Background Pulmonary embolism (PE) remains a significant cause of hospital admission and health-care costs. Estimates of PE incidence came from the 1990s, and data are limited to describe trends in ...hospital admissions for PE over the past decade. Methods We analyzed Nationwide Inpatient Sample data from 1993 to 2012 to identify patients admitted with PE. We included admissions with International Classification of Diseases, 9th revision, codes listing PE as the principal diagnosis as well as admissions with PE listed secondary to principal diagnoses of respiratory failure or DVT. Massive PE was defined by mechanical ventilation, vasopressors, or nonseptic shock. Outcomes included hospital lengths of stay, adjusted charges, and all-cause hospital mortality. Linear regression was used to analyze changes over time. Results Admissions for PE increased from 23 per 100,000 in 1993 to 65 per 100,000 in 2012 ( P < .001). The percent of admissions meeting criteria for massive PE decreased (5.3% to 4.4%, P = .002), but the absolute number of admissions for massive PE increased (from 1.5 to 2.8 per 100,000, P < .001). Median length of stay decreased from 8 (interquartile range IQR, 6-11) to 4 (IQR, 3-6) days ( P < .001). Adjusted hospital charges increased from $16,475 (IQR, $10,748-$26,211) in 1993 to $25,728 (IQR, $15,505-$44,493) in 2012 ( P < .001). All-cause hospital mortality decreased from 7.1% to 3.2% ( P < .001), but population-adjusted deaths during admission for PE increased from 1.6 to 2.1 per 100,000 ( P < .001). Conclusions Total admissions and hospital charges for PE have increased over the past two decades. However, the population-adjusted admission rate has increased disproportionately to the incidence of patients with severe PE. We hypothesize that these findings reflect a concerning national movement toward more admissions of less severe PE.
The etiology of community-acquired pneumonia requiring hospitalization in adults is evolving, in light of vaccine deployment and new diagnostic tests. This article defines pathogens potentially ...causing pneumonia. In a majority of cases, no pathogen was identified.
Pneumonia is a leading infectious cause of hospitalization and death among adults in the United States,
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,
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with medical costs exceeding $10 billion in 2011.
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Routine administration of the pneumococcal conjugate vaccine in children has resulted in an overall reduction in the rate of invasive disease and pneumonia among adults, owing to herd immunity.
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The last U.S. population–based incidence estimates of hospitalization due to community-acquired pneumonia were made in the 1990s,
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before the availability of the pneumococcal conjugate vaccine and more sensitive molecular and antigen-based laboratory diagnostic tests. Thus, contemporary population-based etiologic studies involving U.S. adults with pneumonia are . . .
Abstract Objective To evaluate the diagnostic performance of chest x-ray (CXR) compared to computed tomography (CT) for detection of pulmonary opacities in adult emergency department (ED) patients. ...Methods We conducted an observational cross-sectional study of adult patients presenting to 12 EDs in the United States from July 1, 2003, through November 30, 2006, who underwent both CXR and chest CT for routine clinical care. CXRs and CT scans performed on the same patient were matched. CXRs and CT scans were interpreted by attending radiologists and classified as containing pulmonary opacities if the final radiologist report noted opacity, infiltrate, consolidation, pneumonia, or bronchopneumonia. Using CT as a criterion standard, the diagnostic test characteristics of CXR to detect pulmonary opacities were calculated. Results The study cohort included 3423 patients. Shortness of breath, chest pain and cough were the most common complaints, with 96.1% of subjects reporting at least one of these symptoms. Pulmonary opacities were visualized on 309 (9.0%) CXRs and 191 (5.6 %) CT scans. CXR test characteristics for detection of pulmonary opacities included: sensitivity 43.5% (95% CI, 36.4%-50.8%); specificity 93.0% (95% CI, 92.1%-93.9%); positive predictive value 26.9% (95% CI, 22.1%-32.2%); and negative predictive value 96.5% (95% CI, 95.8%-97.1%). Conclusion In this multicenter cohort of adult ED patients with acute cardiopulmonary symptoms, CXR demonstrated poor sensitivity and positive predictive value for detecting pulmonary opacities. Reliance on CXR to identify pneumonia may lead to significant rates of misdiagnosis.
