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1.
Acad Emerg Med ; 28(10): 1100-1107, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34403539

RESUMO

BACKGROUND: Widespread vaccination is an essential component of the public health response to the COVID-19 pandemic, yet vaccine hesitancy remains pervasive. This prospective survey investigation aimed to measure the prevalence of vaccine hesitancy in a patient cohort at two urban emergency departments (EDs) and characterize underlying factors contributing to hesitancy. METHODS: Adult ED patients with stable clinical status (Emergency Severity Index 3-5) and without active COVID-19 disease or altered mental status were considered for participation. Demographic elements were collected as well as reported barriers/concerns related to vaccination and trusted sources of health information. Data were collected in person via a survey instrument proctored by trained research assistants. RESULTS: A total of 1,555 patients were approached, and 1,068 patients completed surveys (completion rate = 68.7%). Mean (±SD) age was 44.1 (±15.5) years (range = 18-93 years), 61% were female, and 70% were Black. A total of 31.6% of ED patients reported vaccine hesitancy. Of note, 19.7% of the hesitant cohort were health care workers. In multivariable regression analysis, Black race (odds ratio [OR] = 4.24, 95% confidence interval [CI] = 2.62 to 6.85) and younger age (age 18-24 years-OR = 4.57, 95% CI = 2.66 to 7.86; age 25-35 years-OR = 5.71, 95% CI = 3.71 to 8.81) were independently associated with hesitancy, to a greater degree than level of education (high school education or less-OR = 2.27, 95% CI = 1.23 to 4.19). Hesitant patients were significantly less likely to trust governmental sources of vaccine information than nonhesitant patients (39.6% vs. 78.9%, p < 0.001); less difference was noted in the domain of trust toward friends/family (51.1% vs. 61.0%, p = 0.004). Hesitant patients also reported perceived vaccine safety concerns and perceived insufficient research. CONCLUSIONS: Vaccine hesitancy is common among ED patients and more common among Black and younger patients, independent of education level. Hesitant patients report perceived safety concerns and low trust in government information sources but less so friends or family. This suggests that strategies to combat hesitancy may need tailoring to specific populations.


Assuntos
COVID-19 , Vacinas , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Vacinas contra COVID-19 , Serviço Hospitalar de Emergência , Feminino , Humanos , Pessoa de Meia-Idade , Pandemias , Estudos Prospectivos , SARS-CoV-2 , Vacinas/efeitos adversos , Adulto Jovem
2.
JMIR Hum Factors ; 2021 Jul 04.
Artigo em Inglês | MEDLINE | ID: mdl-34264197

RESUMO

BACKGROUND: The use of graphic narratives, defined as stories that use images for narration, is growing in health communication. OBJECTIVE: In this study, we describe the design and implementation of a graphic narrative screensaver (GNS) to communicate a guideline recommendation (avoiding low-value acid suppressive therapy (AST) use in hospital inpatients), and examine the comparative effectiveness of the GNS versus a text-based screensaver (TBS) on clinical practice (low-value AST prescriptions) and clinician recall. METHODS: During a two-year period, GNS and TBS were displayed on inpatient clinical workstations. The number of new AST prescriptions were examined in the four quarters before, the three quarters during, and the one quarter after screensavers were implemented. Additionally, an electronic survey was sent to resident physicians one year after the intervention to assess screensaver recall. RESULTS: Designing an aesthetically engaging graphic that could be rapidly understood was critical in the development of the GNS. The odds of receiving an AST prescription on medicine and medicine subspecialty services after the screensavers were implemented was lower for all 4 quarters (GNS and TBS broadcast together; only TBS broadcast; only GNS broadcast; no AST screensavers broadcast) compared to the quarter prior to implementation (Odds Ratio (OR) 0.85, 95% Confidence Interval (CI) 0.78-0.92; OR 0.89, CI 0.82-0.97; OR 0.87, CI 0.80-0.95; OR 0.81, CI 0.75-0.89, respectively; p<0.0001 for all comparisons). There were no statistically significant decreases for other high volume services such as the surgical services. These declines appear to have begun prior to screensaver implementation. When surveyed about the screensaver content one year later, resident physicians recalled both the GNS and TBS (61% vs 77%, p=0.07), and were more likely to recall the main message of the GNS compared to the TBS (70% vs 2%, p <0.0001). CONCLUSIONS: It is feasible to use a graphic narrative embedded in a broadcast screensaver to communicate a guideline recommendation, but further study is needed to determine the impact of graphic narratives on clinical practice.

