD=1.30, 95% CI: 0.79-1.80, P=0.0001). CONCLUSION: COPD patients had considerably greater incidence of HL when compared with controls. Interestingly, although the mean PTA thresholds at every frequency for COPD patients were higher than those for controls, these values were still in the slight to mild HL ranges. Prolonged ABR wave latencies in the COPD patients suggest retro-cochlear involvement. Thus, COPD most frequently clusters with HL, but it is worth noting that alteration in hearing is not always recognized by medical experts as a frequent comorbidity associated with COPD.

Do Patients with Chest Pain Benefit from Installing Triage System in Emergency Department?

INTRODUCTION: Chest pain, which can be cardiac or non-cardiac and either benign or life-threatening, needs appropriate diagnosis and treatment in emergency department (ED). OBJECTIVE: The aim of this study was to compare delivery time of primary care for patients with chest pain before and after applying triage system in ED. METHODS: Medical records were reviewed of thirty patients (group one) with chief complaint of chest pain who referred to ED between April and July 2008 (before installing triage system) and thirty-five patients (group two) with the same chief complaint who referred between August and September 2009 (after installing triage system). Time between patients' arrival and beginning of diagnostic and therapeutic interventions including cardiac monitoring, first physician visit time, intravenous line insertion, and electrocardiogram performance were compared between the two groups. RESULTS: Based on the findings, the mean age and sex ratio of studied patients in the two groups were not significantly different (p>0.05). Door to ECG performance, Door to intravenous line insertion, and Door to cardiac monitoring were significantly shorter in post triage installing period than previously (p<0.001). Door to first visit by physician was not statistically different in the two study periods (p=0.421). CONCLUSION: It is likely that patients with chest pain who referred to ED benefit from installing triage system in terms of performing some nursing care including ECG performance, starting cardiac monitoring, and IV insertion.

Scalable Joint Models for Reliable Uncertainty-Aware Event Prediction.

Missing data and noisy observations pose significant challenges for reliably predicting events from irregularly sampled multivariate time series (longitudinal) data. Imputation methods, which are typically used for completing the data prior to event prediction, lack a principled mechanism to account for the uncertainty due to missingness. Alternatively, state-of-the-art joint modeling techniques can be used for jointly modeling the longitudinal and event data and compute event probabilities conditioned on the longitudinal observations. These approaches, however, make strong parametric assumptions and do not easily scale to multivariate signals with many observations. Our proposed approach consists of several key innovations. First, we develop a flexible and scalable joint model based upon sparse multiple-output Gaussian processes. Unlike state-of-the-art joint models, the proposed model can explain highly challenging structure including non-Gaussian noise while scaling to large data. Second, we derive an optimal policy for predicting events using the distribution of the event occurrence estimated by the joint model. The derived policy trades-off the cost of a delayed detection versus incorrect assessments and abstains from making decisions when the estimated event probability does not satisfy the derived confidence criteria. Experiments on a large dataset show that the proposed framework significantly outperforms state-of-the-art techniques in event prediction.

Semisupervised, Multilabel, Multi-Instance Learning for Structured Data.

Many classification tasks require both labeling objects and determining label associations for parts of each object. Example applications include labeling segments of images or determining relevant parts of a text document when the training labels are available only at the image or document level. This task is usually referred to as multi-instance (MI) learning, where the learner typically receives a collection of labeled (or sometimes unlabeled) bags, each containing several segments (instances). We propose a semisupervised MI learning method for multilabel classification. Most MI learning methods treat instances in each bag as independent and identically distributed samples. However, in many practical applications, instances are related to each other and should not be considered independent. Our model discovers a latent low-dimensional space that captures structure within each bag. Further, unlike many other MI learning methods, which are primarily developed for binary classification, we model multiple classes jointly, thus also capturing possible dependencies between different classes. We develop our model within a semisupervised framework, which leverages both labeled and, typically, a larger set of unlabeled bags for training. We develop several efficient inference methods for our model. We first introduce a Markov chain Monte Carlo method for inference, which can handle arbitrary relations between bag labels and instance labels, including the standard hard-max MI assumption. We also develop an extension of our model that uses stochastic variational Bayes methods for inference, and thus scales better to massive data sets. Experiments show that our approach outperforms several MI learning and standard classification methods on both bag-level and instance-level label prediction. All code for replicating our experiments is available from https://github.com/hsoleimani/MLTM .

Synthetic Zeolites as Controlled-Release Delivery Systems for Anti-Inflammatory Drugs.

Scientists have always been trying to use artificial zeolites to make modified-release drug delivery systems in the gastrointestinal tract. An ideal carrier should have the capability to release the drug in the intestine, which is the main area of absorption. Zeolites are mineral aluminosilicate compounds with regular structure and huge porosity, which are available in natural and artificial forms. In this study, soaking, filtration and solvent evaporation methods were used to load the drugs after activation of the zeolites. Weight measurement, spectroscopy FTIR, thermogravimetry and scanning electronic microscope were used to determine drug loading on the systems. Finally, consideration of drug release was made in a simulated gastric fluid and a simulated intestinal fluid for all matrixes (zeolites containing drugs) and drugs without zeolites. Diclofenac sodium (D) and piroxicam (P) were used as the drug models, and zeolites X and Y as the carriers. Drug loading percentage showed that over 90% of drugs were loaded on zeolites. Dissolution tests in stomach pH environment showed that the control samples (drug without zeolite) released considerable amount of drugs (about 90%) within first 15 min when it was about 10-20% for the matrixes. These results are favorable as NSAIDs irritate the stomach wall and it is ideal not to release much drugs in the stomach. Furthermore, release rate of drugs from matrixes has shown slower rate in comparison with control samples in intestine pH environment.

