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2.
J Med Toxicol ; 2022 Apr 12.
Artigo em Inglês | MEDLINE | ID: mdl-35415804

RESUMO

BACKGROUND: Despite the evidence in support of the use of buprenorphine in the treatment of OUD and increasing ability of emergency medicine (EM) clinicians to prescribe it, emergency department (ED)-initiated buprenorphine is uncommon. Many EM clinicians lack training on how to manage acute opioid withdrawal or initiate treatment with buprenorphine. We developed a brief buprenorphine training program and assessed the impact of the training on subsequent buprenorphine initiation and knowledge retention. METHODS: We conducted a pilot randomized control trial enrolling EM clinicians to receive either a 30-min didactic intervention about buprenorphine (standard arm) or the didactic plus weekly messaging and a monetary inducement to administer and report buprenorphine use (enhanced arm). All participants were incentivized to complete baseline, immediate post-didactic, and 90-day knowledge and attitude assessment surveys. Our objective was to achieve first time ED buprenorphine prescribing events in clinicians who had not previously prescribed buprenorphine in the ED and to improve EM-clinician knowledge and perceptions about ED-initiated buprenorphine. We also assessed whether the incentives and reminder messaging in the enhanced arm led to more clinicians administering buprenorphine than those in the standard arm following the training; we measured changes in knowledge of and attitudes toward ED-initiated buprenorphine. RESULTS: Of 104 EM clinicians enrolled, 51 were randomized to the standard arm and 53 to the enhanced arm. Clinical knowledge about buprenorphine improved for all clinicians immediately after the didactic intervention (difference 19.4%, 95% CI 14.4% to 24.5%). In the 90 days following the intervention, one-third (33%) of all participants reported administering buprenorphine for the first time. Clinicians administered buprenorphine more frequently in the enhanced arm compared to the standard arm (40% vs. 26.3%, p = 0.319), but the difference was not statistically significant. The post-session knowledge improvement was not sustained at 90 days in the enhanced (difference 9.6%, 95% CI - 0.37% to 19.5%) or in the standard arm (difference 3.7%, 95% CI - 5.8% to 13.2%). All the participants reported an increased ability to recognize patients with opioid withdrawal at 90 days (enhanced arm difference .55, 95% CI .01-1.09, standard arm difference .85 95% CI .34-1.37). CONCLUSIONS: A brief educational intervention targeting EM clinicians can be utilized to achieve first-time prescribing and improve knowledge around buprenorphine and opioid withdrawal. The use of weekly messaging and gain-framed incentivization conferred no additional benefit to the educational intervention alone. In order to further expand evidence-based ED treatment of OUD, focused initiatives that improve clinician competence with buprenorphine should be explored. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03821103.