3.
Resusc Plus ; 6: 100110, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-34223370

RESUMO

Aim: Pseudo-pulseless electrical activity (pseudo-PEA) is a global hypotensive ischemic state with retained coordinated myocardial contractile activity and an organized ECG with no clinically detectable pulses. The role of standard external chest compressions (CPR) and its associated intrinsic hemodynamics remains unclear in the setting of pseudo-PEA. We undertook an experimental trial to compare epinephrine alone versus epinephrine with CPR in the treatment of pseudo-PEA. Methods: Using a porcine model of hypoxic pseudo-PEA, we randomized 12 Yorkshire male swine to resuscitation with epinephrine only (control) (0.0015 mg/kg) versus epinephrine plus standard CPR (intervention). Animals who achieved return of spontaneous circulation (ROSC) were stabilized, fully recovered to hemodynamic and respiratory baseline, and rearrested up to 6 times. Primary outcome was ROSC defined as a sustained systolic blood pressure (SBP) of 60 mmHg for 2 min. Secondary outcomes included time to ROSC, coronary perfusion pressure (CoPP), and end-tidal carbon dioxide (ETCO2). Results: Among 47 events of pseudo-PEA in 12 animals, we observed significantly higher proportion of ROSC when treatment included CPR (14/21 - 67%) compared to epinephrine alone (4/26 - 15%) (p = 0.0007). CoPP, aortic pressures and ETCO2 were significantly higher, and right atrial pressures were lower in the intervention group. Conclusions: In a swine model of hypoxia-induced pseudo-PEA, epinephrine plus CPR was associated with improved intra-arrest hemodynamics and higher probability of ROSC. Thus, epinephrine plus CPR may be superior to epinephrine alone in the treatment of patients with pseudo-PEA.

4.
JAMA Netw Open ; 4(7): e2118801, 2021 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-34323984

RESUMO

Importance: Although racial disparities in acute pain control are well established, the role of patient analgesic preference and the factors associated with these disparities remain unclear. Objective: To characterize racial disparities in opioid prescribing for acute pain after accounting for patient preference and to test the hypothesis that racial disparities may be mitigated by giving clinicians additional information about their patients' treatment preferences and risk of opioid misuse. Design, Setting, and Participants: This study is a secondary analysis of data collected from Life STORRIED (Life Stories for Opioid Risk Reduction in the ED), a multicenter randomized clinical trial conducted between June 2017 and August 2019 in the emergency departments (EDs) of 4 academic medical centers. Participants included 1302 patients aged 18 to 70 years who presented to the ED with ureter colic or musculoskeletal back and/or neck pain. Interventions: The treatment arm was randomized to receive a patient-facing intervention (not examined in this secondary analysis) and a clinician-facing intervention that consisted of a form containing information about each patient's analgesic treatment preference and risk of opioid misuse. Main Outcomes and Measures: Concordance between patient preference for opioid-containing treatment (assessed before ED discharge) and receipt of an opioid prescription at ED discharge. Results: Among 1302 participants in the Life STORRIED clinical trial, 1012 patients had complete demographic and treatment preference data available and were included in this secondary analysis. Of those, 563 patients (55.6%) self-identified as female, with a mean (SD) age of 40.8 (14.1) years. A total of 455 patients (45.0%) identified as White, 384 patients (37.9%) identified as Black, and 173 patients (17.1%) identified as other races. After controlling for demographic characteristics and clinical features, Black patients had lower odds than White patients of receiving a prescription for opioid medication at ED discharge (odds ratio [OR], 0.42; 95% CI, 0.27-0.65). When patients who did and did not prefer opioids were considered separately, Black patients continued to have lower odds of being discharged with a prescription for opioids compared with White patients (among those who preferred opioids: OR, 0.43 [95% CI, 0.24-0.77]; among those who did not prefer opioids: OR, 0.45 [95% CI, 0.23-0.89]). These disparities were not eliminated in the treatment arm, in which clinicians were given additional data about their patients' treatment preferences and risk of opioid misuse. Conclusions and Relevance: In this secondary analysis of data from a randomized clinical trial, Black patients received different acute pain management than White patients after patient preference was accounted for. These disparities remained after clinicians were given additional patient-level data, suggesting that a lack of patient information may not be associated with opioid prescribing disparities. Trial Registration: ClinicalTrials.gov Identifier: NCT03134092.