OBJECTIVES:To prospectively validate that the inability to decrease procalcitonin levels by more than 80% between baseline and day 4 is associated with increased 28-day all-cause mortality in a large ...sepsis patient population recruited across the United States.
DESIGN:Blinded, prospective multicenter observational clinical trial following an Food and Drug Administration-approved protocol.
SETTING:Thirteen U.S.-based emergency departments and ICUs.
PATIENTS:Consecutive patients meeting criteria for severe sepsis or septic shock who were admitted to the ICU from the emergency department, other wards, or directly from out of hospital were included.
INTERVENTIONS:Procalcitonin was measured daily over the first 5 days.
MEASUREMENTS AND MAIN RESULTS:The primary analysis of interest was the relationship between a procalcitonin decrease of more than 80% from baseline to day 4 and 28-day mortality using Cox proportional hazards regression. Among 858 enrolled patients, 646 patients were alive and in the hospital on day 4 and included in the main intention-to-diagnose analysis. The 28-day all-cause mortality was two-fold higher when procalcitonin did not show a decrease of more than 80% from baseline to day 4 (20% vs 10%; p = 0.001). This was confirmed as an independent predictor in Cox regression analysis (hazard ratio, 1.97 95% CI, 1.18–3.30; p < 0.009) after adjusting for demographics, Acute Physiology and Chronic Health Evaluation II, ICU residence on day 4, sepsis syndrome severity, antibiotic administration time, and other relevant confounders.
CONCLUSIONS:Results of this large, prospective multicenter U.S. study indicate that inability to decrease procalcitonin by more than 80% is a significant independent predictor of mortality and may aid in sepsis care.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.
Here we present a secondary analysis from a parent database of 97 acutely injured participants enrolled in a prospective inception cohort study of whiplash recovery after motor vehicle collision ...(MVC). The purpose was to investigate the deep and superficial neck extensor muscles with peri-traumatic computed tomography (CT) and longitudinal measures of magnetic resonance imaging (MRI) in participants with varying levels of whiplash-related disability. Thirty-six underwent standard care imaging of the cervical spine with CT at a level-1 trauma designated emergency department. All 36 participants were assessed with MRI of the cervical spine at 1-week, 2-weeks, 3-, and 12-months post-injury and classified into three groups using initial pain severity and percentage scores on the Neck Disability Index (recovered (NDI of 0-8%), mild (NDI of 10-28%), or severe (NDI greater than or equal to 30%)) at 3-months post MVC. CT muscle attenuation values were significantly correlated to muscle fat infiltration (MFI) on MRI at one-week post MVC. There was no significant difference in muscle attenuation across groups at the time of enrollment. A trend of lower muscle attenuation in the deep compared to the superficial extensors was observed in the severe group. MFI values in the deep muscles on MRI were significantly higher in the severe group when compared to the mild group at 1-year post MVC. This study provides further evidence that the magnitude of 1) deep MFI appears unique to those at risk of and eventually transitioning to chronic WAD and that 2) pre- or peri-traumatic muscular health, determined by CT muscle attenuation, may be contribute to our understanding of long-term recovery.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
This issue contains two articles1, 2 that are at the same time a culmination of a multiyear effort but also the first early steps of the journal and the Society for Academic Emergency Medicine (SAEM) ...leadership into the science of practice guideline creation and dissemination. It is anticipated that readers could raise three basic questions about this endeavor: (1) what is the rationale for this effort, and how is it unique relative to what has been done to date? (2) What can I take to the bedside regarding chest pain? and (3) What can we learn from this first effort—to provide evidence-based guidance for undifferentiated repeat chest pain—that might inform future guidelines on other topics?
