Background:
During the spread of coronavirus disease (COVID-19), mandatory quarantines increased social isolation and anxiety, with inevitable consequences on mental health and health seeking ...behavior. We wished to estimate those trends.
Methods:
We examined all psychiatric visits to the emergency department (ED) during March, April 2020, compared to identical months in 2018, 2019. We evaluated both number and nature of referrals.
Results:
Throughout the years, psychiatric referrals comprised about 5% of the total number of ED visits. In March-April 2020, 30% decreases were observed in overall ED visits and in psychiatric referrals in the ED. Compared to 2018–2019, in 2020, the proportions of these diagnoses were higher: anxiety disorders (14.5 vs. 5.4%,
p
< 0.001), personality disorders (6.7 vs. 3.2%,
p
= 0.001), psychosis (9.5 vs. 6.7%,
p
= 0.049), post-traumatic stress disorder (3.2 vs. 1.5%,
p
= 0.023). Compared to 2018–2019, in 2020, proportions were lower for adjustment disorder (5.8 vs. 8.9%,
p
= 0.036) and for consultation regarding observation (11.7 vs. 31.6%,
p
< 0.001). Differences were not observed between 2018-2019 and 2020 in the proportions of other diagnoses including suicide and self-harm disorders. Referrals concerning suicide and self-harm in a rural hospital and community clinic were 30% lower in the COVID-19 lockdown than in the same months in 2018, 2019.
Conclusion:
Psychiatric ED visits decreased by the same proportion as overall visits to the ED, apparently driven by fears of COVID-19. Referrals relating suicidality and self-harm shown nominal decrease, but their proportioned share remained constant. Increased anxiety and delayed care may eventually lead to increased mental health needs.
Abstract
Background
The opioid epidemic in the United States has had devastating consequences, with many opioid-related deaths and a significant economic toll. Opioids have a significant role in ...postoperative pain management. Here we aim to analyze differences in postoperative opioid and non-opioid pain medications regimens following common otolaryngological surgeries between two large tertiary care medical centers: the Milton S. Hershey Medical Center, USA (HMC) and The Chaim Sheba Medical center, Israel (SMC).
Methods
A retrospective chart review of patients undergoing common otolaryngological procedures during the years 2017–2019 was conducted at two tertiary care centers, one in the U.S. and the other in Israel. Types and doses of postoperative pain medications ordered and administered during admission were analyzed. Average doses ordered and administered in 24 h were calculated. Opioid medications were converted to a standardized unit of morphine milliequivalents (MME). Chi-square test and Wilcoxon rank-sum test were used to compare the groups.
Results
The study included 204 patients (103 U.S., 101 Israel). Patient demographics were similar except for a longer length of stay in Israel (
p
< 0.01). In the U.S., 95% of patients were ordered opioids compared to 70% in Israel (
P
< 0.01). In the U.S., 68.9% of patients ordered opioids received the medications compared to 29.7% in Israel. The median opioid dose ordered in the U.S. was 45MME/24 h compared to 30MME/24 h in Israel (
P
< 0.01), while median dose received in the U.S. was 15MME/24 h compared to 3.8MME/24 h in Israel (
P
< 0.01). Opioid prescriptions at discharge were given to 92% of patients in the U.S. compared to 4% of patients in Israel (
p
< 0.01). A significantly higher number of patients in the U.S. were prescribed acetaminophen and ibuprofen (
p
< 0.0001). Dipyrone was prescribed to 78% of patients in Israel.
Conclusions
HMC demonstrated a significantly more permissive approach to both prescribing and consuming opioid medications for postoperative pain management than SMC for similar, common otolaryngological surgeries. Non-opioid alternatives and examining the cultural and medical practice-based differences contributing to the opioid epidemic should be discussed and reevaluated.
In addition to the immediate casualties of armed conflicts, their indirect impact may bring even more damage by causing malfunctioning of health systems and impaired access to diagnosis and ...treatment. We conducted a population-based study, to assess the utilization rates of health services due to skin disorders, among civilians exposed to missile attacks and siren alarms during three military operations in Israel. The study was designed as a natural experiment, whereas periods of military operations were compared to the non-military times. During the military operations, when sirens and missiles were an everyday experience, the number of visits to dermatologists was 1.07-1.16 times lower Relative Risk (RR)=0.86-0.92 as compared to the non-military periods, especially evident for patients residing closer to the military zone, where it dropped almost 2- folds (RR=0.52). Although perceived nonurgent in their majority, the routine care should not be delayed to prevent more serious skin conditions.
