Investigation of erectile dysfunction.

PubMed

Patel, D V; Halls, J; Patel, U

2012-11-01

Erectile dysfunction (ED) represents a common and debilitating condition with a wide range of organic and non-organic causes. Physical aetiologies can be divided into disorders affecting arterial inflow, the venous occlusion mechanism or the penile structure itself. Various imaging modalities can be utilised to investigate the physical causes of ED, but penile Doppler sonography (PDS) is the most informative technique, indicated in those patients with ED who do not respond to oral pharmacological agents (e.g. phosphodiesterase type 5 inhibitors). This review will examine the anatomical and physiological basis of penile erection, the method for performing PDS and features of specific causes of ED, and will also consider the alternative imaging modalities available.

Growth in Western Australian emergency department demand during 2007-2013 is due to people with urgent and complex care needs.

PubMed

Aboagye-Sarfo, Patrick; Mai, Qun; Sanfilippo, Frank M; Preen, David B; Stewart, Louise M; Fatovich, Daniel M

2015-06-01

To determine the magnitude and characteristics of the increase in ED demand in Western Australia (WA) from 2007 to 2013. We conducted a population-based longitudinal study examining trends in ED demand, stratified by area of residence, age group, sex, Australasian Triage Scale category and discharge disposition. The outcome measures were annual number and rate of ED presentations. We calculated average annual growth, and age-specific and age-standardised rates. We assessed the statistical significance of trends, overall and within each category, using the Mann-Kendall trend test and analysis of variance ANOVA. We also calculated the proportions of growth in ED demand that were attributable to changes in population and utilisation rate. From 2007 to 2013, ED presentations increased by an average 4.6% annually from 739,742 to 945,244. The rate increased 1.4% from 354.1 to 382.6 per 1000 WA population (P = 0.02 for the trend). The main increase occurred in metropolitan WA, age 45+ years, triage category 2 and 3 and admitted cohorts. Approximately three-quarters of this increase was due to population change (growth and ageing) and one-quarter due to increase in utilisation. Our study reveals a 4.6% annual increase in ED demand in WA in 2007-2013, mostly because of an increase in people with urgent and complex care needs, and not a shift (demand transfer) from primary care. This indicates that a system-wide integrated approach is required for demand management. © 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Trends and predicted trends in presentations of older people to Australian emergency departments: effects of demand growth, population aging and climate change.

PubMed

Burkett, Ellen; Martin-Khan, Melinda G; Scott, Justin; Samanta, Mayukh; Gray, Leonard C

2017-07-01

Objectives The aim of the present study was to describe trends in and age and gender distributions of presentations of older people to Australian emergency departments (EDs) from July 2006 to June 2011, and to develop ED utilisation projections to 2050. Methods A retrospective analysis of data collected in the National Non-admitted Patient Emergency Department Care Database was undertaken to assess trends in ED presentations. Three standard Australian Bureau of Statistics population growth models, with and without adjustment for current trends in ED presentation growth and effects of climate change, were examined with projections of ED presentations across three age groups (0-64, 65-84 and ≥85 years) to 2050. Results From 2006-07 to 2010-11, ED presentations increased by 12.63%, whereas the Australian population over this time increased by only 7.26%. Rates of presentation per head of population were greatest among those aged ≥85 years. Projections of ED presentations to 2050 revealed that overall ED presentations are forecast to increase markedly, with the rate of increase being most marked for older people. Conclusion Growth in Australian ED presentations from 2006-07 to 2010-11 was greater than that expected from population growth alone. The predicted changes in demand for ED care will only be able to be optimally managed if Australian health policy, ED funding instruments and ED models of care are adjusted to take into account the specific care and resource needs of older people. What is known about the topic? Rapid population aging is anticipated over coming decades. International studies and specific local-level Australian studies have demonstrated significant growth in ED presentations. There have been no prior national-level Australian studies of ED presentation trends by age group. What does this paper add? The present study examined national ED presentation trends from July 2006 to June 2011, with specific emphasis on trends in presentation by age group. ED presentation growth was found to exceed population growth in all age groups. The rate of ED presentations per head of population was highest among those aged ≥85 years. ED utilisation projections to 2050, using standard Australian Bureau of Statistics population modelling, with and without adjustment for current ED growth, were developed. The projections demonstrated linear growth in ED presentation for those aged 0-84 years, with growth in ED presentations of the ≥85 year age group demonstrating marked acceleration after 2030. What are the implications for practitioners? Growth in ED presentations exceeding population growth suggests that current models of acute health care delivery require review to ensure that optimal care is delivered in the most fiscally efficient manner. Trends in presentation of older people emphasise the imperative for ED workforce planning and education in care of this complex patient cohort, and the requirement to review funding models to incentivise investment in ED avoidance and substitutive care models targeting older people.

Examination of changes in pathology tests ordered by Diagnosis-Related Group (DRGs) following CPOE introduction.

PubMed

Vecellio, Elia; Georgiou, Andrew; Toouli, George; Eigenstetter, Alex; Li, Ling; Wilson, Roger; Westbrook, Johanna I

2013-01-01

Electronic test ordering, via the Electronic Medical Record (EMR), which incorporates computerised provider order entry (CPOE), is widely considered as a useful tool to support appropriate pathology test ordering. Diagnosis-related groups (DRGs) are clinically meaningful categories that allow comparisons in pathology utilisation by patient groups by controlling for many potentially confounding variables. This study used DRG data linked to pathology test data to examine changes in rates of test ordering across four years coinciding with the introduction of an EMR in six hospitals in New South Wales, Australia. This method generated a list of high pathology utilisation DRGs. We investigated patients with a Chest pain DRG to examine whether tests rates changed for specific test groups by hospital emergency department (ED) pre- and post-EMR. There was little change in testing rates between EDs or between time periods pre- and post-EMR. This is a valuable method for monitoring the impact of EMR and clinical decision support on test order rates.

Unlocking the Potential of Public Libraries in Supporting Distance Learning

ERIC Educational Resources Information Center

Nabushawo, Harriet Mutambo; Aguti, Jessica Norah; Winterbottom, Mark

2016-01-01

This paper examines the place of public libraries in supporting distance learners in Makerere University, exploring the factors which affect utilisation of their services. The study adopted a survey design with 300 B.Ed. students, collecting data through focus group discussions, structured questionnaires and individual interviews.

Why do children present to emergency departments? Exploring motivators and measures of presentation appropriateness for children presenting to a paediatric emergency department.

PubMed

Cheek, John A; Braitberg, George; Craig, Simon; West, Adam

2017-05-01

To compare the parental motivators and referring general practitioner's (GP's) reasons for advising emergency department (ED) attendance with the assessment of ED medical staff. To compare ED clinician opinion with other published methods that have attempted to define 'primary care suitable' presentations to the ED. A prospective observational study and series of surveys regarding the attendance of children presenting to a single tertiary paediatric ED. Surveys were distributed to the treating ED clinician, the child's parent/guardian, and the referring GP. Results between the three groups were analysed and compared. There were a total of 1069 presentations during the study period. Six hundred (58.4%, 95% CI 55.3-61.4%) presentations were judged as 'ED appropriate' by the treating ED clinician. When compared with methods used to retrospectively judge whether ED patients are considered 'primary care suitable', ED clinicians disagree between 22.4 and 38.8% of the time. For patients who presented directly to ED, 85.6% did so for a medical reason, whilst 32.1% did so for a GP access reason. Being referred by a GP improved the ED clinicians' opinion of the appropriateness of the presentation (49.2 vs. 73.9%, P < 0.05). We caution that many strategies attempting to 'solve' the issue of increasing ED attendances by paediatric patients have been driven by opinion, and a better understanding of the motivators that drive this behaviour is needed. We believe the solution to increasing utilisation of EDs by children must be a balanced approach that addresses community expectations and appropriately resources EDs. © 2017 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).

