Study objective We apply a previously described tool to forecast emergency department (ED) crowding at multiple institutions and assess its generalizability for predicting the near-future waiting ...count, occupancy level, and boarding count. Methods The ForecastED tool was validated with historical data from 5 institutions external to the development site. A sliding-window design separated the data for parameter estimation and forecast validation. Observations were sampled at consecutive 10-minute intervals during 12 months (n=52,560) at 4 sites and 10 months (n=44,064) at the fifth. Three outcome measures—the waiting count, occupancy level, and boarding count—were forecast 2, 4, 6, and 8 hours beyond each observation, and forecasts were compared with observed data at corresponding times. The reliability and calibration were measured following previously described methods. After linear calibration, the forecasting accuracy was measured with the median absolute error. Results The tool was successfully used for 5 different sites. Its forecasts were more reliable, better calibrated, and more accurate at 2 hours than at 8 hours. The reliability and calibration of the tool were similar between the original development site and external sites; the boarding count was an exception, which was less reliable at 4 of 5 sites. Some variability in accuracy existed among institutions; when forecasting 4 hours into the future, the median absolute error of the waiting count ranged between 0.6 and 3.1 patients, the median absolute error of the occupancy level ranged between 9.0% and 14.5% of beds, and the median absolute error of the boarding count ranged between 0.9 and 2.8 patients. Conclusion The ForecastED tool generated potentially useful forecasts of input and throughput measures of ED crowding at 5 external sites, without modifying the underlying assumptions. Noting the limitation that this was not a real-time validation, ongoing research will focus on integrating the tool with ED information systems.
BACKGROUND:More than 75% of major limb amputees experience chronic pain; however, data on severity and experience of pain are inconsistent. Without a benchmark using quantitative patient-reported ...outcomes, it is difficult to critically assess the efficacy of novel treatment strategies. Our primary objective is to report quantitative pain parameters for a large sample of amputees using the validated Patient-reported Outcomes Measurement System (PROMIS). Secondarily, we hypothesize that certain patient factors will be associated with worse pain.
METHODS:PROMIS and Numerical Rating Scales for residual limb pain (RLP) and phantom limb pain (PLP) were obtained from a cross-sectional survey of upper and lower extremity amputees recruited throughout North America via amputee clinics and websites. Demographics (gender, age, race, and education) and clinical information (cause, amputation level, and time since amputation) were collected. Regression modeling identified factors associated with worse pain scores (P < 0.05).
RESULTS:Seven hundred twenty-seven surveys were analyzed, in which 73.4% reported RLP and 70.4% reported PLP. Median residual PROMIS scores were 46.6 interquartile range (IQR), 41–52 for RLP Intensity, 56.7 (IQR, 51–61) for RLP Behavior, and 55.9 (IQR, 41–63) for RLP Interference. Similar scores were calculated for PLP parameters46.8 (IQR, 41–54) for PLP Intensity, 56.2 (IQR, 50–61) for PLP Behavior, and 54.6 (IQR, 41–62) for PLP Interference. Female sex, lower education, trauma-related amputation, more proximal amputation, and closer to time of amputation increased odds of PLP. Female sex, lower education, and infection/ischemia-related amputation increased odds of RLP.
CONCLUSION:This survey-based analysis provides quantitative benchmark data regarding RLP and PLP in amputees with more granularity than has previously been reported.
Although several investigations have demonstrated that prolonged aerobic exercise results in decreased left ventricular (LV) function, few have examined the impact of an acute bout of high-intensity ...exercise on right ventricular (RV) and LV systolic and diastolic function. Cardiac magnetic resonance imaging with tagging was used to study the impact of high-intensity interval exercise on biventricular function in 9 endurance-trained (ET; V o2 max 69 ± 7 ml/kg/min) and 9 normally active (NA; V o2 max 44 ± 9 ml/kg/min) men. Subjects underwent baseline cardiac magnetic resonance imaging assessments (pre) and then performed an average of 14 1-minute intervals at 97 ± 11% (NA) and 99 ± 6% (ET) of peak power output, separated by 2 minutes of recovery at 21 ± 6% (NA) and 21 ± 9% (ET) of peak power output. After exercise, 2 cardiac magnetic resonance imaging assessments (post 1 at 6.2 ± 2.6 minutes and post 2 at 38.4 ± 3.8 minutes) were completed. RV and LV ejection fractions, twist, basal and apical rotation rates, rate of untwisting, circumferential strain, and timings were examined. No significant change in RV and LV ejection fractions, twist, untwisting rate, or strain after exercise occurred in the NA group. In the ET group, RV ejection fraction (pre 56 ± 4%, post 1 54 ± 4%, post 2 54 ± 3%) and LV ejection fraction (pre 62 ± 4%, post 1 59 ± 4%, post 2 58 ± 4%) were decreased at post 1 and post 2, while untwisting rate, apical rotation rate, and circumferential strain were decreased at post 2 (all p values <0.05). In conclusion, biventricular systolic and diastolic dysfunction occurred after 14 minutes of high-intensity exercise in ET athletes, a phenomenon not observed in NA subjects.