Computer-Assisted Fluid Therapy Eshel, Ron; Snider, Eric J.; Avital, Guy
Current anesthesiology reports (Philadelphia),
06/2023, Letnik:
13, Številka:
2
Journal Article
Purpose of Review
This review provides an overview of the rapidly evolving field of computer-assisted fluid management systems, aimed at familiarizing clinicians with its key concepts and ...advancements.
Recent Findings
Over the past two decades, several attempts have been made to develop computerized systems to support clinicians with the complicated task of patient fluid management. These systems vary in their purpose, logic, evaluation methods, and more, but they share the principle of utilizing closed-loop control mechanisms.
Summary
Computer-assisted fluid management systems (CAFMs) provide automated tools to support the task of fluid management, promoting precise fluid therapy that is continuously adjusted to meet the set goal. As advanced physiological sensors and algorithms continue to evolve and mature, the implementation of CAFMs within the realm of anesthesia and critical care will continue to grow.
The aim of the study was to quantitatively measure the effect of teaching cardiopulmonary resuscitation (CPR) using a real-time audiovisual feedback manikin system on first-year medical student's CPR ...performance.
This is a prospective, manikin-based intervention study, including 2 consecutive classes of medical school students enlisted to a mandatory first aid course. One class (control group) was taught using manikin-based standard CPR education models. The second class (intervention group) was taught similarly, but with the addition of real-time CPR quality feedback provided by the manikins. Students' performance was assessed using a standardized Objective Structured Clinical Examination scenario, during which no real-time feedback was provided. Critical CPR parameters were measured including compression depth, chest recoil, ventilation volume, and "hands-off" time.
A total of 201 participants were included in the study, 106 in the control group and 95 in the intervention group. Baseline demographic characteristics and previous medical knowledge were similar for the 2 groups. A significant improvement was observed for all primary study outcomes in favor of the real-time feedback group for median (interquartile range) chest compression fraction 57 (52.75%-60%) vs. 49 (43%-55%), P < 0.001, compressions with adequate depth 66.5 (19.5%-95.25%) vs. 0 (0%-12%), P < 0.001, ventilations with adequate volume 68.5 (33%-89%) vs. 37 (0%-70%), P < 0.00, and a simulator-derived composite "total CPR score" 39 (24%-61.25%) vs. 13 (3.5%-22%), P < 0.001. In multiple regression analysis, the real-time feedback group's performance was significantly better than the control group in all primary outcomes, adjusting for participant's characteristics of age, sex, and body mass index.
The use of audiovisual feedback techniques to teach CPR improves skill acquisition with significant improvement in crucial prognosis-improving parameters, as tested in a "no-feedback" test scenario.
This study aimed to characterize self-reported postoperative pain after tympanoplasty and tympanomastoidectomy and correlate pain severity with the patient's preoperative anxiety state.
Prospective ...cohort study.
Tertiary referral medical center.
Adult patients undergoing any middle ear surgery between July 2018 and July 2019.
Patient responses to an otology questionnaire (OQ) for scoring pain intensity on a visual analog scale preoperatively and on postoperative days (PODs) 1-4, 21, and 63. The responses were correlated with anxiety state (assessed by State-Trait Personality Inventory STPI scores) and clinical and operative data, including surgical technique-related details.
Sixty patients were enrolled (mean age ± standard deviation, 40 ± 19.7 yr, 26 men). Their median preoperative (baseline) visual analog scale pain score was 6 on POD1, 5 on POD3, and 1 at 3 and 7 weeks. Their median preoperative OQ score was 32 of 70 (45.7%), 37 of 70 (52.8%) on POD1, 33 of 70 (47.1%) on POD3, 6 of 70 (8.5%) at 3 weeks, and 6 of 70 at 7 weeks. Their overall mean preoperative anxiety level (STPI score) was 2.63 ± 1.50. STPI scores were significantly higher among patients who reported OQ scores equal to or higher than the median during PODs 1 to 4 in comparison to patients who reported OQ scores lower than the median. The α Cronbach correlation between anxiety and postoperative pain scores on POD1 was 0.97.
Preoperative anxiety levels are closely associated with postoperative pain levels after any middle ear surgery. Measures to control preoperative anxiety are warranted to alleviate postoperative pain.