3.
Ann Intern Med ; 175(2): 179-190, 2022 02.
Artigo em Inglês | MEDLINE | ID: mdl-34781715

RESUMO

BACKGROUND: Although most patients with SARS-CoV-2 infection can be safely managed at home, the need for hospitalization can arise suddenly. OBJECTIVE: To determine whether enrollment in an automated remote monitoring service for community-dwelling adults with COVID-19 at home ("COVID Watch") was associated with improved mortality. DESIGN: Retrospective cohort analysis. SETTING: Mid-Atlantic academic health system in the United States. PARTICIPANTS: Outpatients who tested positive for SARS-CoV-2 between 23 March and 30 November 2020. INTERVENTION: The COVID Watch service consists of twice-daily, automated text message check-ins with an option to report worsening symptoms at any time. All escalations were managed 24 hours a day, 7 days a week by dedicated telemedicine clinicians. MEASUREMENTS: Thirty- and 60-day outcomes of patients enrolled in COVID Watch were compared with those of patients who were eligible to enroll but received usual care. The primary outcome was death at 30 days. Secondary outcomes included emergency department (ED) visits and hospitalizations. Treatment effects were estimated with propensity score-weighted risk adjustment models. RESULTS: A total of 3488 patients enrolled in COVID Watch and 4377 usual care control participants were compared with propensity score weighted models. At 30 days, COVID Watch patients had an odds ratio for death of 0.32 (95% CI, 0.12 to 0.72), with 1.8 fewer deaths per 1000 patients (CI, 0.5 to 3.1) (P = 0.005); at 60 days, the difference was 2.5 fewer deaths per 1000 patients (CI, 0.9 to 4.0) (P = 0.002). Patients in COVID Watch had more telemedicine encounters, ED visits, and hospitalizations and presented to the ED sooner (mean, 1.9 days sooner [CI, 0.9 to 2.9 days]; all P < 0.001). LIMITATION: Observational study with the potential for unobserved confounding. CONCLUSION: Enrollment of outpatients with COVID-19 in an automated remote monitoring service was associated with reduced mortality, potentially explained by more frequent telemedicine encounters and more frequent and earlier presentation to the ED. PRIMARY FUNDING SOURCE: Patient-Centered Outcomes Research Institute.


Assuntos
COVID-19/terapia , Consulta Remota/métodos , Envio de Mensagens de Texto , Adulto , Idoso , COVID-19/mortalidade , Pesquisa Comparativa da Efetividade , Serviço Hospitalar de Emergência , Feminino , Serviços de Assistência Domiciliar , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos/epidemiologia
4.
JCO Oncol Pract ; 18(4): e516-e524, 2022 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-34914566

RESUMO

PURPOSE: Palliative care (PC) improves outcomes in advanced cancer, and guidelines recommend early outpatient referral. However, many PC teams see more inpatient than outpatient consults. We conducted a retrospective study of hospitalized patients with cancer to quantify exposure to inpatient and outpatient PC and describe associations between PC and end-of-life (EOL) quality measures. METHODS: We identified all decedents admitted to an inpatient oncology unit in 1 year (October 1, 2017-September 30, 2018) and abstracted hospitalization statistics, inpatient and outpatient PC visits, and EOL outcomes. Descriptive statistics, univariate tests, and multivariate analysis evaluated associations between PC and patient outcomes. RESULTS: In total, 522 decedents were identified. 50% saw PC; only 21% had an outpatient PC visit. Decedents seen by PC were more likely to enroll in hospice (78% v 44%; P < .001), have do-not-resuscitate status (87% v 55%; P < .001), have advance care planning documents (53% v 31%; P < .001), and die at home or inpatient hospice instead of in hospital (67% v 40%; P < .01). Decedents seen by PC had longer hospital length-of-stay (LOS; 8.4 v 7.0 days; P = .03), but this association reversed for decedents seen by outpatient PC (6.3 v 8.3 days; P < .001), who also had longer hospice LOS (46.5 v 27.1 days; P < .01) and less EOL intensive care (6% v 15%; P < .05). CONCLUSION: PC was associated with significantly more hospice utilization and advance care planning. Patients seen specifically by outpatient PC had shorter hospital LOS and longer hospice LOS. These findings suggest different effects of inpatient and outpatient PC, underscoring the importance of robust outpatient PC.


Assuntos
Neoplasias , Cuidados Paliativos , Morte , Humanos , Pacientes Internados , Neoplasias/complicações , Neoplasias/epidemiologia , Neoplasias/terapia , Pacientes Ambulatoriais , Estudos Retrospectivos
6.
J Clin Med ; 10(9)2021 May 03.
Artigo em Inglês | MEDLINE | ID: mdl-34063729

RESUMO

OBJECTIVE: Patients requiring hospital care for COVID-19 may be stable for discharge soon after admission. This study sought to describe patient characteristics associated with short-stay hospitalization for COVID-19. METHODS: We performed a retrospective cohort study of patients with COVID-19 admitted to five United States hospitals from March to December 2020. We used multivariable logistic regression to identify patient characteristics associated with short hospital length-of-stay. RESULTS: Of 3103 patients, 648 (20.9%) were hospitalized for less than 48 h. These patients were significantly less likely to have an age greater than 60, diabetes, chronic kidney disease; emergency department vital sign abnormalities, or abnormal initial diagnostic testing. For patients with no significant risk factors, the adjusted probability of short-stay hospitalization was 62.4% (95% CI 58.9-69.6). CONCLUSION: Identification of candidates for early hospital discharge may allow hospitals to streamline throughput using protocols that optimize the efficiency of hospital care and coordinate post-discharge monitoring.