Whether the risk factors for cardiovascular (CV) outcomes are different in primary versus secondary prevention implantable cardioverter-defibrillator (ICD) patients is unclear. We sought to identify ...predictors of CV outcomes in ICD recipients for primary (G1) versus secondary prevention (G2). Consecutive patients who had ICD implanted during August 2005 to December 2009 were included. The primary outcome was a composite of appropriate shock, acute coronary syndrome, ischemic stroke, coronary revascularization, heart failure exacerbation, CV hospitalization, or all-cause death. We used Cox proportional hazards model and a stepwise selection method to fit the most parsimonious model to predict the primary outcome in all patients and separately for G1 and G2 patients. We followed 223 (184 G1 and 39 G2, mean age 61 years) patients through December 31, 2012; 141 (63.2%) developed the primary outcome. In all patients, atrial fibrillation (AF; hazard ratio 6.72, 95% CI 4.20 to 10.75; p <0.001), use of antiarrhythmic drug (1.55, 1.02 to 2.36; p = 0.04), and lower estimated glomerular filtration rate (0.99, 0.98 to 0.997; p = 0.01) were associated with increased risk of the primary outcome; the attributable risks were 21.6%, 16.0%, and 15.9%, respectively. In G1, AF, hypertension, and lower estimated glomerular filtration rate were associated with increased risk, whereas in G2, AF, use of antiarrhythmic drug, and nonischemic cardiomyopathy were associated with increased risk. In conclusion, although risk factors are different for primary and secondary prevention patients, AF is a strong and consistent risk factor for adverse outcomes in both populations.
To determine whether ibudilast has an effect on brain volume and new lesions in progressive forms of multiple sclerosis (MS).
A randomized, placebo-controlled, blinded study evaluated ibudilast at a ...dose of up to 100 mg over 96 weeks in primary and secondary progressive MS. In this secondary analysis of a previously reported trial, secondary and tertiary endpoints included gray matter atrophy, new or enlarging T2 lesions as measured every 24 weeks, and new T1 hypointensities at 96 weeks. Whole brain atrophy measured by structural image evaluation, using normalization, of atrophy (SIENA) was a sensitivity analysis.
A total of 129 participants were assigned to ibudilast and 126 to placebo. New or enlarging T2 lesions were observed in 37.2% on ibudilast and 29.0% on placebo (
= 0.82). New T1 hypointense lesions at 96 weeks were observed in 33.3% on ibudilast and 23.5% on placebo (
= 0.11). Gray matter atrophy was reduced by 35% for those on ibudilast vs placebo (
= 0.038). Progression of whole brain atrophy by SIENA was slowed by 20% in the ibudilast group compared with placebo (
= 0.08).
Ibudilast treatment was associated with a reduction in gray matter atrophy. Ibudilast treatment was not associated with a reduction in new or enlarging T2 lesions or new T1 lesions. An effect on brain volume contributes to prior data that ibudilast appears to affect markers associated with neurodegenerative processes, but not inflammatory processes.
This study provides Class II evidence that for people with MS, ibudilast does not significantly reduce new or enlarging T2 lesions or new T1 lesions.
We present Stanford’s experience with patients post–arterial switch operation presenting with chest pain found to have hemodynamically significant myocardial bridging. The evaluation of symptomatic ...patients post–arterial switch should not only include assessment for coronary ostial patency but also for nonobstructive coronary conditions such as myocardial bridging. (Level of Difficulty: Advanced.)