5.
Pediatr Res ; 2021 Jun 26.
Artigo em Inglês | MEDLINE | ID: mdl-34175891

RESUMO

BACKGROUND: Early detection of delay or impairment in motor function is important to guide clinical management and inform prognosis during a critical window for the development of motor control in children. The purpose of this study was to investigate the ability of biomechanical measures of early postural control to distinguish infants with future impairment in motor control from their typically developing peers. METHODS: We recorded postural control from infants lying in supine in several conditions. We compared various center of pressure metrics between infants grouped by birth status (preterm and full term) and by future motor outcome (impaired motor control and typical motor control). RESULTS: One of the seven postural control metrics-path length-was consistently different between groups for both group classifications and for the majority of conditions. CONCLUSIONS: Quantitative measures of early spontaneous infant movement may have promise to distinguish early in life between infants who are at risk for motor impairment or physical disability and those who will demonstrate typical motor control. Our observation that center of pressure path length may be a potential early marker of postural instability and motor control impairment needs further confirmation and further investigation to elucidate the responsible neuromotor mechanisms. IMPACT: The key message of this article is that quantitative measures of infant postural control in supine may have promise to distinguish between infants who will demonstrate future motor impairment and those who will demonstrate typical motor control. One of seven postural control metrics-path length-was consistently different between groups. This metric may be an early marker of postural instability in infants at risk for physical disability.

6.
Am J Emerg Med ; 46: 63-69, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33735698

RESUMO

OBJECTIVE: Although timely administration of antibiotics has an established benefit in serious bacterial infection, the majority of studies evaluating antibiotic delay focus only on the first dose. Recent evidence suggests that delays in redosing may also be associated with worse clinical outcome. In light of the increasing burden of boarding in Emergency Departments (ED) and subsequent need to redose antibiotic in the ED, we examined the association between delayed second antibiotic dose administration and mortality among patients admitted from the ED with a broad array of infections and characterized risk factors associated with delayed second dose administration. METHODS: We performed a retrospective cohort study of patients admitted through five EDs in a single healthcare system from 1/2018 through 12/2018. Our study included all patients, aged 18 years or older, who received two intravenous antibiotic doses within a 30-h period, with the first dose administered in the ED. Patients with end stage renal disease, cirrhosis and extremes of weight were excluded due to a lack of consensus on antibiotic dosing intervals for these populations. Delay was defined as administration of the second dose at a time-point greater than 125% of the recommended interval. The primary outcome was in-hospital mortality. RESULTS: A total of 5605 second antibiotic doses, occurring during 4904 visits, met study criteria. Delayed administration of the second dose occurred during 21.1% of visits. After adjustment for patient characteristics, delayed second dose administration was associated with increased odds of in-hospital mortality (OR 1.50, 95%CI 1.05-2.13). Regarding risk factors for delay, every one-hour increase in allowable compliance time was associated with a 18% decrease in odds of delay (OR 0.82 95%CI 0.75-0.88). Other risk factors for delay included ED boarding more than 4 h (OR 1.47, 95%CI 1.27-1.71) or a high acuity presentation as defined by emergency severity index (ESI) (OR 1.54, 95%CI 1.30-1.81 for ESI 1-2 versus 3-5). CONCLUSIONS: Delays in second antibiotic dose administration were frequent in the ED and early hospital course, and were associated with increased odds of in-hospital mortality. Several risk factors associated with delays in second dose administration, including ED boarding, were identified.


Assuntos
Antibacterianos/administração & dosagem , Infecções Bacterianas/tratamento farmacológico , Administração Intravenosa , Antibacterianos/uso terapêutico , Infecções Bacterianas/mortalidade , Esquema de Medicação , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo
7.
J Public Health Manag Pract ; 27(Suppl 3): S186-S190, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33785694

RESUMO

The United States continues to battle the addiction and overdose deaths with the opioid epidemic. Prescription opioids are responsible for more than half of these deaths. This before-after study was conducted to assess the effect of the Centers for Disease Control and Prevention's (CDC's) opioid prescription guidelines. Data were abstracted from electronic health records of adult patients presenting with low back pain seen in the emergency department during the study period. SAS statistical software was used to compare opioid prescription practices before and after the intervention. A total of 1006 patients were included in the analysis. Opioid prescriptions decreased by 11% post-CDC guidelines (45% vs 34%). Of patients receiving opioids (n = 383), there was a 6% reduction in the number of days (<5 days) for which opioids were prescribed post-CDC guidelines (14% vs 8%). CDC guidelines on opioid prescribing were associated with a significant reduction in opioid prescribing in terms of both quantity and length of time prescribed. Public health policies as guidelines may positively influence provider decision making and behaviors.


