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1.
Hosp Pediatr ; 10(2): 138-146, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31980442

RESUMO

OBJECTIVES: Suicide is the second leading cause of death in the adolescent population, presenting a public health crisis. The goal of this study was to evaluate adolescent intentional ingestions in a community hospital and to identify variables associated with the risk of admission to inpatient medical and psychiatric settings. METHODS: This study was a retrospective chart review from a hospital system in the Pacific Northwest over 2 years for patients aged 9 to 18 years. Variables examined include age, sex, type of ingestion, emergency department length of stay (LOS), admission to the inpatient setting, LOS of inpatient admission, admission to psychiatry, presence of a therapist, and insurance type. RESULTS: During the study period, 233 individual intentional ingestions occurred. The most commonly ingested substances were psychiatric medications (30.9%), prescription medications (28.3%), and ibuprofen (24.0%). One-third of patients (33.9%) required admission to a medical hospital, whereas one-quarter (24.9%) required admission to a psychiatric hospital. The following variables were associated with risk of admission to a medical hospital: female sex, shorter emergency department LOS, and ingestion of psychiatric medications, prescription medication, and/or salicylates. Risk of admission to a psychiatric hospital was associated with an inpatient medical admission, an increased duration of medical admission, and an ingestion of a psychiatric medication. CONCLUSIONS: In this study, we describe important epidemiology on adolescent intentional ingestions in a community setting, providing variables associated with a risk of admission to medical and psychiatric hospitals.

2.
Artigo em Inglês | MEDLINE | ID: mdl-31968182

RESUMO

RATIONALE: Gender gaps exist in academic leadership positions in critical care. Peer-reviewed publications are crucial to career advancement, yet little is known regarding gender differences in authorship of critical care research. OBJECTIVES: To evaluate gender differences in authorship of critical care literature. METHODS: We used a validated database of author gender to analyze authorship of critical care articles indexed in PubMed between 2008-2018 in 40 frequently-cited journals. High-impact journals were defined as those in the top 5% of all journals. We used mixed-effects logistic regression to evaluate the association of senior author gender with first and middle author gender, and first author gender with journal impact factor. RESULTS: Among 18,483 studies, 30.8% had female first authors and 19.5% had female senior authors. Female authorship rose slightly over the last decade (average annual increase of 0.44% (p<0.01) and 0.51% (p<0.01) for female first and senior authors, respectively). When the senior author was female, the odds of female co-authorship rose substantially (first author aOR1.93, 95%CI:1.71-2.17; middle author aOR1.48, 95%CI:1.29-1.69). Female first authors had higher odds of publishing in lower-impact journals than men (aOR1.30, 95%CI:1.16-1.45). CONCLUSIONS: Women comprise less than one-third of first authors and one-quarter of senior authors of critical care research, with minimal increase over the past decade. When the senior author was female, the odds of female co-authorship rose substantially. However, female first authors tend to publish in lower-impact journals. These findings may help explain the underrepresentation of women in critical care academic leadership positions and identify targets for improvement.