Atraumatic headache in US emergency departments: recent trends in CT/MRI utilisation and factors associated with severe intracranial pathology.

PubMed

Gilbert, John W; Johnson, Kevin M; Larkin, Gregory L; Moore, Christopher L

2012-07-01

To estimate recent trends in CT/MRI utilisation among patients seeking emergency care for atraumatic headache in the USA and to identify factors associated with a diagnosis of significant intracranial pathology (ICP) in these patients. Data were obtained from the USA National Hospital Ambulatory Medical Care Survey of emergency department (ED) visits between 1998 and 2008. A cohort of atraumatic headache-related visits were identified using preassigned 'reason-for-visit' codes. Sample visits were weighted to provide national estimates. Between 1998 and 2008 the percentage of patients presenting to the ED with atraumatic headache who underwent imaging increased from 12.5% to 31.0% (p < 0.01) while the prevalence of ICP among those visits decreased from 10.1% to 3.5% (p < 0.05). The length of stay in the ED was 4.6 h (95% CI 4.4 to 4.8) for patients with headache who received imaging compared with 2.7 (95% CI 2.6 to 2.9) for those who did not. Of 18 factors evaluated in patients with headache, 10 were associated with a significantly increased odds of an ICP diagnosis: age ≥ 50 years, arrival by ambulance, triage immediacy <15 min, systolic blood pressure ≥ 160 mm Hg or diastolic blood pressure ≥ 100 mm Hg and disturbance in sensation, vision, speech or motor function including neurological weakness. The use of CT/MRI for evaluation of atraumatic headache increased dramatically in EDs in the USA between 1998 and 2008. The prevalence of ICP among patients who received CT/MRI declined concurrently, suggesting a role for clinical decision support to guide more judicious use of imaging.

RESPECT-ED: Rates of Pulmonary Emboli (PE) and Sub-Segmental PE with Modern Computed Tomographic Pulmonary Angiograms in Emergency Departments: A Multi-Center Observational Study Finds Significant Yield Variation, Uncorrelated with Use or Small PE Rates.

PubMed

Mountain, David; Keijzers, Gerben; Chu, Kevin; Joseph, Anthony; Read, Catherine; Blecher, Gabriel; Furyk, Jeremy; Bharat, Chrianna; Velusamy, Karthik; Munro, Andrew; Baker, Kylie; Kinnear, Frances; Mukherjee, Ahses; Watkins, Gina; Buntine, Paul; Livesay, Georgia; Fatovich, Daniel

2016-01-01

Overuse of CT Pulmonary Angiograms (CTPA) for diagnosing pulmonary embolism (PE), particularly in Emergency Departments (ED), is considered problematic. Marked variations in positive CTPA rates are reported, with American 4-10% yields driving most concerns. Higher resolution CTPA may increase sub-segmental PE (SSPE) diagnoses, which may be up to 40% false positive. Excessive use and false positives could increase harm vs. benefit. These issues have not been systematically examined outside America. To describe current yield variation and CTPA utilisation in Australasian ED, exploring potential factors correlated with variation. A retrospective multi-centre review of consecutive ED-ordered CTPA using standard radiology reports. ED CTPA report data were inputted onto preformatted data-sheets. The primary outcome was site level yield, analysed both intra-site and against a nominated 15.3% yield. Factors potentially associated with yield were assessed for correlation. Fourteen radiology departments (15 ED) provided 7077 CTPA data (94% ≥64-slice CT); PE were reported in 1028 (yield 14.6% (95%CI 13.8-15.4%; range 9.3-25.3%; site variation p <0.0001) with four sites significantly below and one above the 15.3% target. Admissions, CTPA usage, PE diagnosis rates and size of PE were uncorrelated with yield. Large PE (≥lobar) were 55% (CI: 52.1-58.2%) and SSPE 8.8% (CI: 7.1-10.5%) of positive scans. CTPA usage (0.2-1.5% adult attendances) was correlated (p<0.006) with PE diagnosis but not SSPE: large PE proportions. We found significant intra-site CTPA yield variation within Australasia. Yield was not clearly correlated with CTPA usage or increased small PE rates. Both SSPE and large PE rates were similar to higher yield historical cohorts. CTPA use was considerably below USA 2.5-3% rates. Higher CTPA utilisation was positively correlated with PE diagnoses, but without evidence of increased proportions of small PE. This suggests that increased diagnoses seem to be of clinically relevant sized PE.

Impact Evaluation of a System-Wide Chronic Disease Management Program on Health Service Utilisation: A Propensity-Matched Cohort Study.

PubMed

Billot, Laurent; Corcoran, Kate; McDonald, Alina; Powell-Davies, Gawaine; Feyer, Anne-Marie

2016-06-01

The New South Wales Health (NSW Health) Chronic Disease Management Program (CDMP) delivers interventions to adults at risk of hospitalisation for five target chronic conditions that respond well to ambulatory care: diabetes, hypertension, chronic obstructive pulmonary disease, congestive heart failure, and coronary artery disease. The intervention consists of two main components: (1) care coordination across sectors (acute, ambulatory, and community care from both public and private sectors) and clinical specialties, facilitated by program care coordinators, and (2) health coaching including management of lifestyle risk factors and medications and self-management. These components were broadly prescribed by the head office of NSW Health, which funded the program, and were implemented by regional health services (local health districts) in ways that best suited their own history, environment, workforce, and patient need. We used a propensity-matched cohort study to evaluate health service utilisation after enrolment in the CDMP. The evaluation cohort included 41,303 CDMP participants enrolled between 1 January 2011 and 31 December 2013 who experienced at least one hospital admission or emergency department (ED) presentation for a target condition in the 12 mo preceding enrolment. Potential controls were selected from patients not enrolled in the CDMP but experiencing at least one hospital admission or ED presentation over the same period. Each CDMP patient in the evaluation cohort was matched to one control using 1:1 propensity score matching. The primary outcome was avoidable hospitalisations. Secondary outcomes included avoidable readmissions, avoidable bed days, unplanned hospitalisations, unplanned readmissions, unplanned bed days, ED presentations, and all-cause death. The primary analysis consisted of 30,057 CDMP participants and 30,057 matched controls with a median follow-up of 15 mo. Of those, 25,638 (85.3%) and 25,597 (85.2%) were alive by the end of follow-up in the CDMP and control groups, respectively. Baseline characteristics (including history of health service utilisation) were well balanced between the matched groups. In both groups, utilisation peaked just before the time of enrolment/matching, declined sharply immediately following enrolment, and then continued to decrease more gradually; however, after enrolment, avoidable and unplanned health service utilisation remained higher for CDMP participants compared to controls. The adjusted yearly rate of avoidable hospital admissions was 0.57 (95% CI 0.52 to 0.62) in the CDMP group versus 0.33 (95% CI 0.31 to 0.37) in the control group (adjusted rate ratio 1.70, 95% CI 1.62 to 1.79, p < 0.001). Significant increases in service utilisation were also observed for unplanned hospitalisations (1.42, 95% CI 1.37 to 1.47, p < 0.001) and ED presentations (1.37, 95% CI 1.32 to 1.42, p < 0.001) as well as avoidable (2.00, 95% CI 1.80 to 2.22, p < 0.001) and unplanned (1.51, 95% CI 1.40 to 1.62, p < 0.001) readmissions and avoidable (1.70, 95% CI 1.59 to 1.82, p < 0.001) and unplanned (1.43, 95% CI 1.36 to 1.49, p < 0.001) bed days. No evidence of a difference was seen for all-cause death (adjusted risk ratio 0.96, 95% CI 0.96 to 1.01, p = 0.10) or non-avoidable hospitalisations (all hospitalisations minus avoidable hospitalisations; adjusted rate ratio 1.03, 95% CI 0.97 to 1.10, p = 0.26). Despite the robustness of these results to sensitivity analyses, in the absence of a randomised control group, one cannot exclude the possibility of residual or unmeasured confounding that was not controlled for by the matching process and multivariable analyses. Participation in the CDMP was associated with an increase in avoidable hospital admissions compared to matched controls but no difference in the rate of other types of hospitalisation or death. A possible explanation is that the program identified conditions that required participants to be hospitalised. Service utilisation decreased sharply following its peak for both groups. This finding reflects the natural tendency for high-risk patients to show reductions in use following intense phases of service utilisation and highlights that, despite the additional complexity, a carefully selected control group is essential when assessing the effectiveness of interventions on hospital use.

