Study objective We seek to determine the impact of emergency department (ED) crowding on delays in antibiotic administration for patients with community-acquired pneumonia. Methods We performed a ...retrospective cohort study of adult patients admitted with community-acquired pneumonia from January 1, 2003, to April 31, 2005, at a single, urban academic ED. The main outcome was a delay (>4 hours from arrival) or nonreceipt of antibiotics in the ED. Eight ED crowding measures were assigned at triage. Multivariable regression and bootstrapping were used to test the adjusted impact of ED crowding measures of delayed (or no) antibiotics. Predicted probabilities were then calculated to assess the magnitude of the impact of ED crowding on the probability of delayed (or no) antibiotics. Results In 694 patients, 44% (95% confidence interval CI 40% to 48%) received antibiotics within 4 hours and 92% (95% CI 90% to 94%) received antibiotics in the ED. Increasing levels of ED crowding were associated with delayed (or no) antibiotics, including waiting room number (odds ratio OR 1.05 for each additional waiting room patient 95% CI 1.01 to 1.10) and recent ED length of stay for admitted patients (OR 1.14 for each additional hour 95% CI 1.04 to 1.25). When the waiting room and recent length of stay were both at the lowest quartiles (ie, not crowded), the predicted probability of delayed (or no) antibiotics within 4 hours was 31% (95% CI 21% to 42%); when both were at the highest quartiles, the predicted probability was 72% (95% CI 61% to 81%). Conclusion ED crowding is associated with delayed and nonreceipt of antibiotics in the ED for patients admitted with community-acquired pneumonia.
Objectives
The relationship between COVID‐19‐related telehealth calls could be used to predict emergency department visits and hospital surges 3 days later potentially facilitating staffing ...adjustments in advance of patient arrivals. The purpose of this research was to study the temporal association between frequencies of on demand telehealth calls and emergency department surges during the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) pandemic.
Methods
This cohort study examined patients who self‐initiated synchronous audio‐video on‐demand telehealth calls between January 1, 2020 and June 30, 2022, and compared these to emergency department arrivals. The exposure in question was a synchronous audio‐video on‐demand telehealth visit. Our main outcome measured was frequency of emergency department visits. After autocorrelation, a multivariate linear regression model was utilized to determine temporal relationships between the two variables.
Results
This cohort study examined 42,429 synchronous audio‐video on‐demand telehealth calls, of which 43.6% were COVID‐19 related, and 540,686 emergency department visits, of which 3.9% were diagnosed with COVID‐19. COVID‐19‐related telehealth calls 3 days prior were predictive of emergency department encounters (r2 = 0.85, p < 0.001). Emergency department encounters were strongly correlated with hospital admissions (r2 = 0.71, p < 0.001).
Conclusions
Our results demonstrate that telehealth calls related to COVID‐19 were an accurate predictor of emergency department encounters 3 days later, and emergency department encounters are highly correlated with hospital admissions. Limitations include that we only assessed a single health system in the region covered by the telemedicine healthcare professionals. We did not examine direct links between these two encounter types nor severity of illness at the patient level. Understanding that telehealth calls related to COVID‐19 are highly predictive of emergency department encounters within 3 days may provide a brief but important window to upstaff hospitals at the beginning of future COVID‐19 surges.
Morphine is a long-standing therapy in acute decompensated heart failure (ADHF), despite few supporting data. A study was undertaken to compare the outcomes of patients who did and did not receive ...morphine for ADHF.
The study was a retrospective analysis of the Acute Decompensated Heart Failure National Registry (ADHERE) which enrols hospitalised patients with treatment for, or a primary discharge diagnosis of, ADHF. Patients were stratified into cohorts based on whether or not they received intravenous morphine. ANOVA, Wilcoxon and chi(2) tests were used in univariate analysis, followed by multivariate analysis controlling for parameters previously associated with mortality. Analyses were repeated for ejection fraction subgroups and in patients not on mechanical ventilation.