3.
Ann Emerg Med ; 75(2): 171-180, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31248675

RESUMO

STUDY OBJECTIVE: Physician Orders for Life-Sustaining Treatment (POLST) forms are intended to help prevent the provision of unwanted medical interventions among patients with advanced illness or frailty who are approaching the end of life. We seek to evaluate how POLST form completion, treatment limitations, or both influence intensity of treatment among patients who present to the emergency department (ED). METHODS: This was a retrospective cohort study of adults who presented to the ED at an academic medical center in Oregon between April 2015 and October 2016. POLST form completion and treatment limitations were the main exposures. Primary outcome was hospital admission; secondary outcomes included ICU admission and a composite measure of aggressive treatment. RESULTS: A total of 26,128 patients were included; 1,769 (6.8%) had completed POLST forms. Among patients with POLST, 52.1% had full treatment orders, and 6.4% had their forms accessed before admission. POLST form completion was not associated with hospital admission (adjusted odds ratio [aOR]=0.97; 95% confidence interval [CI] 0.84 to 1.12), ICU admission (aOR=0.82; 95% CI 0.55 to 1.22), or aggressive treatment (aOR=1.06; 95% CI 0.75 to 1.51). Compared with POLST forms with full treatment orders, those with treatment limitations were not associated with hospital admission (aOR=1.12; 95% CI 0.92 to 1.37) or aggressive treatment (aOR=0.87; 95% CI 0.5 to 1.52), but were associated with lower odds of ICU admission (aOR=0.31; 95% CI 0.16 to 0.61). CONCLUSION: Among patients presenting to the ED with POLST, the majority of POLST forms had orders for full treatment and were not accessed by emergency providers. These findings may partially explain why we found no association of POLST with treatment intensity. However, treatment limitations on POLST forms were associated with reduced odds of ICU admission. Implementation and accessibility of POLST forms are crucial when considering their effect on the provision of treatment consistent with patients' preferences.

4.
J Neurotrauma ; 2019 Aug 06.
Artigo em Inglês | MEDLINE | ID: mdl-31382848

RESUMO

Progression of intracranial hemorrhage (PICH) is a significant cause of secondary brain injury in patients with traumatic brain injury (TBI). Previous studies have implicated a variety of mediators that contribute to PICH. We hypothesized that patients with PICH would display either a hypocoagulable state, hyperfibrinolysis, or both. We conducted a prospective study of adult trauma patients with isolated TBI. Blood was obtained for routine coagulation assays, platelet count, fibrinogen, thrombelastography, markers of thrombin generation, and markers of fibrinolysis at admission and 6, 12, 24, and 48 hours. Univariate analyses were performed to compare baseline characteristics between groups. Linear regression models were created, adjusting for baseline differences, to determine the relationship between individual assays and PICH. 141 patients met entry criteria, of whom 71 had hemorrhage progression. Patients with PICH had a higher Injury Severity Score and Abbreviated Injury Scale score (head), a lower Glasgow Coma Scale score, and lower plasma sodium on admission. Patients with PICH had higher D-dimers on admission. After adjusting for baseline differences, elevated D-dimers remained significantly associated with PICH compared to patients without PICH at admission. Hypocoagulation was not significantly associated with PICH in these patients. The association between PICH and elevated D-dimers early after injury suggests that fibrinolytic activation may contribute to PICH in patients with TBI.

5.
Am J Emerg Med ; 37(12): 2215-2223, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30928476

RESUMO

BACKGROUND: Syncope is a common chief complaint among older adults in the Emergency Department (ED), and orthostatic vital signs are often a part of their evaluation. We assessed whether abnormal orthostatic vital signs in the ED are associated with composite 30-day serious outcomes in older adults presenting with syncope. METHODS: We performed a secondary analysis of a prospective, observational study at 11 EDs in adults ≥ 60 years who presented with syncope or near syncope. We excluded patients lost to follow up. We used the standard definition of abnormal orthostatic vital signs or subjective symptoms of lightheadedness upon standing to define orthostasis. We determined the rate of composite 30-day serious outcomes, including those during the index ED visit, such as cardiac arrhythmias, myocardial infarction, cardiac intervention, new diagnosis of structural heart disease, stroke, pulmonary embolism, aortic dissection, subarachnoid hemorrhage, cardiopulmonary resuscitation, hemorrhage/anemia requiring transfusion, with major traumatic injury from fall, recurrent syncope, and death) between the groups with normal and abnormal orthostatic vital signs. RESULTS: The study cohort included 1974 patients, of whom 51.2% were male and 725 patients (37.7%) had abnormal orthostatic vital signs. Comparing those with abnormal to those with normal orthostatic vital signs, we did not find a difference in composite 30-serious outcomes (111/725 (15.3%) vs 184/1249 (14.7%); unadjusted odds ratio, 1.05 [95%CI, 0.81-1.35], p = 0.73). After adjustment for gender, coronary artery disease, congestive heart failure (CHF), history of arrhythmia, dyspnea, hypotension, any abnormal ECG, physician risk assessment, medication classes and disposition, there was no association with composite 30-serious outcomes (adjusted odds ratio, 0.82 [95%CI, 0.62-1.09], p = 0.18). CONCLUSIONS: In a cohort of older adult patients presenting with syncope who were able to have orthostatic vital signs evaluated, abnormal orthostatic vital signs did not independently predict composite 30-day serious outcomes.