Gout and subsequent erectile dysfunction: a population-based cohort study from England.

PubMed

Abdul Sultan, Alyshah; Mallen, Christian; Hayward, Richard; Muller, Sara; Whittle, Rebecca; Hotston, Matthew; Roddy, Edward

2017-06-06

An association has been suggested between gout and erectile dysfunction (ED), however studies quantifying the risk of ED amongst gout patients are lacking. We aimed to precisely determine the population-level absolute and relative rate of ED reporting among men with gout over a decade in England. We utilised the UK-based Clinical Practice Research Datalink to identify 9653 men with incident gout age- and practice-matched to 38,218 controls. Absolute and relative rates of incident ED were calculated using Cox regression models. Absolute rates within specific time periods before and after gout diagnosis were compared to control using a Poisson regression model. Overall, the absolute rate of ED post-gout diagnosis was 193 (95% confidence interval (CI): 184-202) per 10,000 person-years. This corresponded to a 31% (hazard ratio (HR): 1.31 95%CI: 1.24-1.40) increased relative risk and 0.6% excess absolute risk compared to those without gout. We did not observe statistically significant differences in the risk of ED among those prescribed ULT within 1 and 3 years after gout diagnosis. Compared to those unexposed, the risk of ED was also high in the year before gout diagnosis (relative rate = 1.63 95%CI 1.27-2.08). Similar findings were also observed for severe ED warranting pharmacological intervention. We have shown a statistically significant increased risk of ED among men with gout. Our findings will have important implications in planning a multidisciplinary approach to managing patients with gout.

Communication and Influencing for ED Professionals: A training programme developed in the emergency department for the emergency department.

PubMed

Rixon, Andrew; Rixon, Sascha; Addae-Bosomprah, Hansel; Ding, Mingshuang; Bell, Anthony

2016-08-01

The objective of the present study is to develop and pilot a communication and influencing skills training programme that meets ED health professionals' needs at an urban district hospital. Qualitative methods within a participatory action research framework were utilised. An interdisciplinary team guided the programme's design and development. A training needs analysis saw team meetings, interviews, focus groups and observations conducted across the ED. Thematic analysis of the data identified health professionals' communication and influencing challenges. The training needs analysis informed the training programme curriculum's development. The pilot programme involved an interdisciplinary group of seven health professionals across 5 × 2 h sessions over 3 months, followed by a post-training survey. Five themes of communication and influencing challenges were identified: participating in effective handovers, involving patients in bedside handovers, effectively communicating with interdepartmental colleagues, asking ED colleagues to do tasks and understanding ED colleagues' roles, expectations and assumptions. Based on these challenges, the formulated RESPECT model (which stands for Relationships, Expectations, Styles, Partnerships, Enquiry, Coaching and Teamwork) informed the training curriculum. The peer coaching model used in the training programme was highly regarded by participants. Communication and Influencing for ED Professionals™ (Babel Fish Group Pty Ltd, Melbourne, Victoria, Australia) addresses a gap for communication programmes developed in the ED for the ED. Future research will evaluate the programme's impact in this ED. © 2016 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

A clinical trial of nurse practitioner care in residential aged care facilities.

PubMed

Arendts, Glenn; Deans, Pamela; O'Brien, Keith; Etherton-Beer, Christopher; Howard, Kirsten; Lewin, Gill; Sim, Moira

2018-05-04

Optimising quality of life and reducing hospitalisation for people living in residential aged care facilities (RACF) are important health policy goals. A cluster controlled clinical trial of nurse practitioner care in RACF. Six facilities were included: three randomly allocated to intervention where nurse practitioners working with general practitioners and using a best practice guide were responsible for care, and three control. Participants were followed up for a minimum of 12 months unless dead or transferred to another facility. We enrolled two hundred patients (101 intervention and 99 control) with a mean (SD) follow up of 604 (276) days. There were 98 ED visits by intervention participants, resulting in 56 hospitalisations, compared with 121 ED visits and 70 hospitalisations for controls (risk reduction = 8%, 95% CI = -1% -17%, p = 0.10). For the pre-specified secondary outcomes of transfers within the first 12 months of enrolment, the number of residents making at least one visit (46 in each study arm) and rate of ED attendance (0.66 visits per intervention resident versus 0.70 visits per control resident) was not affected by the intervention. After adjusting for dependency and comorbidity, the intervention group had non-significantly lower transfers (OR 0.7, 95% CI 0.3-1.5, p = 0.34). There was a reduction in the rate of decline in the quality of life of intervention compared to control residents. Nurse practitioner care coordination resulted in no statistically significant change in rates of ED transfer or health care utilisation, but better maintained resident quality of life. Copyright © 2018 Elsevier B.V. All rights reserved.

Western Australian emergency department presentations related to child maltreatment and intentional injury: population level study utilising linked health and child protection data.

PubMed

O'Donnell, Melissa; Nassar, Natasha; Jacoby, Peter; Stanley, Fiona

2012-01-01

The aim of this study is to determine the proportion of child maltreatment-related emergency department (ED) presentations in Western Australia (WA) and describe the type of injuries associated with them. It is also to investigate the proportion of maltreatment-related ED presentations resulting in hospitalisation, the proportion referred to the Department for Child Protection and their outcomes. This is a retrospective cohort study of all children aged 0-17 years residing in WA from 2001 to 2005 who had an ED presentation recorded in the ED Data Collection. This study used de-identified administrative data linked across the Departments of Health and Child Protection. Only 0.03% of ED presentations were identified as maltreatment related and 0.2% for all intentional injury presentations. One in five children with maltreatment-related ED presentations was admitted to hospital and a similar proportion had a notification to Department for Child Protection and 87% of these subsequently substantiated. This study showed that there are limitations with ED data for child maltreatment surveillance in WA and raises concerns that there may be missed opportunities for identifying maltreatment and for referring families for further assessment and support. Recommendations are provided to improve maltreatment surveillance and ED data, particularly for the identification of external causes of injury. © 2011 The Authors. Journal of Paediatrics and Child Health © 2011 Paediatrics and Child Health Division (Royal Australasian College of Physicians).