There were 147 362 hospitalisations in ADHERE at December 2004, 20 782 of whom (14.1%) received morphine and 126 580 (85.9%) did not. There were no clinically relevant differences between the groups in the initial age, heart rate, blood pressure, blood urea nitrogen, creatinine, haemoglobin, ejection fraction or atrial fibrillation. A higher prevalence of rest dyspnoea, congestion on chest radiography, rales and raised troponin occurred in the morphine group. Patients on morphine received more inotropes and vasodilators, were more likely to require mechanical ventilation (15.4% vs 2.8%), had a longer median hospitalisation (5.6 vs 4.2 days), more ICU admissions (38.7% vs 14.4%), and had greater mortality (13.0% vs 2.4%) (all p<0.001). Even after risk adjustment and exclusion of ventilated patients, morphine was an independent predictor of mortality (OR 4.84 (95% CI 4.52 to 5.18), p<0.001).
Morphine is associated with increased adverse events in ADHF which includes a greater frequency of mechanical ventilation, prolonged hospitalisation, more ICU admissions and higher mortality.
Background
Accurate image-derived input function (IDIF) from highly sensitive large axial field of view (LAFOV) PET/CT scanners could avoid the need of invasive blood sampling for kinetic modelling. ...The aim is to validate the use of IDIF for two kinds of tracers, 3 different IDIF locations and 9 different reconstruction settings.
Methods
Eight
18
FFDG and 10
18
FDPA-714 scans were acquired respectively during 70 and 60 min on the Vision Quadra PET/CT system. PET images were reconstructed using various reconstruction settings. IDIFs were taken from ascending aorta (AA), descending aorta (DA), and left ventricular cavity (LV). The calibration factor (CF) extracted from the comparison between the IDIFs and the manual blood samples as reference was used for IDIFs accuracy and precision assessment. To illustrate the effect of various calibrated-IDIFs on Patlak linearization for
18
FFDG and Logan linearization for
18
FDPA-714, the same target time-activity curves were applied for each calibrated-IDIF.
Results
For
18
FFDG, the accuracy and precision of the IDIFs were high (mean CF ≥ 0.82, SD ≤ 0.06). Compared to the striatum influx (
K
i
) extracted using calibrated AA IDIF with the updated European Association of Nuclear Medicine Research Ltd. standard reconstruction (EARL2),
K
i
mean differences were < 2% using the other calibrated IDIFs. For
18
FDPA714, high accuracy of the IDIFs was observed (mean CF ≥ 0.86) except using absolute scatter correction, DA and LV (respectively mean CF = 0.68, 0.47 and 0.44). However, the precision of the AA IDIFs was low (SD ≥ 0.10). Compared to the distribution volume (
V
T
) in a frontal region obtained using calibrated continuous arterial sampler input function as reference,
V
T
mean differences were small using calibrated AA IDIFs (for example
V
T
mean difference = -5.3% using EARL2), but higher using calibrated DA and LV IDIFs (respectively + 12.5% and + 19.1%).
Conclusions
For
18
FFDG, IDIF do not need calibration against manual blood samples. For
18
FDPA-714, AA IDIF can replace continuous arterial sampling for simplified kinetic quantification but only with calibration against arterial blood samples. The accuracy and precision of IDIF from LAFOV PET/CT system depend on tracer, reconstruction settings and IDIF VOI locations, warranting careful optimization.
Recent studies have highlighted the relation between erectile dysfunction (ED) and cardiovascular disease. In particular, the role of endothelial dysfunction and nitric oxide in ED and ...atherosclerotic disease has been elucidated. Given the large number of men receiving medical treatment for ED, concerns regarding the risk for sexual activity triggering acute cardiovascular events and potential risks of adverse or unanticipated drug interactions need to be addressed. A risk stratification algorithm was developed by the First Princeton Consensus Panel to evaluate the degree of cardiovascular risk associated with sexual activity for men with varying degrees of cardiovascular disease. Patients were assigned to 3 categories: low, intermediate (including those requiring further evaluation), and high risk. This consensus study from the Second Princeton Consensus Conference corroborates and clarifies the algorithm and emphasizes the importance of risk factor evaluation and management for all patients with ED. The panel reviewed recent safety and drug interaction data for 3 phosphodiesterase (PDE)-5 inhibitors (sildenafil, tadalafil, vardenafil), with emphasis on the safety of these agents in men with ED and concomitant cardiovascular disease. Increasing evidence supports the role of lifestyle intervention in ED, specifically weight loss and increased physical activity, particularly in patients with ED and concomitant cardiovascular disease. Special management recommendations for patients taking PDE-5 inhibitors who present at the emergency department and other emergency medical situations are described. Finally, further research on the role of PDE-5 inhibition in treating patients with other medical or cardiovascular disorders is recommended.
