Increased opioid consumption in diabetics with operative ankle fractures: a retrospective case-control study.

INTRODUCTION: Opioids are commonly used for post-operative pain control. It is known that diabetic patients with ankle fractures will experience prolonged healing, higher risk of hardware failure, and an increased risk of infection. However, the opioid requirements amongst this patient cohort have not been previously evaluated. Thus, the purpose of this study is to retrospectively compare opioid utilization amongst ankle fracture patients with and without diabetes mellitus (DM). METHODS: An IRB approval was obtained for the retrospective review of patients who presented with an ankle fracture and underwent surgery between November 2013 and January 2017. A total of 180 patients (144 without DM, 36 with DM) with a mean age of 50 years (± 18 years) were included. Opioid consumption was quantified utilizing a morphine-milliequivalent conversion algorithm. A repeated measures ANOVA was conducted to compare opioid consumption. A two-tailed p value of 0.05 was set as the threshold for statistical significance. RESULTS: Repeated measures ANOVA revealed a statistically significant decrease in total opioid consumption during the 4-month duration (p < 0.001). The model demonstrated a mean difference in opioid consumption of - 214.3 morphine meq between the patients without and with DM (p = 0.022). Post hoc pair-wise comparison revealed less opioid consumption amongst non-diabetic patients at 2 (- 418.5 Meq; p = 0.009), 3 months (- 355.6 Meq; p = 0.021), and 4 months (- 152.6 Meq; p = 0.006) after surgery. CONCLUSION: Our study revealed increased opioid consumption amongst diabetic patients who are treated surgically for ankle fractures. With increasing efforts aimed at reducing opioid administration, orthopaedic surgeons should be aware of higher opioid consumption amongst this patient cohort. Further studies are needed to verify the results of this study.

Emergency department variation in utilization and diagnostic yield of advanced radiography in diagnosis of pulmonary embolus.

BACKGROUND: There is growing pressure to measure and reduce unnecessary imaging in the emergency department. OBJECTIVE: We study provider and hospital variation in utilization and diagnostic yield for advanced radiography in diagnosis of pulmonary embolism (PE) and to assess patient- and provider-level factors associated with diagnostic yield. METHODS: Retrospective chart review of all adult patients presenting to four hospitals from January 2006 through December 2009 who had a computed tomography or ventilation/perfusion scan to evaluate for PE. Demographic data on the providers ordering the scans were collected. Diagnostic yield (positive scans/total scans ordered) was calculated at the hospital and provider level. The study was not designed to assess appropriateness of imaging. RESULTS: There was significant variation in utilization and diagnostic yield at the hospital level (chi-squared, p < 0.05). Diagnostic yield ranged from 4.2% to 8.2%; after adjusting for patient- and provider-level factors; the two hospitals with an emergency medicine residency training program had higher diagnostic yields (odds ratio [OR] 2.0, 95% confidence interval [CI] 1.6-2.5 and OR 1.9, 95% CI 1.5-2.4). There was no significant variation in diagnostic yield among the 90 providers after adjusting for patient, hospital, and provider characteristics. Providers with < 10 years of experience had lower odds of diagnosing a PE than more experienced graduates (OR 0.8, 95% CI 0.6-0.9). CONCLUSIONS: Although we found significant variation in utilization of advanced radiography for PE and diagnostic yield at the hospital level, there was no significant variation at the provider level after adjusting for patient-, hospital-, and provider-level factors.

Physiologic affects of altitude on recreational climbers.