RESPECT-ED: Rates of Pulmonary Emboli (PE) and Sub-Segmental PE with Modern Computed Tomographic Pulmonary Angiograms in Emergency Departments: A Multi-Center Observational Study Finds Significant Yield Variation, Uncorrelated with Use or Small PE Rates

PubMed Central

Chu, Kevin; Joseph, Anthony; Read, Catherine; Blecher, Gabriel; Furyk, Jeremy; Bharat, Chrianna; Velusamy, Karthik; Munro, Andrew; Baker, Kylie; Kinnear, Frances; Mukherjee, Ahses; Watkins, Gina; Buntine, Paul; Livesay, Georgia

2016-01-01

Introduction Overuse of CT Pulmonary Angiograms (CTPA) for diagnosing pulmonary embolism (PE), particularly in Emergency Departments (ED), is considered problematic. Marked variations in positive CTPA rates are reported, with American 4–10% yields driving most concerns. Higher resolution CTPA may increase sub-segmental PE (SSPE) diagnoses, which may be up to 40% false positive. Excessive use and false positives could increase harm vs. benefit. These issues have not been systematically examined outside America. Aims To describe current yield variation and CTPA utilisation in Australasian ED, exploring potential factors correlated with variation. Methods A retrospective multi-centre review of consecutive ED-ordered CTPA using standard radiology reports. ED CTPA report data were inputted onto preformatted data-sheets. The primary outcome was site level yield, analysed both intra-site and against a nominated 15.3% yield. Factors potentially associated with yield were assessed for correlation. Results Fourteen radiology departments (15 ED) provided 7077 CTPA data (94% ≥64-slice CT); PE were reported in 1028 (yield 14.6% (95%CI 13.8–15.4%; range 9.3–25.3%; site variation p <0.0001) with four sites significantly below and one above the 15.3% target. Admissions, CTPA usage, PE diagnosis rates and size of PE were uncorrelated with yield. Large PE (≥lobar) were 55% (CI: 52.1–58.2%) and SSPE 8.8% (CI: 7.1–10.5%) of positive scans. CTPA usage (0.2–1.5% adult attendances) was correlated (p<0.006) with PE diagnosis but not SSPE: large PE proportions. Discussion/ Conclusions We found significant intra-site CTPA yield variation within Australasia. Yield was not clearly correlated with CTPA usage or increased small PE rates. Both SSPE and large PE rates were similar to higher yield historical cohorts. CTPA use was considerably below USA 2.5–3% rates. Higher CTPA utilisation was positively correlated with PE diagnoses, but without evidence of increased proportions of small PE. This suggests that increased diagnoses seem to be of clinically relevant sized PE. PMID:27918576

Impact of universal health coverage on urban–rural inequity in psychiatric service utilisation for patients with first admission for psychosis: a 10-year nationwide population-based study in Taiwan

PubMed Central

Chiang, Chih-Lin; Chen, Pei-Chun; Huang, Ling-Ya; Kuo, Po-Hsiu; Tung, Yu-Chi; Liu, Chen-Chung; Chen, Wei J

2016-01-01

Objective To examine the disparities in psychiatric service utilisation over a 10-year period for patients with first admission for psychosis in relation to urban–rural residence following the implementation of universal health coverage in Taiwan. Design Population-based retrospective cohort study. Setting Taiwan's National Health Insurance Research Database, which has a population coverage rate of over 99% and contains all medical claim records of a nationwide cohort of patients with at least one psychiatric admission between 1996 and 2007. Participants 69 690 patients aged 15–59 years with first admission between 1998 and 2007 for any psychotic disorder. Main exposure measure Patients’ urban–rural residence at first admissions. Main outcome measures Absolute and relative inequality indexes of the following quality indicators after discharge from the first admission: all-cause psychiatric readmission at 2 and 4 years, dropout of psychiatric outpatient service at 30 days, and emergency department (ED) treat-and-release encounter at 30 days. Results Between 1998 and 2007, the 4-year readmission rate decreased from 65% to 58%, the 30-day dropout rate decreased from 18% to 15%, and the 30-day ED encounter rate increased from 8% to 10%. Risk of readmission has significantly decreased in rural and urban patients, but at a slower speed for the rural patients (p=0.026). The adjusted HR of readmission in rural versus urban patients has increased from 1.00 (95% CI 0.96 to 1.04) in 1998–2000 to 1.08 (95% CI 1.03 to 1.12) in 2005–2007, indicating a mild widening of the urban–rural gap. Urban–rural differences in 30-day dropout and ED encounter rates have been stationary over time. Conclusions The universal health coverage in Taiwan did not narrow urban–rural inequity of psychiatric service utilisation in patients with psychosis. Therefore, other policy interventions on resource allocation, service delivery and quality of care are needed to improve the outcome of rural-dwelling patients with psychosis. PMID:26940114

The financial consequences of lost demand and reducing boarding in hospital emergency departments.

PubMed

Pines, Jesse M; Batt, Robert J; Hilton, Joshua A; Terwiesch, Christian

2011-10-01

Some have suggested that emergency department (ED) boarding is prevalent because it maximizes revenue as hospitals prioritize non-ED admissions, which reimburse higher than ED admissions. We explore the revenue implications to the overall hospital of reducing boarding in the ED. We quantified the revenue effect of reducing boarding-the balance of higher ED demand and the reduction of non-ED admissions-using financial modeling informed by regression analysis and discrete-event simulation with data from 1 inner-city teaching hospital during 2 years (118,000 ED visits, 22% ED admission rate, 7% left without being seen rate, 36,000 non-ED admissions). Various inpatient bed management policies for reducing non-ED admissions were tested. Non-ED admissions generated more revenue than ED admissions ($4,118 versus $2,268 per inpatient day). A 1-hour reduction in ED boarding time would result in $9,693 to $13,298 of additional daily revenue from capturing left without being seen and diverted ambulance patients. To accommodate this demand, we found that simulated management policies in which non-ED admissions are reduced without consideration to hospital capacity (ie, static policies) mostly did not result in higher revenue. Many dynamic policies requiring cancellation of various proportions of non-ED admissions when the hospital reaches specific trigger points increased revenue. The optimal strategies tested resulted in an estimated $2.7 million and $3.6 in net revenue per year, depending on whether left without being seen patients were assumed to be outpatients or mirrored ambulatory admission rates, respectively. Dynamic inpatient bed management in inner-city teaching hospitals in which non-ED admissions are occasionally reduced to ensure that EDs have reduced boarding times is a financially attractive strategy. Copyright © 2010 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Informing Intervention Strategies to Reduce Energy Drink Consumption in Young People: Findings From Qualitative Research.

PubMed

Francis, Jacinta; Martin, Karen; Costa, Beth; Christian, Hayley; Kaur, Simmi; Harray, Amelia; Barblett, Ann; Oddy, Wendy Hazel; Ambrosini, Gina; Allen, Karina; Trapp, Gina

2017-10-01

To determine young people's knowledge of energy drinks (EDs), factors influencing ED consumption, and intervention strategies to decrease ED consumption in young people. Eight group interviews with young people (aged 12-25 years). Community groups and secondary schools in Perth, Western Australia. Forty-one young people, 41% of whom were male and 73% of whom consumed EDs. Factors influencing ED consumption and intervention strategies informed by young people to reduce ED consumption. Two researchers conducted a qualitative content analysis on the data using NVivo software. Facilitators of ED consumption included enhanced energy, pleasant taste, low cost, peer pressure, easy availability, and ED promotions. Barriers included negative health effects, unpleasant taste, high cost, and parents' disapproval. Strategies to reduce ED consumption included ED restrictions, changing ED packaging, increasing ED prices, reducing visibility in retail outlets, and research and education. Because many countries allow the sale of EDs to people aged <18 years, identifying ways to minimize potential harm from EDs is critical. This study provided unique insights into intervention strategies suggested by young people to reduce ED consumption. In addition to more research and education, these strategies included policy changes targeting ED sales, packaging, price, and visibility. Future research might examine the feasibility of implementing such interventions. Copyright © 2017 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved.

Colectomy for constipation: time trends and impact based on the US Nationwide Inpatient Sample, 1998-2011.