Assuntos
Analgésicos Opioides , Hospitais Comunitários , Adulto , Analgésicos Opioides/efeitos adversos , Centers for Disease Control and Prevention, U.S. , Serviço Hospitalar de Emergência , Humanos , Padrões de Prática Médica , Estados Unidos
8.
J Public Health Manag Pract ; 27(Suppl 3): S200-S205, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33785697

RESUMO

CONTEXT: There is a long-standing shortage of formally trained Occupational & Environmental Medicine (OEM) physicians despite OEM practitioners experiencing high satisfaction and low burnout. OBJECTIVE: To explore the root causes of this shortage and suggest potential remedies. METHODS: Cross-sectional surveys were administered to medical students queried regarding OEM training, practicing OEM physicians queried regarding timing of specialty choice, and OEM Train-in-Place (TIP) program graduates queried regarding satisfaction with training. RESULTS: Of 247 medical student respondents, 70% had heard of OEM, 60% through one lecture. Of the 160 OEM physicians, 17% first became aware of OEM as medical students, and most would have chosen a different path had they heard sooner. Most TIP program trainees reported that they would not have undertaken specialty training without a TIP program (89%). CONCLUSIONS: Strategies to introduce OEM earlier in medical education and TIP programs for mid-career physicians may help overcome persistent shortages of OEM specialists.


Assuntos
Esgotamento Profissional , Medicina do Trabalho , Médicos , Escolha da Profissão , Estudos Transversais , Humanos , Inquéritos e Questionários , Estados Unidos
9.
Artigo em Inglês | MEDLINE | ID: mdl-33534709

RESUMO

There is a pressing need for strategies to slow or treat the progression of functional decline in people living with HIV. This paper explores a novel rehabilitation robotics approach to measuring cognitive and motor impairment in adults living with HIV, including a subset with stroke. We conducted a cross-sectional study with 21 subjects exhibiting varying levels of cognitive and motor impairment. We tested three robot-based tasks - trajectory tracking, N-back, and spatial span - to assess if metrics derived from these tasks were sensitive to differences in subjects with varying levels of executive function and upper limb motor impairments. We also examined how well these metrics could estimate clinical cognitive and motor scores. The results showed that the average sequence length on the robot-based spatial span task was the most sensitive to differences between various cognitive and motor impairment levels. We observed strong correlations between robot-based measures and clinical cognitive and motor assessments relevant to the HIV population, such as the Color Trails 1 (rho = 0.83), Color Trails 2 (rho = 0.71), Digit Symbol - Coding (rho = 0.81), Montreal Cognitive Assessment - Executive Function subscore (rho = 0.70), and Box and Block Test (rho = 0.74). Importantly, our results highlight that gross motor impairment may be overlooked in the assessment of HIV-related disability. This study shows that rehabilitation robotics can be expanded to new populations beyond stroke, namely to people living with HIV and those with cognitive impairments.


Assuntos
Disfunção Cognitiva , Infecções por HIV , Reabilitação Neurológica , Robótica , Reabilitação do Acidente Vascular Cerebral , Acidente Vascular Cerebral , Adulto , Estudos Transversais , Infecções por HIV/complicações , Humanos , Recuperação de Função Fisiológica , Extremidade Superior
10.
Clin Toxicol (Phila) ; 59(9): 801-809, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33529085