To test the equivalence of two fetal weight estimation formulas generated by Hadlock, a formula that includes head circumference parameter (H1), and another (H2) which excludes this parameter. A ...secondary aim was to identify the patients in which H2 formula is less reliable to use.
This retrospective cohort study included a total of 1220 sonographic fetal weight estimations performed within seven days of delivery and recorded at a single medical center from January 2014 to December 2016. Estimated fetal weight was calculated using H1 and H2 formulas. Their accuracies were compared using percentage error, the proportion of weight estimations falling within ±15% error interval and by Bland-Altman analysis. Multivariate regression was performed to evaluate factors affecting weight estimation by H2 formula.
The mean birth weight was 3288.92 ± 641.27gr. The H2 formula presented with statistically significant higher value of systemic mean percent error comparing to H1 (3.19% vs. 1.87%, p < 0.001 respectively). H2 formula had a lower accuracy compared to H1 in predicting fetal weight within ±15% of birth weight (90.49% vs. 93.44%, p < 0.01 respectively). Using Bland-Altman analysis, the 95% limits of agreement between both formulas were (-142.03) to 231.79gr with a mean of 44.88gr. Factors found to influence significantly on H2 formula were long femur length (OR 1.144, p < 0.0001) and low maternal age (OR 0.947, p < 0.01).
H1formula was more accurate than H2 formula in predicting fetal weight at term. However, the accuracy difference was found to be small. Therefore, if ultrasonographic evaluation of HC is technically difficult, Hadlock formula that excludes head circumference can be used with confidence. Caution should be paid with higher values of femur length and lower maternal age.
Medical encounters require an efficient and focused history of present illness (HPI) to create differential diagnoses and guide diagnostic testing and treatment. Our aim was to compare the HPI of ...notes created by an automated digital intake tool versus standard medical notes created by clinicians.
Prospective trial in a quaternary academic Emergency Department (ED). Notes were compared using the 5-point Physician Documentation Quality Instrument (PDQI-9) scale and the Centers for Medicare & Medicaid Services (CMS) level of complexity index. Reviewers were board certified emergency medicine physicians blinded to note origin. Reviewers received training and calibration prior to note assessments. A difference of 1 point was considered clinically significant. Analysis included McNemar's (binary), Wilcoxon-rank (Likert), and agreement with Cohen's Kappa.
A total of 148 ED medical encounters were charted by both digital note and standard clinical note. The ability to capture patient information was assessed through comparison of note content across paired charts (digital-standard note on the same patient), as well as scores given by the reviewers. Reviewer agreement was kappa 0.56 (CI 0.49–0.64), indicating moderate level of agreement between reviewers scoring the same patient chart. Considering all 18 questions across PDQI-9 and CMS scales, the average agreement between standard clinical note and digital note was 54.3% (IQR 44.4–66.7%). There was a moderate level of agreement between content of standard and digital notes (kappa 0.54, 95%CI 0.49–0.60).
The quality of the digital note was within the 1 point clinically significant difference for all of the attributes, except for conciseness. Digital notes had a higher frequency of CMS severity elements identified.
Digitally generated clinical notes had moderate agreement compared to standard clinical notes and within the one point clinically significant difference except for the conciseness attribute. Digital notes more reliably documented billing components of severity. The use of automated notes should be further explored to evaluate its utility in facilitating documentation of patient encounters.
To the Editor The longitudinal integrated clerkship (LIC), an approach to clinical medical education that is gaining in popularity, represents a transformative trend that emphasizes relationships ...between medical students, patients, and physicians as a means of shaping the educational experience.1-3 This variation on the standard sequential, time-limited specialtyspecific 'block' rotations, often referred to as traditional block rotations (TBRs), aims to enhance students' experience of continuity of care, doctor-patient relationships, and academic supervision.4-6 The Joyce and Irving Goldman Medical School of BenGurion University of the Negev is the first Israeli institution to adopt the LIC model in their current clinical curricula. The LIC program operated under an established prearranged weekly schedule that included engagement in the clinical routine of selected internal and pediatric wards, specific subject-oriented academic sessions, and active participation in the community clinic of a selected general practitioner who was directly responsible for guiding and supervising the students. The involvement of community health facilities requires substantial resources for the recruitment of physicians and students, providing and funding transportation solutions for students, and creating an academic and administrative support system for the entire program. ...we wish to share the words of Y.G., one of the students who volunteered to participate in the LIC pilot: "It was an excellent experience.
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