7.
J Emerg Med ; 54(5): 600-606, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29456086

RESUMO

BACKGROUND: Migraine headaches are a common reason for pediatric emergency department (ED) visits. Small studies suggest the potential efficacy of sub-anesthetic doses of propofol for migraine with a favorable side effect profile and potentially decreased length of stay (LOS). OBJECTIVE: The objective of this study was to compare the efficacy of low-dose propofol (LDP) to standard therapy (ST) in pediatric migraine treatment. METHODS: We conducted a prospective, pragmatic randomized controlled trial from April 2014 through June 2016 in the ED at two pediatric hospitals. Patients aged 7-19 years were eligible if they were diagnosed with migraine by the emergency physician and had a presenting visual analog pain score (VAS) of 6-10. Primary outcome was the percent of pain reduction. Secondary outcomes were ED LOS, 24-h rebound headache, return visits to the ED, and adverse reactions. RESULTS: Seventy-four patients were enrolled, but 8 were excluded, leaving 66 patients in the final analysis (36 ST, 30 LDP). Pain reduction was 59% for ST and 51% for LDP (p = 0.34) with 72.2% vs. 73.3% achieving a VAS ≤ 4 with initial therapy (p = 0.92). There was a nonsignificant trend toward shorter median LOS from drug administration to final disposition favoring propofol (79 min vs. 111 min; p = 0.09). Rebound headache was significantly more common in the ST vs. LDP group (66.7% vs. 25.0%; p = 0.01). CONCLUSIONS: LDP did not achieve better pain reduction than ST, however, LDP was associated with significantly fewer rebound headaches and a nonsignificant trend toward shorter median LOS from drug administration to disposition.


Assuntos
Transtornos de Enxaqueca/tratamento farmacológico , Manejo da Dor/normas , Propofol/administração & dosagem , Adolescente , Anestésicos Intravenosos/administração & dosagem , Anestésicos Intravenosos/farmacologia , Anestésicos Intravenosos/uso terapêutico , Criança , Serviço Hospitalar de Emergência/organização & administração , Feminino , Humanos , Injeções Intravenosas , Tempo de Internação/estatística & dados numéricos , Masculino , Manejo da Dor/métodos , Pediatria/métodos , Propofol/farmacologia , Propofol/uso terapêutico , Estudos Prospectivos , Resultado do Tratamento , Adulto Jovem
8.
Ann Emerg Med ; 71(4): 452-461.e3, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29275946