RESUMO

OBJECTIVES: The purpose of this study is the development of a porcine model of carbon monoxide (CO) poisoning to investigate alterations in brain and heart mitochondrial function. DESIGN: Two group large animal model of CO poisoning. SETTING: Laboratory. SUBJECTS: Ten swine were divided into two groups: Control (n = 4) and CO (n = 6). INTERVENTIONS: Administration of a low dose of CO at 200 ppm to the CO group over 90 min followed by 30 min of re-oxygenation at room air. The Control group received room air for 120 min. MEASUREMENTS: Non-invasive optical monitoring was used to measure cerebral blood flow and oxygenation. Cerebral microdialysis was performed to obtain semi real time measurements of cerebral metabolic status. At the end of the exposure, both fresh brain (cortical and hippocampal tissue) and heart (apical tissue) were immediately harvested to measure mitochondrial respiration and reactive oxygen species (ROS) generation and blood was collected to assess plasma cytokine concentrations. MAIN RESULTS: Animals in the CO group showed significantly decreased Complex IV-linked mitochondrial respiration in hippocampal and apical heart tissue but not cortical tissue. There also was a significant increase in mitochondrial ROS generation across all measured tissue types. The CO group showed a significantly higher cerebral lactate-to-pyruvate ratio. Both IL-8 and TNFα were significantly increased in the CO group compared with the Control group obtained from plasma. While not significant there was a trend to an increase in optically measured cerebral blood flow and hemoglobin concentration in the CO group. CONCLUSIONS: Low-dose CO poisoning is associated with early mitochondrial disruption prior to an observable phenotype highlighting the important role of mitochondrial function in the pathology of CO poisoning. This may represent an important intervenable pathway for therapy and intervention.


Assuntos
Intoxicação por Monóxido de Carbono/fisiopatologia , Circulação Cerebrovascular/fisiologia , Cérebro/irrigação sanguínea , Cérebro/metabolismo , Cérebro/fisiopatologia , Coração/fisiopatologia , Mitocôndrias/metabolismo , Animais , Respiração Celular/fisiologia , Modelos Animais de Doenças , Testes de Função Cardíaca , Humanos , Suínos
11.
Sci Rep ; 11(1): 1804, 2021 01 19.
Artigo em Inglês | MEDLINE | ID: mdl-33469101

RESUMO

We found ADAM8 enzymatic activity elevated in degenerative human intervertebral disc (IVD). Here, we examined the discs in ADAM8-inactivation mice that carry a mutation preventing self-activation of the enzyme. Surprisingly, elevated gene expression for inflammatory markers (Cxcl1, IL6) was observed in injured discs of ADAM8 mutant mice, along with elevated expression of type 2 collagen gene (Col2a1), compared with wild type controls. Injured annulus fibrosus of mutant and wild type mice contained a higher proportion of large collagen fibers compared with intact discs, as documented by microscopic examination under circular polarized light. In the intact IVDs, Adam8EQ mouse AF contained lower proportion of yellow (intermediate) fiber than WT mice. This suggests that ADAM8 may regulate inflammation and collagen fiber assembly. The seemingly contradictory findings of elevated inflammatory markers in mutant mice and excessive ADAM8 activity in human degenerative discs suggest that ADAM8 may interact with other enzymatic and pro-inflammatory processes needed for tissue maintenance and repair. As a future therapeutic intervention to retard intervertebral disc degeneration, partial inhibition of ADAM8 proteolysis may be more desirable than complete inactivation of this enzyme.


Assuntos
Proteínas ADAM/genética , Antígenos CD/genética , Expressão Gênica , Inflamação/genética , Disco Intervertebral/metabolismo , Proteínas de Membrana/genética , Animais , Camundongos , Camundongos Mutantes , Proteólise
12.
Shock ; 56(2): 245-254, 2021 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-33394972

RESUMO

INTRODUCTION: Lactic acidosis after cardiac surgery with cardiopulmonary bypass is common and associated with an increase in postoperative morbidity and mortality. A number of potential causes for an elevated lactate after cardiopulmonary bypass include cellular hypoxia, impaired tissue perfusion, ischemic-reperfusion injury, aerobic glycolysis, catecholamine infusions, and systemic inflammatory response after exposure to the artificial cardiopulmonary bypass circuit. Our goal was to examine the relationship between early abnormalities in microcirculatory convective blood flow and diffusive capacity and lactate kinetics during early resuscitation in the intensive care unit. We hypothesized that patients with impaired microcirculation after cardiac surgery would have a more severe postoperative hyperlactatemia, represented by the lactate time-integral of an arterial blood lactate concentration greater than 2.0 mmol/L. METHODS: We measured sublingual microcirculation using incident darkfield video microscopy in 50 subjects on intensive care unit admission after cardiac surgery. Serial measurements of systemic hemodynamics, blood gas, lactate, and catecholamine infusions were recorded each hour for the first 6 h after surgery. Lactate area under the curve (AUC) was calculated over the first 6 h. The lactate AUC was compared between subjects with normal and low perfused vessel density (PVD < 18 mm/mm2), high microcirculatory heterogeneity index (MHI > 0.4), and low vessel-by-vessel microvascular flow index (MFIv < 2.6). RESULTS: Thirteen (26%) patients had a low postoperative PVD, 20 patients (40%) had a high MHI, and 26 (52%) patients had a low MFIv. Patients with low perfused vessel density had higher lactate AUC compared with subjects with a normal PVD (22.3 [9.4-31.0] vs. 2.6 [0-8.8]; P < 0.0001). Patients with high microcirculatory heterogeneity had a higher lactate AUC compared with those with a normal MHI (2.5 [0.1-8.2] vs. 13.1 [3.7-31.1]; P < 0.001). We did not find a difference in lactate AUC when comparing high and low MFIv. CONCLUSION: Low perfused vessel density and high microcirculatory heterogeneity are associated with an increased intensity and duration of lactic acidosis after cardiac surgery with cardiopulmonary bypass.