PubMed

Dudekula, A; Huftless, S; Bielefeldt, K

2015-12-01

Current guidelines include subtotal colectomy as treatment for refractory slow transit constipation. To use the US Nationwide Inpatient Sample (NIS) (1998-2011) and longitudinal data from the State Inpatient Database (2005-2011), comparable to NIS, to examine colectomy rates, in-hospital morbidity and emergency department (ED) visits or readmissions among patients treated for constipation. Colectomies for any reason were identified based on the primary procedural code (ICD-9-CM 45.8x). Index hospitalisations were defined by the primary diagnosis of constipation (ICD-9-CM 564.x) associated with the primary procedural code for colectomy (ICD-9-CM45.8x) after exclusion of other diseases associated with colectomy. Demographic variables, comorbidities, complications and adverse events during the hospitalisation were captured, and ED visits and admissions were recorded for periods before and after colectomy. Nationally, colectomies for constipation rose from 104 procedures in 1998 (1.2% of annual colectomies) to 311 in 2011 (2.4% of annual colectomies). While there were no perioperative deaths, perioperative complications occurred in 42.7% of patients during the index hospitalisation. Longitudinal data were analysed for 181 patients, with similar perioperative complications and a readmission rate of 28.9% within the first 30 days after the index hospitalisation. Resource utilisation was tracked for a median time of 630 (0-2386) before and 463 (0-2204) days after colectomy with unchanged ED visits (median: 2 vs. 2, P = 0.21), but increased hospitalisations (median: 1 vs. 2, P = 0.003). Colectomy rates for constipation are rising, are associated with significant morbidity and do not decrease resource utilisation, raising questions about the true benefit of surgery for slow transit constipation. © 2015 John Wiley & Sons Ltd.

Nursing praxis, compassionate caring and interpersonal relations: an observational study.

PubMed

Fry, Margaret; MacGregor, Casimir; Ruperto, Kate; Jarrett, Kate; Wheeler, Janet; Fong, Jacqueline; Fetchet, Wendy

2013-05-01

The Clinical Initiative Nurse (CIN) is a role that requires experienced emergency nurses to assess, initiate diagnostic tests, treat and manage a range of patient conditions. The CIN role is focused on the waiting room and to 'communicate the wait', initiate diagnostics or treatment and follow-up for waiting room patients. We aim to explore what emergency nurses' do in their extended practice role in observable everyday life in the emergency department (ED). The paper argues that compassionate caring is a core nursing skill that supports CIN interpersonal relations, despite the role's highly clinical nature. Sixteen non-participant observations were undertaken in three EDs in New South Wales, Australia. Nurses were eligible for inclusion if they had two years of emergency experience and had worked in the CIN role for more than one year. All CIN's that were observed were highly experienced with a minimum three year ED experience. The CIN observations revealed how compassionate caring was utilised by CIN's to quickly build a therapeutic relationship with patients and colleagues, and helped to facilitate core communication and interpersonal skills. While the CIN role was viewed as extended practice, the role relied heavily on compassionate care to support interpersonal relationships and to actualise extended practice care. The study supports the contribution made by emergency nurses and demonstrates how compassionate caring is central to nursing praxis. This paper also demonstrates that the CIN role utilises a complex mix between advanced clinical skills and compassion that supports interpersonal and therapeutic relationships. Further research is needed to understand how compassionate care can be optimised within nursing praxis and the duty of care between nurses and patients, nurses and other health care professionals so that future healthcare goals can be realised. Copyright © 2013 College of Emergency Nursing Australasia Ltd. All rights reserved.

Implementation of a novel communication tool and its effect on patient comprehension of care and satisfaction.

PubMed

Simmons, Stefanie Anne; Sharp, Brian; Fowler, Jennifer; Singal, Bonita

2013-05-01

Emergency department (ED) communication has been demonstrated as requiring improvement and ED patients have repeatedly demonstrated poor comprehension of the care they receive. Through patient focus groups, the authors developed a novel tool designed to improve communication and patient comprehension. This is a prospective, randomised controlled clinical trial to test the efficacy of a novel, patient-centred communication tool. Patients in a small community hospital ED were randomised to receive the instrument, which was utilised by the entire ED care team and served as a checklist or guide to the patients' ED stay. At the end of the ED stay, patients completed a survey of their comprehension of the care and a communication assessment tool-team survey (a validated instrument to assess satisfaction with communication). Three blinded chart reviewers scored patients' comprehension of their ED care as concordant, partially concordant or discordant with charted care. The authors tested whether there was a difference in satisfaction using a two-sample t test and a difference in comprehension using ordinal logistic regression analysis. 146 patients were enrolled in the study with 72 randomised to receive the communication instrument. There was no significant difference between groups in comprehension (OR=0.65, 95% CI 0.34 to 1.23, p=0.18) or communication assessment tool-team scores (difference=0.2, 95% CI: -3.4 to 3.8, p=0.91). Using their novel communication tool, the authors were not able to show a statistically significant improvement in either comprehension or satisfaction, though a tendency towards improved comprehension was seen.

A systematic review and meta-analysis of early goal-directed therapy for septic shock: the ARISE, ProCESS and ProMISe Investigators.

PubMed

Angus, D C; Barnato, A E; Bell, D; Bellomo, R; Chong, C-R; Coats, T J; Davies, A; Delaney, A; Harrison, D A; Holdgate, A; Howe, B; Huang, D T; Iwashyna, T; Kellum, J A; Peake, S L; Pike, F; Reade, M C; Rowan, K M; Singer, M; Webb, S A R; Weissfeld, L A; Yealy, D M; Young, J D

2015-09-01

To determine whether early goal-directed therapy (EGDT) reduces mortality compared with other resuscitation strategies for patients presenting to the emergency department (ED) with septic shock. Using a search strategy of PubMed, EmBase and CENTRAL, we selected all relevant randomised clinical trials published from January 2000 to January 2015. We translated non-English papers and contacted authors as necessary. Our primary analysis generated a pooled odds ratio (OR) from a fixed-effect model. Sensitivity analyses explored the effect of including non-ED studies, adjusting for study quality, and conducting a random-effects model. Secondary outcomes included organ support and hospital and ICU length of stay. From 2395 initially eligible abstracts, five randomised clinical trials (n = 4735 patients) met all criteria and generally scored high for quality except for lack of blinding. There was no effect on the primary mortality outcome (EGDT: 23.2% [495/2134] versus control: 22.4% [582/2601]; pooled OR 1.01 [95% CI 0.88-1.16], P = 0.9, with heterogeneity [I(2) = 57%; P = 0.055]). The pooled estimate of 90-day mortality from the three recent multicentre studies (n = 4063) also showed no difference [pooled OR 0.99 (95% CI 0.86-1.15), P = 0.93] with no heterogeneity (I(2) = 0.0%; P = 0.97). EGDT increased vasopressor use (OR 1.25 [95% CI 1.10-1.41]; P < 0.001) and ICU admission [OR 2.19 (95% CI 1.82-2.65); P < 0.001]. Including six non-ED randomised trials increased heterogeneity (I(2) = 71%; P < 0.001) but did not change overall results [pooled OR 0.94 (95% CI 0.82 to 1.07); P = 0.33]. EGDT is not superior to usual care for ED patients with septic shock but is associated with increased utilisation of ICU resources.

Burnout among workers in emergency Departments in Palestinian hospitals: prevalence and associated factors.