RESUMO

STUDY OBJECTIVE: Cardiac arrhythmia is a life-threatening condition in older adults who present to the emergency department (ED) with syncope. Previous work suggests the initial ED ECG can predict arrhythmia risk; however, specific ECG predictors have been variably specified. Our objective is to identify specific ECG abnormalities predictive of 30-day serious cardiac arrhythmias in older adults presenting to the ED with syncope. METHODS: We conducted a prospective, observational study at 11 EDs in adults aged 60 years or older who presented with syncope or near syncope. We excluded patients with a serious cardiac arrhythmia diagnosed during the ED evaluation from the primary analysis. The outcome was occurrence of 30-day serous cardiac arrhythmia. The exposure variables were predefined ECG abnormalities. Independent predictors were identified through multivariate logistic regression. The sensitivities and specificities of any predefined ECG abnormality and any ECG abnormality identified on adjusted analysis to predict 30-day serious cardiac arrhythmia were also calculated. RESULTS: After exclusion of 197 patients (5.5%; 95% confidence interval [CI] 4.7% to 6.2%) with serious cardiac arrhythmias in the ED, the study cohort included 3,416 patients. Of these, 104 patients (3.0%; 95% CI 2.5% to 3.7%) had a serious cardiac arrhythmia within 30 days from the index ED visit (median time to diagnosis 2 days [interquartile range 1 to 5 days]). The presence of nonsinus rhythm, multiple premature ventricular conductions, short PR interval, first-degree atrioventricular block, complete left bundle branch block, and Q wave/T wave/ST-segment abnormalities consistent with acute or chronic ischemia on the initial ED ECG increased the risk for a 30-day serious cardiac arrhythmia. This combination of ECG abnormalities had a similar sensitivity in predicting 30-day serious cardiac arrhythmia compared with any ECG abnormality (76.9% [95% CI 67.6% to 84.6%] versus 77.9% [95% CI 68.7% to 85.4%]) and was more specific (55.1% [95% CI 53.4% to 56.8%] versus 46.6% [95% CI 44.9% to 48.3%]). CONCLUSION: In older ED adults with syncope, approximately 3% receive a diagnosis of a serious cardiac arrhythmia not recognized on initial ED evaluation. The presence of specific abnormalities on the initial ED ECG increased the risk for 30-day serious cardiac arrhythmias.


Assuntos
Eletrocardiografia , Serviço Hospitalar de Emergência , Medição de Risco/métodos , Síncope/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Síncope/epidemiologia , Síncope/fisiopatologia , Estados Unidos/epidemiologia
9.
J Trauma Acute Care Surg ; 84(1): 19-24, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-28640776

RESUMO

BACKGROUND: Fever is strongly associated with poor outcome after traumatic brain injury (TBI). We hypothesized that early fever is a direct result of brain injury and thus would be more common in TBI than in patients without brain injury and associated with inflammation. METHODS: We prospectively enrolled patients with major trauma with and without TBI from a busy Level I trauma center intensive care unit (ICU). Patients were assigned to one of four groups based on their presenting Head Abbreviated Injury Severity Scale scores: multiple injuries: head Abbreviated Injury Scale (AIS) score greater than 2, one other region greater than 2; isolated head: head AIS score greater than 2, all other regions less than 3; isolated body: one region greater than 2, excluding head/face; minor injury: no region with AIS greater than 2. Early fever was defined as at least one recorded temperature greater than 38.3°C in the first 48 hours after admission. Outcome measures included neurologic deterioration, length of stay in the ICU, hospital mortality, discharge Glasgow Outcome Scale-Extended, and plasma levels of seven key cytokines at admission and 24 hours (exploratory). RESULTS: Two hundred sixty-eight patients were enrolled, including subjects with multiple injuries (n = 59), isolated head (n = 97), isolated body (n = 100), and minor trauma (n = 12). The incidence of fever was similar in all groups irrespective of injury (11-24%). In all groups, there was a significant association between the presence of early fever and death in the hospital (6-18% vs. 0-3%), as well as longer median ICU stays (3-7 days vs. 2-3 days). Fever was significantly associated with elevated IL-6 at admission (50.7 pg/dL vs. 16.9 pg/dL, p = 0.0067) and at 24 hours (83.1 pg/dL vs. 17.1 pg/dL, p = 0.0025) in the isolated head injury group. CONCLUSION: Contrary to our hypothesis, early fever was not more common in patients with brain injury, though fever was associated with longer ICU stays and death in all groups. Additionally, fever was associated with elevated IL-6 levels in isolated head injury. LEVEL OF EVIDENCE: Prognostic and Epidemiological study, level III.