13.
Scand J Trauma Resusc Emerg Med ; 29(1): 23, 2021 Jan 28.
Artigo em Inglês | MEDLINE | ID: mdl-33509242

RESUMO

BACKGROUND: One factor leading to the high mortality rate seen in sepsis is the subtle, dynamic nature of the disease, which can lead to delayed detection and under-resuscitation. This study investigated whether serial hemodynamic parameters obtained from a non-invasive cardiac output monitor (NICOM) predicts disease severity in patients at risk for sepsis. METHODS: Prospective clinical trial of the NICOM device in a convenience sample of adult ED patients at risk for sepsis who did not have obvious organ dysfunction at the time of triage. Hemodynamic data were collected immediately following triage and 2 hours after initial measurement and compared in two outcome groupings: (1) admitted vs. dehydrated, febrile, hypovolemicdischarged patients; (2) infectious vs. non-infectious sources. Receiver operator characteristic (ROC) curves were calculated to determine whether the NICOM values predict hospital admission better than a serum lactate. RESULTS: 50 patients were enrolled, 32 (64 %) were admitted to the hospital. Mean age was 49.5 (± 16.5) years and 62 % were female. There were no significant associations between changes in hemodynamic variables and patient disposition from the ED or diagnosis of infection. Lactate was significantly higher in admitted patients and those with infection (p = 0.01, p = 0.01 respectively). The area under the ROC [95 % Confidence Intervals] for lactate was 0.83 [0.64-0.92] compared to 0.59 [0.41-0.73] for cardiac output (CO), 0.68 [0.49-0.80] for cardiac index (CI), and 0.63 [0.36-0.80] for heart rate (HR) for predicting hospital admission. CONCLUSIONS: CO and CI, obtained at two separate time points, do not help with early disease severity differentiation of patients at risk for severe sepsis. Although mean HR was higher in those patients who were admitted, a serum lactate still served as a better predictor of patient admission from the ED.


Assuntos
Débito Cardíaco , Monitorização Fisiológica , Medição de Risco , Sepse/diagnóstico , Adulto , Idoso , Serviço Hospitalar de Emergência , Feminino , Frequência Cardíaca , Humanos , Ácido Láctico/sangue , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Amostragem , Triagem
14.
J Addict Med ; 15(1): 49-54, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-32541363

RESUMO

OBJECTIVES: We performed a descriptive analysis of patient and treatment characteristics in premature discharges "against medical advice" (AMA) in a cohort of patients with opioid-related hospitalizations. METHODS: We abstracted data from 1152 opioid related hospitalizations of 928 adult patients in a large academic health system. Using electronic health record data, hospitalizations were categorized as AMA or conventional discharge (CD). To determine differences between AMA and CD regarding treatment characteristics, Fisher exact test, t tests, ANOVA, and logistic regression were performed. RESULTS: 74 / 1152 (6%) of opioid-related hospitalizations were discharged AMA. Hospitalizations that resulted in AMA discharge had shorter median length of stay (AMA vs CD 3.5 vs 5.5 days, P < 0.001) and received fewer of any type of opioid agonist treatment (AMA vs CD 73% vs 84%, P = 0.03). Although the number of hospitalizations in which methadone was administered did not differ between the AMA and CD groups, hospitalizations that resulted in AMA had more dose reductions and lesser quantities of methadone overall before discharge. Buprenorphine use was low overall in AMA and CD (0% and 2.1%, respectively). CONCLUSION: In this sample of opioid related hospitalizations, admissions that resulted in AMA discharge had fewer opioid agonist administrations and lower methadone dosing. These findings support efforts to initiate opioid agonist therapy during hospital admissions, and further studies should determine whether this practice mitigates AMA discharges.