PubMed

Hamdan, Motasem; Hamra, Asma'a Abu

2017-06-15

Working in Emergency Departments (EDs) entails high work pressure and stress due to witnessing human suffering and the unpredictable nature of the work. This environment puts personnel at risk of burnout. This analysis aims to assess burnout levels and associated risk factors among health workers in EDs in Palestinian hospitals. Also, it examines the association between burnout and workplace violence, as well as with job turnover. Cross-sectional design utilising a self-administered questionnaire was used to collect data from all workers at 14 EDs; 8 from the West Bank and 6 from the Gaza Strip. Burnout was measured using Maslach Burnout Inventory-Human Services Survey. A total of 444 workers (response rate 74.5%) participated: 161(36.3%) nurses, 142(32.0%) physicians and 141(31.7%) administrative personnel. Results showed high levels of burnout among EDs workers; 64.0% suffered from high emotional exhaustion, 38.1% from high depersonalization and 34.6% from low personal accomplishment. In addition, high levels of emotional exhaustion (72.3%) was significantly prevalent among physicians compared to nurses (69.8%) and administrative workers (51.4%) (p < 0.05). In comparison, high levels of depersonalization was significantly prevalent among nurses (48.8%) compared to physicians (32.1%) and administrative workers (31.9%) (p < 0.05). However, there were no significant differences in the levels of personal accomplishment burnout among the three groups (p > 0.05). Moreover, high degree of burnout was more prevalent among EDs workers in the West Bank than among those working in the Gaza Strip (OR 2.02, 95% CI = 1.11-3.69, p = 0.019), and higher among younger workers (aged ≤30 years old) than their older counterparts (OR 2.4, 95% CI = 1.302-4.458, p = 0.005). Exposure to physical violence was significantly associated with having a high degree of burnout (OR 2.017 95% CI = 1.121-3.631, p = 0.019), but no association was observed with regards to exposure to verbal violence (p > 0.05). Finally, burnout was significantly associated with workers' intention to leave work at EDs (p < 0.05). Burnout is considerably prevalent among EDs' workers, especially nurses and physicians. Burnout is positively associated with job turnover intention and also with exposure to workplace violence. Therefore, there is a need for prevention and management strategies to address occupational burnout and reduce negative consequences on workers, patients and organisations.

Wheel running reduces ethanol seeking by increasing neuronal activation and reducing oligodendroglial/neuroinflammatory factors in the medial prefrontal cortex

PubMed Central

Somkuwar, Sucharita S.; Fannon, McKenzie J.; Ghofranian, Atoosa; Quigley, Jacqueline A.; Dutta, Rahul R.; Galinato, Melissa H.; Mandyam, Chitra D.

2016-01-01

The therapeutic effects of wheel running (WR) during abstinence on reinstatement of ethanol seeking behaviors in rats that self-administered ethanol only (ethanol drinking, ED) or ED with concurrent chronic intermittent ethanol vapor experience (CIE-ED) were investigated. Neuronal activation as well as oligodendroglial and neuroinflammatory factors were measured in the medial prefrontal cortex (mPFC) tissue to determine cellular correlates associated with enhanced ethanol seeking. CIE-ED rats demonstrated escalated and unregulated intake of ethanol and maintained higher drinking than ED rats during abstinence. CIE-ED rats were more resistant to extinction from ethanol self-administration, however, demonstrated similar ethanol seeking triggered by ethanol contextual cues compared to ED rats. Enhanced seeking was associated with reduced neuronal activation, and increased number of myelinating oligodendrocyte progenitors and PECAM-1 expression in the mPFC, indicating enhanced oligodendroglial and neuroinflammatory response during abstinence. WR during abstinence enhanced self-administration in ED rats, indicating a deprivation effect. WR reduced reinstatement of ethanol seeking in CIE-ED and ED rats, indicating protection against relapse. The reduced ethanol seeking was associated with enhanced neuronal activation, reduced number of myelinating oligodendrocyte progenitors, and reduced PECAM-1 expression. The current findings demonstrate a protective role of WR during abstinence in reducing ethanol seeking triggered by ethanol contextual cues and establish a role for oligodendroglia-neuroinflammatory response in ethanol seeking. Taken together, enhanced oligodendroglia-neuroinflammatory response during abstinence may contribute to brain trauma in chronic alcohol drinking subjects and be a risk factor for enhanced propensity for alcohol relapse. PMID:27542327

The NOURISHED randomised controlled trial comparing mentalisation-based treatment for eating disorders (MBT-ED) with specialist supportive clinical management (SSCM-ED) for patients with eating disorders and symptoms of borderline personality disorder.

PubMed

Robinson, Paul; Hellier, Jennifer; Barrett, Barbara; Barzdaitiene, Daiva; Bateman, Anthony; Bogaardt, Alexandra; Clare, Ajay; Somers, Nadia; O'Callaghan, Aine; Goldsmith, Kimberley; Kern, Nikola; Schmidt, Ulrike; Morando, Sara; Ouellet-Courtois, Catherine; Roberts, Alice; Skårderud, Finn; Fonagy, Peter

2016-11-17

In this multi-centre randomized controlled trial (RCT) we compared modified mentalisation-based treatment (MBT-ED) to specialist supportive clinical management (SSCM-ED) in patients with eating disorders (EDs) and borderline personality disorder symptoms (BPD). This group of patients presents complex challenges to clinical services, and a treatment which addresses their multiple problems has the potential to improve outcome. MBT has been shown to be effective in improving outcome in patients with BPD, but its use has not been reported in ED. Sixty-eight eligible participants were randomised to MBT-ED or SSCM-ED. The primary outcome measure was the global score on the Eating Disorder Examination. Secondary outcomes included measures of BPD symptoms (the Zanarini Rating Scale for Borderline Personality Disorder), general psychiatric state, quality of life and service utilisation. Participants were assessed at baseline and at 6, 12 and 18 months after randomisation. Analysis was performed using linear mixed models. Only 15 participants (22 %) completed the 18 month follow-up. Early drop-out occurred significantly more in the SSCM-ED group. Drop-out did not vary with treatment model later in therapy and was sometimes attributed to participants moving away. There was higher drop--out amongst smokers and those with higher neuroticism scores. 47.1 % of participants in the MBT-ED arm and 37.1 % in the SSCM-ED arm attended at least 50 % of therapy sessions offered. Amongst those remaining in the trial, at 12 and 18 months MBT-ED was associated with a greater reduction in Shape Concern and Weight Concern in the Eating Disorder Examination compared to SSCM-ED. At 6, 12 and 18 months there was a decline of ED and BPD symptoms in both groups combined. Ten participants were reported as having had adverse events during the trial, mostly self-harm, and there was one death, attributed as 'unexplained' by the coroner. The high drop-out rate made interpretation of the results difficult. Greater involvement of research staff in clinical management might have improved compliance with both therapy and research assessment. MBT-ED may have had an impact on core body image psychopathology. Current Controlled Trials: ISRCTN51304415 . Registered on 19 April 2011.

Emergency department imaging: are weather and calendar factors associated with imaging volume?

PubMed

Burns, K; Chernyak, V; Scheinfeld, M H

2016-12-01

To identify weather and calendar factors that would enable prediction of daily emergency department (ED) imaging volume to aid appropriate scheduling of imaging resources for efficient ED function. Daily ED triage and imaging volumes for radiography, computed tomography (CT), and ultrasound were obtained from hospital databases for the period between January 2011 and December 2013 at a large tertiary urban hospital with a Level II trauma centre. These data were tabulated alongside daily weather conditions (temperature, wind and precipitation), day of week, season, and holidays. Multivariate analysis was performed. Pearson correlations were used to measure the association between number of imaging studies performed and ED triage volume. For every additional 50 triaged patients, the odds of having high (imaging volume ≥90th percentile) radiography, CT, and ultrasound volume increased by 4.3 times (p<0.001), 1.5 times (p=0.02), and 1.4 times (p=0.02), respectively. Tuesday was an independent predictor of high radiography volume (odds ratio=2.8) and Monday was an independent predictor of high CT volume (odds ratio=3.0). Weekday status was an independent factor increasing the odds of a high US volume compared to Saturday (odds ratios ranging from 5.6-9.8). Weather factors and other calendar variables were not independent predictors of high imaging volume. Using Pearson correlations, ED triage volume correlated with number of radiographs, CT, and ultrasound examinations with r=0.73, 0.37, and 0.41, respectively (p<0.0001). As ED triage volume was found to be the only factor associated with imaging volume for all techniques, analysis of predictors of ED triage volumes at a particular healthcare facility would be useful to determine imaging needs. Although calendar and weather factors were found to be minor or non-significant independent predictors of ED imaging utilisation, these may be important in influencing the actual number of ED triages. Copyright © 2016 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

A generic method for evaluating crowding in the emergency department.