Assuntos
Lesões Encefálicas Traumáticas/complicações , Febre/epidemiologia , Adulto , Idoso , Lesões Encefálicas Traumáticas/sangue , Lesões Encefálicas Traumáticas/mortalidade , Estudos de Casos e Controles , Cuidados Críticos , Citocinas/sangue , Feminino , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Índices de Gravidade do Trauma
10.
Pediatr Emerg Care ; 2017 Nov 14.
Artigo em Inglês | MEDLINE | ID: mdl-29135901

RESUMO

OBJECTIVE: Pediatric headaches are a common presentation to emergency departments accounting for almost half a million annual visits. Providers are left with the difficult task of deciding who has a secondary headache etiology that warrants neuroimaging. METHODS: We conducted a retrospective case-control study. Patients from a pediatric neuro-oncology clinic database with brain cancer and a headache at presentation were identified as cases. Controls were patients from 2 local pediatric tertiary care emergency departments with a final diagnosis of headache after negative neuroimaging. Clinical factors were decided a priori, and logistic regression was used to determine which clinical factors were related to case/control status. RESULTS: A total of 334 patients (203 controls and 131 cases) were included. Patients with a history of headaches had 0.5 (95% confidence interval [CI]: 0.3-0.9; P = 0.03) times the odds of being a case. Patients with vomiting had increased odds of being a case compared with controls regardless of the time of day (early morning 1.8 [95% CI: 1.0-3.2; P = 0.04] and non-early morning 6.6 [95% CI: 2.0-21.7; P < 0.01]). Patients with neurological signs had 10.3 (95% CI: 5.4-19.4; P < 0.01) times the odds of being a case, and patients with an associated seizure had 10.9 (95% CI: 3.8-30.7; P < 0.01) times the odds of being a case. CONCLUSIONS: This study identified clinical factors associated with pediatric brain neoplasms that may guide acute neuroimaging decisions. This study also provides insight into potential clinical factors to be studied prospectively to derive a clinical decision rule.

11.
J Adolesc Health ; 60(2): 191-195, 2017 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-27889404

RESUMO

PURPOSE: Suicide attempts by adolescents most commonly involve the overdose of medications. To date, there has been little information on the over-the-counter or prescription medicines that adolescents ingest for self-harm. Identification of medications chosen in suicide attempts may help guide anticipatory guidance to parents by primary care providers and Poison Centers in prevention programs. METHODS: This was a retrospective observational study using the American Association of Poison Control Center's National Poison Data System. Data were collected on patients aged 13-19 years old at the time of their substance ingestion, between the years 2004 and 2013 and that were coded as reason for ingestion of "intentional-suspected suicide." RESULTS: During the 10-year study period, there were 390,560 poison center calls for intentional-suspected suicide in the United States between 2004 and 2013, accounting for 80.3% of all "intentional" ingestion calls in the adolescent population. Over the entire age range, the most common substance ingested included acetaminophen (10.9%), ibuprofen (9%), selective serotonin reuptake inhibitors (7.7%), atypical antipsychotic (6%), and antihistamines (5%). The most common medications coded as resulting in major clinical effects or death were antidepressants and atypical antipsychotics. CONCLUSIONS: Adolescent ingestion choices for suicide attempts have remained relatively consistent over the past 10 years. However, there was a recent decrease in selective serotonin reuptake inhibitor ingestions. The most common medications used in an overdose attempt were ibuprofen and acetaminophen. Further preventative efforts are needed in this at-risk population from multiple providers at various levels.


Assuntos
Comportamento do Adolescente/psicologia , Overdose de Drogas/epidemiologia , Medicamentos sem Prescrição/envenenamento , Medicamentos sob Prescrição/envenenamento , Tentativa de Suicídio/estatística & dados numéricos , Adolescente , Adulto , Feminino , Humanos , Masculino , Centros de Controle de Intoxicações/estatística & dados numéricos , Estudos Retrospectivos , Distribuição por Sexo , Tentativa de Suicídio/prevenção & controle , Estados Unidos/epidemiologia , Adulto Jovem
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