Assuntos
Analgésicos Opioides , Alta do Paciente , Adulto , Analgésicos Opioides/efeitos adversos , Hospitalização , Humanos , Estudos Retrospectivos , Fatores de Risco , Recusa do Paciente ao Tratamento
15.
J Cardiothorac Vasc Anesth ; 35(1): 106-115, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32505603

RESUMO

OBJECTIVE: Resuscitation after cardiac surgery needs to address multiple pathophysiological processes that are associated with significant morbidity and mortality. Functional microcirculatory derangements despite normal systemic hemodynamics have been previously described but must be tied to clinical outcomes. The authors hypothesized that microcirculatory dysfunction after cardiac surgery would include impaired capillary blood flow and impaired diffusive capacity and that subjects with the lowest quartile of perfused vessel density would have an increased postoperative lactate level and acute organ injury scores. DESIGN: Prospective, observational study. SETTING: A single, tertiary university cardiovascular surgical intensive care unit. PARTICIPANTS: 25 adults undergoing elective cardiac surgery requiring cardiopulmonary bypass. INTERVENTION: Sublingual microcirculation was imaged using incident dark field microscopy before and 2 to 4 hours after surgery in the intensive care unit. MEASUREMENTS AND MAIN RESULTS: Compared with baseline measurements, postoperative vessel-by-vessel microvascular flow index (2.9 [2.8-2.9] v 2.5 [2.4-2.7], p < 0.0001) and perfused vessel density were significantly impaired (20.7 [19.3-22.9] v 16.3 [12.8-17.9], p < 0.0001). The lowest quartile of perfused vessel density (<12.8 mm/mm2) was associated with a significantly increased postoperative lactate level (6.0 ± 2.9 v 1.8 ± 1.2, p < 0.05), peak lactate level (7.6 ± 2.8 v 2.8 ± 1.5, p = 0.03), and sequential organ failure assessment (SOFA) score at 24 and 48 hours. CONCLUSION: In patients undergoing cardiac surgery, there was a significant decrease in postoperative microcirculatory convective blood flow and diffusive capacity during early postoperative resuscitation. Severely impaired perfused vessel density, represented by the lowest quartile of distribution, is significantly related to hyperlactatemia and early organ injury.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Ácido Láctico , Adulto , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Hemodinâmica , Humanos , Microcirculação , Soalho Bucal , Estudos Prospectivos
17.
Am J Emerg Med ; 38(10): 2070-2073, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-33142177

RESUMO

OBJECTIVES: The Resuscitation & Critical Care Unit (ResCCU) is a novel ED-based ICU designed to provide early critical care services. This study sought to identify characteristics of poisoned patients treated in the ResCCU. METHODS: We conducted a retrospective, single-center case study of poisoned patients over the age of 18 years old over a 16-month period. Patient demographics, drug concentrations, and severity of illness scores were extracted from electronic medical records. Patients were divided into two groups, those who required short term ICU level care (< 24 h) and prolonged ICU care (> 24 h). RESULTS: A total of 58 ED visits with a tox-related illness were analyzed. There were 24 women (41%) and 34 men (59%). There were 42 patients (72%) who required short term ICU level care and 16 patients (28%) who required prolonged ICU care. In the short-term ICU group, 13 patients (31%) were discharged home directly from the ResCCU, 29 patients (69%) were sent to the inpatient floor, and 1 of the admitted floor patients expired. There were no patients admitted to the floor that required a step-up to the inpatient ICU. 56 patients (97%) were alive at post-admit day 7 and 28, and only 8 (14%) were re-admitted within 30 days. CONCLUSIONS: Patients who were treated in the ED-based ICU for toxicology-related illnesses were frequently able to be either discharged home or admitted to a regular floor after their initial stabilization and treatment, and none that were sent to the floor required an ICU step-up.