Viral infections in patients with acute respiratory infection in Northwest of Iran.

INTRODUCTION: Acute respiratory infection (ARI) is one of the main causes of morbidity and mortality all around the world. The aim of this study was to determine the frequency, mortality and association with clinical entities of influenza virus type A, influenza virus type B, respiratory syncytial virus (RSV), coronavirus, and adenoviruses in patients with ARI. MATERIALS AND METHODS: During September 2014 till May 2015, 143 respiratory inpatients samples for viral testing collected from central Hospital in Northwest of Iran. A real-time reverse transcription-PCR (RT-PCR) assay was done to allow in one test the detection of influenza A and B viruses. Also, RSV and adenovirus were identified by Immunochromatography test. RESULTS: Twenty-four (46%) cases were positive for influenza A, which 11 (46%) of them were subtype H1N1 and 13 (54%) cases were subtype H3N2. Also, 21 (40%) cases were positive for influenza B, 5 (10%) cases were positive for RSV, and 2 (4%) cases were positive for adenovirus. One of the patients was positive for both influenza A and adenovirus. Two of the patients were positive for both influenza A and RSV. None of the patients were positive for coronavirus. CONCLUSIONS: Our findings show the importance of influenza virus type A, influenza virus type B, RSV, and adenoviruses associated with ARI in hospitalized patient and the different epidemiological patterns of the viruses in Tabriz, Iran.

Ethanolamine oleate versus botulinum toxin in the treatment of idiopathic achalasia.

BACKGROUND: Botulinum toxin (BT) injection reduces lower esophageal sphincter pressure and alleviates symptoms in idiopathic achalasia (IA). Ethanolamine oleate (EO) has also been introduced for the treatment of IA. We compared the long-term efficacy of BT and EO injections in the treatment of IA. METHODS: A total of 189 IA patients were evaluated prospectively, of whom 21 were unwilling to undergo or were poor candidates for pneumatic balloon dilation and Heller myotomy and were enrolled in the study. Eleven patients were treated by BT, and 10 by EO injections. Patients were followed up by achalasia symptom score (ASS), timed barium esophagogram (TBE), and high-resolution manometry at baseline and post-treatment. A good initial response was defined as a decrease in ASS to 4 or less, and a reduction in barium column height and volume in TBE by >50%. RESULTS: All 10 EO group patients and 10 of 11 BT group patients showed a good initial response. Four EO group relapsers and 6 BT group relapsers were managed effectively by re-injections. Mean duration of follow up was 27.38 months. On completion of the study, a sustained good response was seen in 9 and 6 patients in EO and BT groups, respectively (P=0.149). CONCLUSION: This study revealed that BT and EO have comparable efficacy in the treatment of IA. However, the cost of EO is about 2 times lower than BT.

Efficacy of core decompression of femoral head to treat avascular necrosis in intravenous drug users.

Core decompression (CD) of the femoral head is one of the effective treatments of avascular necrosis (AVN), especially in the early stages of the disease. To investigate further the value of CD in treating the AVN, this study was performed on patients with symptomatic AVN with different etiologies who were treated with CD. This study was carried out on 25 patients (with the total number of 37 femoral head) who were diagnosed AVN using X-Ray and MRI. The CD treatments for these patients were started soon after the diagnosis. The results were considered as a success if there was no progression of disease confirmed by X Ray or no subsequent operation was required. Modified Ficat staging was used to record changes before and 2 years after CD treatment. Twenty five patients were participated in this study in which 68% (n=17) were female, 32% (n=8) were male, and the average of the age of the patients were 29.58±4.58. Eight of these patients had systemic lupus erythematous (SLE) (32%), 4 rheumatoid arthritis (RA) (16%), 3 with kidney transplant (12%), 1 Takayasu's vasculitis (4%) and 1 Wegner vasculitis (4%). Eight of patients had a history of intravenous injection of Temgesic (32%). In patients using Temgesic the changes in Modified Ficat staging were significantly different before and after CD treatment (P=0.03) in comparison with other groups. And in all 8 Temgesic users AVN progressed to the stage 3 and 4 after CD treatment. This study demonstrated that CD treatment to prevent the changes in the femoral head has been more effective in patients with collagen vascular diseases and kidney transplant than patients using intravenous Temgesic. These patients, in spite of early operation, showed no benefit of CD to prevent the changes in the femoral head.

Emergency department nonurgent visits in Iran: prevalence and associated factors.

OBJECTIVES: To estimate the number of emergency department (ED) visits due to nonurgent problems and to describe the characteristics of those patients, as well as their reasons for presenting to the ED. STUDY DESIGN: Descriptive cross-sectional study. METHODS: In this study, all adult (aged >15 years) patients presenting to the ED over a 2-week period were evaluated. Data regarding the age, sex, marital status, educational level, and insurance status of all patients were recorded. The time and date of the presentation were also noted. Those classified by the triage nurse as having nonurgent conditions were surveyed regarding their reasons for presenting to the ED. RESULTS: Out of 1923 visits, 400 (20.8%) were classified as nonurgent. The prevalence of inappropriate ED visits was slightly greater in patients aged 15 to 49 years. Patients whose visits were paid for by health insurance accounted for the majority of inappropriate visits (82.75%). There were higher rates of inappropriate visits in the evening and night shifts compared with morning and afternoon shifts (17.39% vs 25.03%). The most common reason for presenting to the ED was "to obtain rapid treatment" (76.5%); only 10.75% presented because of a perceived urgent problem. CONCLUSIONS: The results of our study corroborate the previous findings that inappropriate use of the ED is common. The prevalence of presentation for nonurgent problems was substantive between 6 PM and 6 AM. Gender, marital status, education, insurance, and day of the week had no association with nonurgent presentation.