7.
A A Pract ; 15(5): e01469, 2021 May 17.
Artigo em Inglês | MEDLINE | ID: mdl-33999865

RESUMO

Thoracotomies are classified as moderate to high-risk surgeries due to the preponderance of complex anatomic structures, cardiac dysrhythmias, and respiratory insufficiency. The right vagus nerve innervates the sinoatrial node and controls the heart rate. The parasympathetic activation of the sinoatrial node can lead to bradyarrhythmias. The anatomic aortopulmonary window contains lymph nodes and the left vagus nerve. The occurrence of sudden asystole due to left vagus nerve stimulation is extremely rare. We report an unusual case of intraoperative asystole related to electrosurgical stimulation of the left vagus nerve that required cardiopulmonary resuscitation and cardiac massage.


Assuntos
Parada Cardíaca , Toracotomia , Bradicardia/etiologia , Parada Cardíaca/etiologia , Parada Cardíaca/terapia , Frequência Cardíaca , Humanos , Toracotomia/efeitos adversos , Nervo Vago
8.
J Urban Health ; 98(6): 822-831, 2021 12.
Artigo em Inglês | MEDLINE | ID: mdl-34014451

RESUMO

Spending time in nature is associated with numerous mental health benefits, including reduced depression and improved well-being. However, few studies examine the most effective ways to nudge people to spend more time outside. Furthermore, the impact of spending time in nature has not been previously studied as a postpartum depression (PPD) prevention strategy. To fill these gaps, we developed and pilot tested Nurtured in Nature, a 4-week intervention leveraging a behavioral economics framework, and included a Nature Coach, digital nudges, and personalized goal feedback. We conducted a randomized controlled trial among postpartum women (n = 36) in Philadelphia, PA between 9/9/2019 and 3/27/2020. Nature visit frequency and duration was determined using GPS data. PPD was measured using the Edinburgh Postnatal Depression Scale (EPDS). Participants were from low-income, majority Black neighborhoods. Compared to control, the intervention arm had a strong trend toward longer duration and higher frequency of nature visits (IRR 2.6, 95%CI 0.96-2.75, p = 0.059). When analyzing women who completed the intervention (13 of 17 subjects), the intervention was associated with three times higher nature visits compared to control (IRR 3.1, 95%CI 1.16-3.14, p = 0.025). No significant differences were found in the EPDS scores, although we may have been limited by the study's sample size. Nurture in Nature increased the amount of time postpartum women spent in nature, and may be a useful population health tool to leverage the health benefits of nature in majority Black, low-resourced communities.


Assuntos
Depressão Pós-Parto , Parques Recreativos , Depressão Pós-Parto/prevenção & controle , Feminino , Humanos , Projetos Piloto , Período Pós-Parto , População Urbana
9.
EC Clin Med Case Rep ; 4(5): 36-38, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-35106522

RESUMO

Peripheral nerve injury is a well-recognized complication of surgery and anesthesia. However, overall incidence is less than 1% [1,2]. Most commonly affected nerves include the ulnar nerve, brachial plexus, and lumbosacral nerve root [2]. Postoperative facial nerve palsy as a complication of surgery and anesthesia has been documented in the literature, but it is a rare event [3]. The occurrence of any type of nerve injury as a postoperative complication is even less common in the pediatric population [2,3]. In this report, we describe a case of postoperative facial nerve palsy in a pediatric patient after a thoracotomy..