Despite well-established guidelines to treat diabetes, many people with diabetes struggle to manage their disease. For many, this struggle is related to challenges achieving nutrition-related ...lifestyle changes. We examined how people with diabetes describe barriers to maintaining a healthy diet and considered the benefits of using a harm reduction approach to assist patients to achieve nutrition-related goals.
This is a secondary analysis of 89 interviews conducted with adults who had type 1 or type 2 diabetes. Interviews were analyzed using a content analysis approach. Themes regarding food or diet were initially captured in a "food" node. Data in the food node were then sub-coded for this analysis, again using a content analysis approach.
Participants frequently used addiction language to talk about their relationship with food, at times referring to themselves as "an addict" and describing food as "their drug." Participants perceived their unhealthy food choices either as a sign of weakness or as "cheating." They also identified food's ability to comfort them and an unwillingness to change as particular challenges to sustaining a healthier diet.
Participants often described their relationship with food through an addiction lens. A harm reduction approach has been associated with positive outcomes among those with substance abuse disorder. Patient-centered communication incorporating the harm reduction model may improve the patient-clinician relationship and thus improve patient outcomes and quality-of-life while reducing health-related stigma in diabetes care. Future work should explore the effectiveness of this approach in patients with diabetes.
Registered on ClinicalTrials.gov, NCT02792777. Registration information submitted 02/06/2016, with the registration first posted on the ClinicalTrials.gov website 08/06/2016. Data collection began on 29/04/2016.
Background Obsessive-compulsive spectrum disorders (OCSDs) are now recognised as distinct diagnostic entities related to obsessive-compulsive disorder (OCD). The features of OCSDs and OCD overlap in ...many respects including demographics, repetitive intrusive thoughts or behaviours, comorbidity, aetiology and preferential response to anti-obsessional drugs such as the selective serotonin reuptake inhibitors (SSRIs).
Method Literature was reviewed and preliminary data from various studies were re-examined to assess the relationship between compulsivity and impulsivity, and between OCD and OCSDs.
Results OCSDs include both compulsive and impulsive disorders and these can be viewed as lying at opposite ends of the dimension of risk avoidance. Compulsiveness is associated with increased frontal lobe activity and increased serotonergic activity, while impulsiveness is associated with reduced activity of these variables. Neural circuits affected by serotonergic pathways have been identified and pharmacological challenge of OCSD patients with serotonin receptor agonists have supported the involvement of serotonergic processes.
Conclusions SSRIs such as fluvoxamine have established efficacy in OCD and preliminary studies indicate that they are also effective in OCSDs. The features of three specimen OCSDs –body dysmorphic disorder, pathological gambling and autism – and their treatment with SSRIs are reviewed.
Clinical studies have shown that repetitive transcranial magnetic stimulation (rTMS) is effective in a certain percentage of treatment-resistant depression (TRD). The left dorsolateral prefrontal ...cortex (DLPFC) 10 Hz rTMS stimulation received FDA approval in 2008, although different rTMS protocols have also shown their effectiveness in reducing depressive symptoms. We investigated the clinical, cognitive and neurophysiologic effects of a 3 weeks' protocol of low-frequency rTMS applied over the right DLPFC in resistant depression.
Twenty-eight patients with TRD (age range 28-55) received low-frequency rTMS (1 Hz) over the right DLPFC in a 3-week open trial. Hamilton scales for depression and anxiety, Corsi block-tapping test, phonemic verbal fluency, right and left resting motor thresholds were evaluated in each subject over the trial period.
At the end of the trial 42.9% of the subjects were considered as responders. A significant reduction of both HAMD (p < 0.001) and HAMA (p < 0.01) total scores was observed. At the 3rd week, the performances in Corsi test (p < 0.02) and phonemic verbal fluency (p = 0.065) were improved independently from depressive symptoms variation. At the end of the rTMS protocol, a significantly decreased left hemisphere resting motor threshold was registered (p < 0.01), while right hemisphere resting motor threshold did not show significant variation.
Low-frequency rTMS over the right DLPFC appeared effective in 42.9% of depressive resistant subjects in this sample. A significant decrease in left hemisphere resting motor threshold was observed only in responders, while a trend for improvement in cognitive function has been found and appeared independent from clinical response.
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