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Background In 1999, Determinants of Community Health was introduced at the Faculty of Medicine, University of Toronto. The course spanned all 4 years of the undergraduate curriculum and focused on ...addressing individual patient and community needs, prevention and population health, and diverse learning contexts. Purpose To demonstrate the value of an integrated, longitudinal approach to the efficiency of delivering a public health curriculum. Design Time-series comparing the curricular change over two periods of time. Setting/participants Undergraduate medical students from 1993 to 2009. Intervention Using a spiral curriculum, the educational materials are integrated across all 4 years, based on the concept of medical decision making in a community context. Main outcome measures This study compares measures of student satisfaction and national rankings of the University of Toronto with the other 16 Canadian medical schools for the “Population Health, Ethical, Legal, and Organizational aspects of the practice of medicine” component of the Medical Council of Canada Qualifying Examination Part 1. Results The University of Toronto has been ranked either first or second place nationally, in comparison to lower rankings in previous years ( p <0.02 on the Kruskal–Wallis test). Student ratings indicated the course was comparable to others in the curriculum. Conclusions For the same amount of curricular time, an integrated spiral curriculum for teaching public health appears to be more effective than traditional approaches.
To assess the added prognostic value of serial monitoring of urinary C-C motif chemokine ligand 14 (uCCL14) over that of single measurements, which have been shown to be prognostic for development of ...persistent severe acute kidney injury (AKI) in critically ill patients.
Retrospective observational study.
Data derived from two multinational ICU studies (Ruby and Sapphire).
Critically ill patients with early stage 2-3 AKI.
None.
We analyzed three consecutive uCCL14 measurements at 12-hour intervals after diagnosis of stage 2-3 AKI by Kidney Disease Improving Global Outcomes criteria. Primary outcome was persistent severe AKI, defined as 72 consecutive hours of stage 3 AKI, death, or receipt of dialysis prior to 72 hours. uCCL14 was measured using the NEPHROCLEAR uCCL14 Test on the Astute 140 Meter (Astute Medical, San Diego, CA). Based on predefined, validated cutoffs, we categorized uCCL14 as: low (≤ 1.3 ng/mL), medium (> 1.3 to ≤ 13 ng/mL), or high (> 13 ng/mL). Seventy-five of 417 patients with three consecutive uCCL14 measurements developed persistent severe AKI. Initial uCCL14 category strongly correlated with primary endpoint and, in most cases (66%), uCCL14 category was unchanged over the first 24 hours. Compared with no change and accounting for baseline category, decrease in category was associated with decreased odds of persistent severe AKI (odds ratio OR, 0.20; 95% CI, 0.08-0.45;
< 0.001) and an increase in category with increased odds (OR, 4.04; 95% CI, 1.75-9.46;
= 0.001).
In one-third of patients with moderate to severe AKI uCCL14 risk category altered over three serial measurements and such changes were associated with altered risk for persistent severe AKI. Serial CCL-14 measurement may detect progression or resolution of underlying kidney pathology and help refine AKI prognosis.
To analyze the clinical success of radiofrequency volumetric thermal ablation (RFVTA) at 3-year follow-up in terms of subject responses to validated questionnaires and surgical repeat intervention to ...treat myomas.
Prospective follow-up of patients for 36 months after treatment in a multicenter international trial of outpatient, laparoscopic ultrasound-guided RFVTA of symptomatic uterine myomas (Canadian Task Force classification II-1).
University hospitals and private surgical centers.
One hundred thirty-five premenopausal women (mean SD age, 42.5 4.6 years; body mass index, 30.5 6.1) with symptomatic uterine myomas and objectively confirmed heavy menstrual bleeding (≥ 160 to ≤ 500 mL).
Laparoscopic ultrasound-guided RFVTA.
One hundred four participants were followed prospectively for 36 months after treatment of myomas via RFVTA. For 104 evaluable participants with 36-month data, change in mean (SD) symptom severity from baseline (60.2 18.8) to 36 months was -32.6 (95% confidence interval, -37.5 to -27.8; p < .001). Health-related quality of life also was improved, from the baseline value of 39.2 (19.2) to 38.6 (95% confidence interval, 33.3 to 43.9; p < .001) at 36 months. Patient-reported Uterine Fibroid Symptom and Health-Related Quality of Life questionnaire subscores demonstrated statistically significant improvement from baseline to 36 months in all categories (Concern, Activities, Energy/Mood, Control, Self-consciousness, and Sexual Function) (p < .001). For the 104 participants with 36-month data, mean state of health scores (EuroQOL-5D Health State Index) improved from a baseline value of 71.0 (19.3) to 86.2 (11.7) at 36 months. The cumulative repeat intervention rate of 11% (14 of 135 participants) at 36 months was well below the possible 25% maximum expected at the beginning of the trial.
RFVTA of uterine myomas resulted in sustained relief from myoma symptoms and continued improvement in health-related quality of life through 36 months after ablation. The low repeat intervention data through 36 months is a positive outcome for patient well-being.
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