10.
Artigo em Inglês | MEDLINE | ID: mdl-32832932

RESUMO

Stiff-person syndrome (SPS) is a rare disorder of the nervous system, characterized by muscle stiffness, rigidity, and painful spasms involving truncal and limb musculature that may severely limit mobility. Our case documents a 53-year-old patient with SPS and endometrial cancer who was positive for anti-GAD and paraneoplastic antibodies, who presented to our institution for robotic surgery. These patients are at high risk for prolonged hypotonia and mechanical ventilation. Our patient underwent general anesthesia without complications despite multiple comorbidities.

12.
Artigo em Inglês | MEDLINE | ID: mdl-32656543

RESUMO

The environmental debate continues to expand in the realm of healthcare, resulting in increased scrutiny of the impact of material waste and gas emissions in the operating room (OR). In a single day, ORs can contribute up to 2000 tons of medical waste, mostly in the form of disposable medical supplies. We review the major challenges associated with "going green" in the OR.

13.
Anesth Analg ; 131(1): 16-23, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32543802

RESUMO

The novel coronavirus disease 2019 (COVID-19) was first reported in China in December 2019. Since then, it has spread across the world to become one of the most serious life-threatening pandemics since the influenza pandemic of 1918. This review article will focus on the specific risks and nuanced considerations of COVID-19 in the cancer patient. Important perioperative management recommendations during this outbreak are emphasized, in addition to discussion of current treatment techniques and strategies available in the battle against COVID-19.


Assuntos
Infecções por Coronavirus/complicações , Infecções por Coronavirus/terapia , Neoplasias/complicações , Neoplasias/terapia , Pneumonia Viral/complicações , Pneumonia Viral/terapia , COVID-19 , Surtos de Doenças , Humanos , Pandemias , Administração dos Cuidados ao Paciente
14.
Ann Emerg Med ; 76(2): 206-214, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32376089

RESUMO

STUDY OBJECTIVE: Emergency department (ED) initiation of buprenorphine for patients with opioid use disorder increases treatment engagement but remains an uncommon practice. One important barrier to ED-initiated buprenorphine is the additional training requirement (X waiver). Our objective is to evaluate the influence of a financial incentive program on emergency physician completion of X-waiver training. Secondary objectives are to evaluate the program's effect on buprenorphine prescribing and to explore physician attitudes toward the incentive. METHODS: We conducted a prospective, observational cohort study set in 3 urban academic EDs before and after implementation of a financial incentive program providing $750 for completion of X-waiver training. We describe program participation as well as rates of buprenorphine prescribing per opioid use disorder-related encounter before and after the intervention period, using electronic health record data. We also completed a postintervention physician survey assessing attitudes about the incentive program. RESULTS: Overall, 89% of eligible emergency physicians (56/63) completed the X-waiver training during the 6-week incentive period. In the 5 months after the incentive, buprenorphine prescribing per opioid use disorder-related encounter increased from 0.5% to 16% (Δ 15%; 95% confidence interval 10.6% to 19.9%), with substantial variability across sites (range 8% to 22% of opioid use disorder-related encounters). In a postintervention survey, 67% of participating physicians indicated that they would have completed the training for a lower amount. CONCLUSION: A financial incentive paying approximately half the clinical rate was effective in promoting emergency physician X-waiver training. The effect on ED-based buprenorphine prescribing was positive but variable across sites, and likely dependent on the availability of additional supports.