Assuntos
Envenenamento/terapia , Ressuscitação/tendências , APACHE , Adolescente , Adulto , Idoso , Estudos de Coortes , Cuidados Críticos/métodos , Cuidados Críticos/tendências , Gerenciamento Clínico , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/tendências , Feminino , Hospitalização , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Escores de Disfunção Orgânica , Envenenamento/complicações , Estudos Prospectivos , Melhoria de Qualidade , Ressuscitação/métodos , Ressuscitação/normas , Estudos Retrospectivos
18.
medRxiv ; 2020 Nov 03.
Artigo em Inglês | MEDLINE | ID: mdl-33173932

RESUMO

There is a pressing need for strategies to slow or treat the progression of functional decline in people living with HIV. This paper explores a novel rehabilitation robotics approach to measuring cognitive and motor impairment in adults living with HIV, including a subset with stroke. We conducted a cross-sectional study with 21 subjects exhibiting varying levels of cognitive and motor impairment. We developed three robot-based tasks trajectory tracking, N-back, and spatial span - to assess if metrics derived from these tasks were sensitive to differences in subjects with varying levels of executive function and upper limb motor impairments. We also examined if these metrics could estimate clinical cognitive and motor scores. The results showed that the average sequence length on the robot-based spatial span task was the most sensitive to differences between subjects' cognitive and motor impairment levels. We observed strong correlations between robot-based measures and clinical cognitive and motor assessments relevant to the HIV population, such as the Color Trails 1 (rho = 0.83), Color Trails 2 (rho = 0.71), Digit Symbol - Coding (rho = 0.81), Montreal Cognitive Assessment - Executive Function subscore (rho = 0.70), and Box and Block Test (rho = 0.74). Importantly, our results highlight that gross motor impairment may be overlooked in the assessment of HIV-related disability. This study shows that rehabilitation robotics can be expanded to new populations beyond stroke, namely to people living with HIV and those with cognitive impairments.

19.
Cannabis Cannabinoid Res ; 5(3): 263-270, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32923663

RESUMO

Objective: To determine if cannabis may be used as an alternative or adjunct treatment for intermittent and chronic prescription opioid users. Design: Retrospective cohort study. Setting: A single-center cannabis medical practice site in California. Patients: A total of 180 patients who had a chief complaint of low back pain were identified (International Classification of Diseases, 10th Revision, code M54.5). Sixty-one patients who used prescription opioids were analyzed. Interventions: Cannabis recommendations were provided to patients as a way to mitigate their low back pain. Outcome Measures: Number of patients who stopped opioids and change in morphine equivalents. Results: There were no between-group differences based on demographic, experiential, or attitudinal variables. We found that 50.8% were able to stop all opioid usage, which took a median of 6.4 years (IQR=1.75-11 years) after excluding two patients who transitioned off opioids by utilizing opioid agonists. For those 29 patients (47.5%) who did not stop opioids, 9 (31%) were able to reduce opioid use, 3 (10%) held the same baseline, and 17 (59%) increased their usage. Forty-eight percent of patients subjectively felt like cannabis helped them mitigate their opioid intake but this sentiment did not predict who actually stopped opioid usage. There were no variables that predicted who stopped opioids, except that those who used higher doses of cannabis were more likely to stop, which suggests that some patients might be able to stop opioids by using cannabis, particularly those who are dosed at higher levels. Conclusions: In this long-term observational study, cannabis use worked as an alternative to prescription opioids in just over half of patients with low back pain and as an adjunct to diminish use in some chronic opioid users.

20.
J Occup Environ Med ; 62(9): 680-685, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32890204

RESUMO

OBJECTIVE: To determine prevalence and key drivers of burnout in Occupational and Environmental Medicine physicians in the United States. METHODS: A nationwide survey of Occupational Medicine physicians was conducted using the Qualtrics® platform. Burnout, measured by the Maslach Burnout Inventory®, Social Support, and Job Satisfaction were assessed. RESULTS: The response rate was 46%, the overall burnout prevalence 38%, and most respondents were men (69%). The mean age and mean years in practice were 56 years and 20 years respectively. Physicians working in government/military (48%) and private medical center group settings (46%) were significantly more likely to report burnout, with consultants (15%) reporting the lowest rate. CONCLUSIONS: Although the overall burnout prevalence is lower in Occupational Medicine physicians compared with most specialties, the rate varies significantly by practice setting (15% to 48%) affirming the impact of organizational factors.


Assuntos
Esgotamento Profissional , Medicina Ambiental , Medicina do Trabalho , Médicos , Estudos Transversais , Feminino , Humanos , Satisfação no Emprego , Masculino , Pessoa de Meia-Idade , Prevalência , Inquéritos e Questionários , Estados Unidos
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