Over the past 20 years, insights from human and mouse genetics have illuminated the central role of the brain leptin-melanocortin pathway in controlling mammalian food intake, with genetic disruption ...resulting in extreme obesity, and more subtle polymorphic variations influencing the population distribution of body weight. At the end of 2020, the U.S. Food and Drug Administration (FDA) approved setmelanotide, a melanocortin 4 receptor agonist, for use in individuals with severe obesity due to either pro-opiomelanocortin (POMC), proprotein convertase subtilisin/kexin type 1 (PCSK1), or leptin receptor (LEPR) deficiency.
Herein, we chart the melanocortin pathway's history, explore its pharmacology, genetics, and physiology, and describe how a neuropeptidergic circuit became an important druggable obesity target.
Unravelling the genetics of the subset of severe obesity has revealed the importance of the melanocortin pathway in appetitive control; coupling this with studying the molecular pharmacology of compounds that bind melanocortin receptors has brought a new obesity drug to the market. This process provides a drug discovery template for complex disorders, which for setmelanotide took 25 years to transform from a single gene into an approved drug.
We sought to identify longitudinal trends in workforce entry and attrition among rural and urban emergency physicians, nonemergency physicians, and advanced practice providers.
We performed a ...repeated cross-sectional analysis, from 2013 to 2019, of emergency clinicians who received reimbursement for at least 50 Evaluation and Management services 99281-99285 from Medicare part B within any study year. We calculated the emergency workforce’s entry and attrition rates annually. Entry was defined as clinicians newly entering or re-entering the workforce, and attrition was defined as clinicians leaving permanently or temporarily. We stratified the analyses by rural designation and assessed the proportions and state-level changes in clinician density.
In total, 82,499 unique clinicians performed at least 50 Evaluation and Management services within any of the 7 study years examined, including 47,000 emergency physicians, 9,029 nonemergency physicians, and 26,470 advanced practice providers. Emergency physicians made up a decreasing proportion of the workforce (68.1% in 2013; 65.5% in 2019), and advanced practice providers made up an increasing proportion of the workforce (20.9% in 2013; 26.1% in 2019). Annually, 5.9% to 6.8% (2,186 to 2,407) of emergency physicians newly entered and 0.8% to 1.4% (264 to 515) re-entered the workforce, whereas 3.8% to 4.9% (1,241 to 1,793) permanently left and 0.8% to 1.6% (276 to 521) temporarily left. Additionally, the total proportion of clinicians practicing in rural designations decreased, and advanced practice providers separately made up a substantially increasing proportion of the rural workforce (23.0% in 2013; 32.7% in 2019). Substantial state-level variation existed in the supply and demand of emergency clinician densities per 100,000 population.
The annual rate of emergency physician attrition was collectively more than 5%, well above the 3% assumed in a recently publicized projection, suggesting a potential overestimation of the anticipated future clinician surplus. Notably, the attrition of emergency physicians has disproportionately affected vulnerable rural areas. This work can inform emergency medicine workforce decisions regarding residency training, advanced practice provider utilization, and clinician employment.
Throughout the northern extent of its range, Chinook salmon (Oncorhynchus tshawytscha) adult returns have been in decline for over a decade, leading to severe harvest restrictions on subsistence, ...commercial, and recreational fisheries. In addition to these overall declines in abundance, changes in size structure and age structure, including a proportional decrease of older age classes returning to spawn, suggest that late-stage marine mortality for this species may be more frequent than currently assumed. To examine this late-stage mortality hypothesis, we examined diagnostic evidence of predation on large (57–100 cm fork length) Chinook salmon (n = 33) from depth, temperature, and light records collected during recent satellite tagging research. Satellite tags provided evidence of predation on tagged Chinook salmon by salmon sharks (Lamna ditropis) (n = 14), marine mammals (n = 2), ectothermic fish(es) (n = 3), and unidentified predators (n = 5) in the Bering Sea and Gulf of Alaska. High mortality rates in this study suggest that fisheries scientists should consider that late-stage mortality by marine apex predators may be shaping this species’ abundance and demographics.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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