Assuntos
Analgésicos Opioides/uso terapêutico , Buprenorfina/uso terapêutico , Medicina de Emergência/educação , Motivação , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Certificação , Humanos , Tratamento de Substituição de Opiáceos , Estudos Prospectivos
15.
J Pain Symptom Manage ; 60(2): e22-e25, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32454184

RESUMO

The Coronavirus disease 2019 (COVID-19) pandemic has led to high numbers of critically ill and dying patients in need of expert management of dyspnea, delirium, and serious illness communication. The rapid spread of severe acute respiratory syndrome-Coronavirus-2 creates surges of infected patients requiring hospitalization and puts palliative care programs at risk of being overwhelmed by patients, families, and clinicians seeking help. In response to this unprecedented need for palliative care, our program sought to create a collection of palliative care resources for nonpalliative care clinicians. A workgroup of interdisciplinary palliative care clinicians developed the Palliative Care Toolkit, consisting of a detailed chapter in a COVID-19 online resource, a mobile and desktop Web application, one-page guides, pocket cards, and communication skills training videos. The suite of resources provides expert and evidence-based guidance on symptom management including dyspnea, pain, and delirium, as well as on serious illness communication, including conversations about goals of care, code status, and end of life. We also created a nurse resource hotline staffed by palliative care nurse practitioners and virtual office hours staffed by a palliative care attending physician. Since its development, the Toolkit has helped us disseminate best practices to nonpalliative care clinicians delivering primary palliative care, allowing our team to focus on the highest-need consults and increasing acceptance of palliative care across hospital settings.


Assuntos
Infecções por Coronavirus/terapia , Cuidados Paliativos/métodos , Pneumonia Viral/terapia , COVID-19 , Gerenciamento Clínico , Comunicação em Saúde/métodos , Pessoal de Saúde/educação , Humanos , Internet , Pandemias , Guias de Prática Clínica como Assunto
16.
Neurol Clin Pract ; 10(2): 149-155, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32309033

RESUMO

OBJECTIVE: To use the variations in neurology consultations requested by emergency department (ED) physicians to identify opportunities to implement multidisciplinary interventions in an effort to reduce ED overcrowding. METHODS: We retrospectively analyzed ED visits across 3 urban hospitals to determine the top 10 most common chief complaints leading to neurology consultation. For each complaint, we evaluated the likelihood of consultation, admission rate, admitting services, and provider-to-provider variability of consultation. RESULTS: Of 145,331 ED encounters analyzed, 3,087 (2.2%) involved a neurology consult, most commonly with chief complaints of acute-onset neurologic deficit, subacute neurologic deficit, or altered mental status. ED providers varied most in their consultation for acute-onset neurologic deficit, dizziness, and headache. Neurology consultation was associated with a 2.3-hour-longer length of stay (LOS) (95% CI: 1.6-3.1). Headache in particular has an average of 6.7-hour-longer ED LOS associated with consultation, followed by weakness or extremity weakness (4.4 hours) and numbness (4.1 hours). The largest estimated cumulative difference (number of patients with the specific consultation multiplied by estimated difference in LOS) belongs to headache, altered mental status, and seizures. CONCLUSION: A systematic approach to identify variability in neurology consultation utilization and its effect on ED LOS helps pinpoint the conditions most likely to benefit from protocolized pathways.