OBJECTIVES: Previous analyses of physiologic parameter changes during ascent to altitude have incorporated small numbers of well-trained climbers. The effects of altitude illness are more likely to occur and may come to medical attention more frequently in unacclimatized recreational individuals. We sought to evaluate acute changes in physiologic parameters during ascent to high altitude (14,100 ft) in recreational climbers. METHODS: We performed a prospective naturalistic study of 221 recreational climbers at Mount Shasta (peak altitude of 14,162 ft). Baseline vital signs were recorded at 3500 ft (blood pressure, heart rate, respiratory rate, pulse oximetry, and peak flow). Subsequent measurements were obtained at 6700 ft, 10,400 ft, and at the summit. Mean vital signs and the amount they changed with altitude were estimated using mixed linear models. RESULTS: One hundred twenty-five climbers (56.6%) reached the summit. Heart rate increased and pulse oximetry decreased with ascent (mean, 71.9, 79, 97, and 102.4 beats/min and 96.9%, 93.9%, 88.8%, and 80.8%, respectively), with estimates at each altitude differing statistically at P < .0001. Mean systolic and diastolic blood pressures varied significantly by altitude (not measured at summit), but the changes were not monotonic. Peak flow progressively declined with ascent, but the difference between 6700 and 10,400 was not statistically significant. Respiratory rate did not change significantly. CONCLUSIONS: Acute compensation for altitude-induced hypoxia involves numerous physiologic changes; this is supported by our data that demonstrate significant changes in blood pressure and stepwise changes in pulse oximetry, peak flow, and heart rate. Consideration of these changes can be incorporated in future studies of the affect of altitude on recreational climbers.

A review of costing methodologies in critical care studies.

Clinical decision making in critical care has traditionally been based on clinical outcome measures such as mortality and morbidity. Over the past few decades, however, increasing competition in the health care marketplace has made it necessary to consider costs when making clinical and managerial decisions in critical care. Sophisticated costing methodologies have been developed to aid this decision-making process. We performed a narrative review of published costing studies in critical care during the past 6 years. A total of 282 articles were found, of which 68 met our search criteria. They involved a mean of 508 patients (range, 20-13,907). A total of 92.6% of the studies (63 of 68) used traditional cost analysis, whereas the remaining 7.4% (5 of 68) used cost-effectiveness analysis. None (0 of 68) used cost-benefit analysis or cost-utility analysis. A total of 36.7% (25 of 68) used hospital charges as a surrogate for actual costs. Of the 43 articles that actually counted costs, 37.2% (16 of 43) counted physician costs, 27.9% (12 of 43) counted facility costs, 34.9% (15 of 43) counted nursing costs, 9.3% (4 of 43) counted societal costs, and 90.7% (39 of 43) counted laboratory, equipment, and pharmacy costs. Our conclusion is that despite considerable progress in costing methodologies, critical care studies have not adequately implemented these techniques. Given the importance of financial implications in medicine, it would be prudent for critical care studies to use these more advanced techniques.

Age 14 starts a child's increased risk of major knife or gun injury in Washington, DC.

This retrospective review of eight years of trauma registry data at an inner-city level-1 trauma center was undertaken to discover at what age urban children start to become at high risk of being victims of either a major gunshot wound or stabbing. We reviewed data from 2,191 patients who were the victim of either a gunshot wound or stabbing, were 18 years of age or under, and met pre-established criteria to qualify as a major trauma victim. There was a rise and subsequent fall in both overall crime and intentional injury rates during the eight-year period. Nevertheless, in each of the eight years studied, the risk of being a victim of a major gunshot wound or stabbing rose abruptly at age 14 (p<0.01) and the incidence continued to rise sharply through age 18.

Mental health and emergency medicine: a research agenda.

The burden of mental illness is profound and growing. Coupled with large gaps in extant psychiatric services, this mental health burden has often forced emergency departments (EDs) to become the de facto primary and acute care provider of mental health care in the United States. An expanded emergency medical and mental health research agenda is required to meet the need for improved education, screening, surveillance, and ED-initiated interventions for mental health problems. As an increasing fraction of undiagnosed and untreated psychiatric patients passes through the revolving doors of U.S. EDs, the opportunities for improving the art and science of acute mental health care have never been greater. These opportunities span macroepidemiologic surveillance research to intervention studies with individual patients. Feasible screening, intervention, and referral programs for mental health patients presenting to general EDs are needed. Additional research is needed to improve the quality of care, including the attitudes, abilities, interests, and virtues of ED providers. Research that optimizes provider education and training can help academic settings validate psychosocial issues as core components and responsibilities of emergency medicine. Transdisciplinary research with federal partners and investigators in neuropsychiatry and related fields can improve the mechanistic understanding of acute mental health problems. To have lasting impact, however, advances in ED mental health care must be translated into real-world policies and sustainable program enhancements to assure the uptake of best practices for ED screening, treatment, and management of mental disorders and psychosocial problems.