PubMed

Eiset, Andreas Halgreen; Erlandsen, Mogens; Møllekær, Anders Brøns; Mackenhauer, Julie; Kirkegaard, Hans

2016-06-14

Crowding in the emergency department (ED) has been studied intensively using complicated non-generic methods that may prove difficult to implement in a clinical setting. This study sought to develop a generic method to describe and analyse crowding from measurements readily available in the ED and to test the developed method empirically in a clinical setting. We conceptualised a model with ED patient flow divided into separate queues identified by timestamps for predetermined events. With temporal resolution of 30 min, queue lengths were computed as Q(t + 1) = Q(t) + A(t) - D(t), with A(t) = number of arrivals, D(t) = number of departures and t = time interval. Maximum queue lengths for each shift of each day were found and risks of crowding computed. All tests were performed using non-parametric methods. The method was applied in the ED of Aarhus University Hospital, Denmark utilising an open cohort design with prospectively collected data from a one-year observation period. By employing the timestamps already assigned to the patients while in the ED, a generic queuing model can be computed from which crowding can be described and analysed in detail. Depending on availability of data, the model can be extended to include several queues increasing the level of information. When applying the method empirically, 41,693 patients were included. The studied ED had a high risk of bed occupancy rising above 100 % during day and evening shift, especially on weekdays. Further, a 'carry over' effect was shown between shifts and days. The presented method offers an easy and generic way to get detailed insight into the dynamics of crowding in an ED.

Hiding vegetables to reduce energy density: an effective strategy to increase children's vegetable intake and reduce energy intake123

PubMed Central

Spill, Maureen K; Birch, Leann L; Roe, Liane S

2011-01-01

Background: Strategies are needed to increase children's intake of a variety of vegetables, including vegetables that are not well liked. Objective: We investigated whether incorporating puréed vegetables into entrées to reduce the energy density (ED; in kcal/g) affected vegetable and energy intake over 1 d in preschool children. Design: In this crossover study, 3- to 5-y-old children (n = 40) were served all meals and snacks 1 d/wk for 3 wk. Across conditions, entrées at breakfast, lunch, dinner, and evening snack were reduced in ED by increasing the proportion of puréed vegetables. The conditions were 100% ED (standard), 85% ED (tripled vegetable content), and 75% ED (quadrupled vegetable content). Entrées were served with unmanipulated side dishes and snacks, and children were instructed to eat as much as they liked. Results: The daily vegetable intake increased significantly by 52 g (50%) in the 85% ED condition and by 73 g (73%) in the 75% ED condition compared with that in the standard condition (both P < 0.0001). The consumption of more vegetables in entrées did not affect the consumption of the vegetable side dishes. Children ate similar weights of food across conditions; thus, the daily energy intake decreased by 142 kcal (12%) from the 100% to 75% ED conditions (P < 0.05). Children rated their liking of manipulated foods similarly across ED amounts. Conclusion: The incorporation of substantial amounts of puréed vegetables to reduce the ED of foods is an effective strategy to increase the daily vegetable intake and decrease the energy intake in young children. This trial was registered at clinicaltrials.gov as NCT01252433. PMID:21775554

Hiding vegetables to reduce energy density: an effective strategy to increase children's vegetable intake and reduce energy intake.

PubMed

Spill, Maureen K; Birch, Leann L; Roe, Liane S; Rolls, Barbara J

2011-09-01

Strategies are needed to increase children's intake of a variety of vegetables, including vegetables that are not well liked. We investigated whether incorporating puréed vegetables into entrées to reduce the energy density (ED; in kcal/g) affected vegetable and energy intake over 1 d in preschool children. In this crossover study, 3- to 5-y-old children (n = 40) were served all meals and snacks 1 d/wk for 3 wk. Across conditions, entrées at breakfast, lunch, dinner, and evening snack were reduced in ED by increasing the proportion of puréed vegetables. The conditions were 100% ED (standard), 85% ED (tripled vegetable content), and 75% ED (quadrupled vegetable content). Entrées were served with unmanipulated side dishes and snacks, and children were instructed to eat as much as they liked. The daily vegetable intake increased significantly by 52 g (50%) in the 85% ED condition and by 73 g (73%) in the 75% ED condition compared with that in the standard condition (both P < 0.0001). The consumption of more vegetables in entrées did not affect the consumption of the vegetable side dishes. Children ate similar weights of food across conditions; thus, the daily energy intake decreased by 142 kcal (12%) from the 100% to 75% ED conditions (P < 0.05). Children rated their liking of manipulated foods similarly across ED amounts. The incorporation of substantial amounts of puréed vegetables to reduce the ED of foods is an effective strategy to increase the daily vegetable intake and decrease the energy intake in young children. This trial was registered at clinicaltrials.gov as NCT01252433.

Health Care Utilisation by Bullying Victims: A Cross-Sectional Study of A 9-Year-Old Cohort in Ireland

PubMed Central

Taut, Cristina; Nixon, Elizabeth; Williams, James; O’Dowd, Thomas; Reulbach, Udo

2018-01-01

Children frequently refrain from disclosing being bullied. Early identification of bullying by healthcare professionals in children may prevent adverse health consequences. The aim of our study was to determine whether Health Care Utilisation (HCU) is higher in 9-year-olds who report being bullied and factors influencing type of HCU. The study consists of cross-sectional surveys of Child Cohort of Irish National Longitudinal Study of Children (Wave 1), 8,568 9-year-olds, and their carers. Being bullied was assessed by a self-reported questionnaire completed by children at home. HCU outcomes consisted of the following: visits to GP, Mental Health Practitioner (MHP), Emergency Department (ED), and nights in hospital by parent interview. Bivariate logistic regression and gender-stratified Poisson models were used to determine association. Victimisation by bullying independently increased visits to GP (OR 1.13, 95% confidence interval (CI): 1.03 to 1.25; p = 0.02), MHP (OR 1.31, 95% CI: 1.05 to 1.63; p = 0.02), though not ED visits (OR 0.99, 95% CI: 0.87 to 1.13; p = 0.8) or nights in hospital (OR 1.07 95% CI: 0.97 to 1.18; p = 0.2), adjusting for underlying chronic condition(s) and socio-demographic confounders. Victimised girls made higher GP visits (RR 1.14, 95% CI: 1.06 to 1.23; p < 0.001) and spent more nights in hospital (RR 1.10, 95% CI: 1.04 to 1.15; p < 0.001). Victimised boys were more likely to contact MHPs (RR 1.21, 95% CI: 1.02 to 1.44; p = 0.03). 9-year-old bullied subjects were more likely to utilise primary care services than non-bullied 9-year-olds. Different HCU patterns were observed according to gender and gender differences in the presentation of victimisation. Our findings may lead to the development of clinical practice guidelines for early detection and appropriate management of bullied children. PMID:29495335

Health Care Utilisation by Bullying Victims: A Cross-Sectional Study of A 9-Year-Old Cohort in Ireland.