17.
Neuro Oncol ; 22(9): 1339-1347, 2020 09 29.
Artigo em Inglês | MEDLINE | ID: mdl-32149345

RESUMO

BACKGROUND: Brain metastases (BM) cause symptoms that supportive medications can alleviate. We assessed whether racial disparities exist in supportive medication utilization after BM diagnosis. METHODS: Medicare-enrolled patients linked with the Surveillance, Epidemiology, and End Results program (SEER) who had diagnoses of BM between 2007 and 2016 were identified. Fourteen supportive medication classes were studied: non-opioid analgesics, opioids, anti-emetics, anti-epileptics, headache-targeting medications, steroids, cognitive aids, antidepressants, anxiolytics, antidelirium/antipsychotic agents, muscle relaxants, psychostimulants, sleep aids, and appetite stimulants. Drug administration ≤30 days following BM diagnosis was compared by race using multivariable logistic regression. RESULTS: Among 17,957 patients, headache aids, antidepressants, and anxiolytics were prescribed less frequently to African Americans (odds ratio [95% CI] = 0.81 [0.73-0.90], P < 0.001; OR = 0.68 [0.57-0.80], P < 0.001; and OR = 0.68 [0.56-0.82], P < 0.001, respectively), Hispanics (OR = 0.83 [0.73-0.94], P = 0.004 OR = 0.78 [0.64-0.97], P = 0.02; and OR = 0.63 [0.49-0.81], P < 0.001, respectively), and Asians (OR = 0.81 [0.72-0.92], P = 0.001, OR = 0.67 [0.53-0.85], P = 0.001, and OR = 0.62 [0.48-0.80], P < 0.001, respectively) compared with non-Hispanic Whites. African Americans also received fewer anti-emetics (OR = 0.75 [0.68-0.83], P < 0.001), steroids (OR = 0.84 [0.76-0.93], P < 0.001), psychostimulants (OR = 0.14 [0.03-0.59], P = 0.007), sleep aids (OR = 0.71 [0.61-0.83], P < 0.001), and appetite stimulants (OR = 0.85 [0.77-0.94], P = 0.002) than Whites. Hispanic patients less frequently received antidelirium/antipsychotic drugs (OR = 0.57 [0.38-0.86], P = 0.008), sleep aids (OR = 0.78 [0.64-0.94, P = 0.01), and appetite stimulants (OR = 0.87 [0.76-0.99], P = 0.04). Asian patients received fewer opioids (OR = 0.86 [0.75-0.99], P = 0.04), anti-emetics (OR = 0.83 [0.73-0.94], P = 0.004), anti-epileptics (OR = 0.83 [0.71-0.97], P = 0.02), steroids (OR = 0.81 [0.72-0.92], P = 0.001), muscle relaxants (OR = 0.60 [0.41-0.89], P = 0.01), and appetite stimulants (OR = 0.87 [0.76-0.99], P = 0.03). No medication class was prescribed significantly less frequently to Whites. CONCLUSIONS: Disparities in supportive medication prescription for non-White/Hispanic groups with BM exist; improved provider communication and engagement with at-risk patients is needed. KEY POINTS: 1. Patients with BM commonly experience neurologic symptoms.2. Supportive medications improve quality of life among patients with BM.3. Non-White patients with BM receive fewer supportive medications than White patients.


Assuntos
Neoplasias Encefálicas , Qualidade de Vida , Idoso , Neoplasias Encefálicas/tratamento farmacológico , Disparidades em Assistência à Saúde , Humanos , Medicare , Estados Unidos/epidemiologia
18.
EC Clin Med Case Rep ; 3(12): 1-6, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33458720

RESUMO

The environmental debate on going green in the operating room (OR) has been a controversial topic for many years. Challengers of greening efforts cite various obstacles and arguments against these initiatives. However, ORs in the United States continue to generate a staggering amount of waste daily. In this article, we review major barriers to going green and highlight simple, yet effective greening strategies that anesthesia practices could adopt to reduce our carbon footprint.

20.
AMIA Jt Summits Transl Sci Proc ; 2019: 809-818, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31259038

RESUMO

Acute Kidney Injury (AKI) in critical care is often a quickly-evolving clinical event with high morbidity and mortality. Early prediction of AKI risk in critical care setting can facilitate early interventions that are likely to provide ben- efit. Recently there have been some research on AKI prediction with patient Electronic Health Records (EHR). The class imbalance problem is encountered in such prediction setting where the number of AKI cases is usually much smaller than the controls. This study systematically investigates the impact of class imbalance on the performance of AKI prediction. We systematically investigate several class-balancing strategies to address class imbalance, includ- ing traditional statistical approaches and the proposed methods (case-control matching approach and individualized prediction approach). Our results show that the proposed class-balancing strategies can effectively improve the AKI prediction performance. Additionally, some important predictors (e.g., creatinine, chloride, and urine) for AKI can be found based on the proposed methods.

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