PubMed

Hayes, Catherine; Kelly, Dervla; Taut, Cristina; Nixon, Elizabeth; Zgaga, Lina; Williams, James; O'Dowd, Thomas; Reulbach, Udo

2018-02-25

Children frequently refrain from disclosing being bullied. Early identification of bullying by healthcare professionals in children may prevent adverse health consequences. The aim of our study was to determine whether Health Care Utilisation (HCU) is higher in 9-year-olds who report being bullied and factors influencing type of HCU. The study consists of cross-sectional surveys of Child Cohort of Irish National Longitudinal Study of Children (Wave 1), 8,568 9-year-olds, and their carers. Being bullied was assessed by a self-reported questionnaire completed by children at home. HCU outcomes consisted of the following: visits to GP, Mental Health Practitioner (MHP), Emergency Department (ED), and nights in hospital by parent interview. Bivariate logistic regression and gender-stratified Poisson models were used to determine association. Victimisation by bullying independently increased visits to GP (OR 1.13, 95% confidence interval (CI): 1.03 to 1.25; p = 0.02), MHP (OR 1.31, 95% CI: 1.05 to 1.63; p = 0.02), though not ED visits (OR 0.99, 95% CI: 0.87 to 1.13; p = 0.8) or nights in hospital (OR 1.07 95% CI: 0.97 to 1.18; p = 0.2), adjusting for underlying chronic condition(s) and socio-demographic confounders. Victimised girls made higher GP visits (RR 1.14, 95% CI: 1.06 to 1.23; p < 0.001) and spent more nights in hospital (RR 1.10, 95% CI: 1.04 to 1.15; p < 0.001). Victimised boys were more likely to contact MHPs (RR 1.21, 95% CI: 1.02 to 1.44; p = 0.03). 9-year-old bullied subjects were more likely to utilise primary care services than non-bullied 9-year-olds. Different HCU patterns were observed according to gender and gender differences in the presentation of victimisation. Our findings may lead to the development of clinical practice guidelines for early detection and appropriate management of bullied children.

A randomised controlled pilot trial evaluating feasibility and acceptability of a computer-based tool to identify and reduce harmful and hazardous drinking among adolescents with alcohol-related presentations in Canadian pediatric emergency departments.

PubMed

Newton, Amanda S; Dow, Nadia; Dong, Kathryn; Fitzpatrick, Eleanor; Cameron Wild, T; Johnson, David W; Ali, Samina; Colman, Ian; Rosychuk, Rhonda J

2017-08-11

This study piloted procedures and obtained data on intervention acceptability to determine the feasibility of a definitive randomised controlled trial (RCT) of the effectiveness of a computer-based brief intervention in the emergency department (ED). Two-arm, multi-site, pilot RCT. Adolescents aged 12-17 years presenting to three Canadian pediatric EDs from July 2010 to January 2013 for an alcohol-related complaint. Standard medical care plus computer-based screening and personalised assessment feedback (experimental group) or standard care plus computer-based sham (control group). ED and research staff, and adolescents were blinded to allocation. Main: change in alcohol consumption from baseline to 1- and 3 months post-intervention. Secondary: recruitment and retention rates, intervention acceptability and feasibility, perception of group allocation among ED and research staff, and change in health and social services utilisation. Of the 340 adolescents screened, 117 adolescents were eligible and 44 participated in the study (37.6% recruitment rate). Adolescents allocated to the intervention found it easy, quick and informative, but were divided on the credibility of the feedback provided (agreed it was credible: 44.4%, disagreed: 16.7%, unsure: 16.7%, no response: 22.2%). We found no evidence of a statistically significant relationship between which interventions adolescents were allocated to and which interventions staff thought they received. Alcohol consumption, and health and social services data were largely incomplete due to modest study retention rates of 47.7% and 40.9% at 1- and 3 months post-intervention, respectively. A computer-based intervention was acceptable to adolescents and delivery was feasible in the ED in terms of time to use and ease of use. However, adjustments are needed to the intervention to improve its credibility. A definitive RCT will be feasible if protocol adjustments are made to improve recruitment and retention rates; and increase the number of study sites and research staff. clinicaltrials.gov NCT01146665. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Telephone-based low intensity therapy after crisis presentations to the emergency department is associated with improved outcomes.

PubMed

Bidargaddi, Niranjan; Bastiampillai, Tarun; Allison, Stephen; Jones, Gabrielle M; Furber, Gareth; Battersby, Malcolm; Richards, David

2015-10-01

In Australia there is an overwhelming need to provide effective treatment to patients presenting to the Emergency Department (ED) in mental health crisis. We adapted Improving Access to Psychological Therapies service model (IAPT) from the National Health Service (NHS) method for the large scale delivery of psychological therapies throughout the United Kingdom to an Australian ED setting. This telephone-based low intensity therapy was provided to people presenting in crisis to the EDs with combinations of anxiety, depression, substance use, and suicidal thinking. This uncontrolled study utilised session-by-session, before-and-after measures of anxiety and depression via Patient Health Questionnaire (PHQ-9) and Generalised Anxiety Disorder-7 (GAD-7). Of 347 eligible post-crisis ED referred patients, 291 (83.9%) engaged with the IAPT team. Most patients (65%) had attended the ED previously on an average of 3.9 (SD = 6.0) occasions. Two hundred and forty one patients received an average of 4.1 (SD = 2.3) contacts of low-intensity psychological therapies including 1.2 (SD = 1.7) community outreach visits between 20th Oct 2011 and 31st Dec 2012. Treated patients reported clinically significant improvements in anxiety, depression and suicidal ideation. Uncontrolled effect sizes were moderate for anxiety (0.6) and depression (0.6). The Australian ED IAPT program demonstrated that the UK IAPT program could be adapted for emergency mental health patients and be associated with similar clinical benefits as the original program. The Flinders Medical Centre IAPT program received Emergency Department project funding from the Australian Commonwealth Government through the Council of Australian Governments (COAG) and the South Australian Government initiative, Every Patient Every Service (EPES). © The Author(s) 2015.

Price and utilisation differences for statins between four countries.

PubMed

Thai, Loc Phuoc; Vitry, Agnes Isabelle; Moss, John Robert

2018-02-01

Australia, England, France and New Zealand use different policies to regulate their medicines market, which can impact on utilisation and price. To compare the prices and utilisation of statins in Australia, England, France and New Zealand from 2011 to 2013. Utilisation of statins in the four countries was compared using Defined Daily Doses (DDD) per 1000 inhabitants per year. Pairwise Laspeyres and Paasche index comparisons were conducted comparing the price and utilisation of statins. The results showed that the price of statins in New Zealand was the cheapest. The price of statins in Australia was most expensive in 2011 and 2012 but France was more expensive in 2013. There were large differences between the Laspeyres index and Paasche index when comparing the price and utilisation of England with Australia and France. The policies that regulate the New Zealand and England medicines markets were more effective in reducing the price of expensive statins. The relative utilisation of cheaper statins was greatest in England and had a large effect on the differences between the two index results. The pricing policies in Australia have been only partly effective in reducing the price of statins compared to other countries.

Using Lean Management to Reduce Emergency Department Length of Stay for Medicine Admissions.

PubMed

Allaudeen, Nazima; Vashi, Anita; Breckenridge, Julia S; Haji-Sheikhi, Farnoosh; Wagner, Sarah; Posley, Keith A; Asch, Steven M

The practice of boarding admitted patients in the emergency department (ED) carries negative operational, clinical, and patient satisfaction consequences. Lean tools have been used to improve ED workflow. Interventions focused on reducing ED length of stay (LOS) for admitted patients are less explored. To evaluate a Lean-based initiative to reduce ED LOS for medicine admissions. Prospective quality improvement initiative performed at a single university-affiliated Department of Veterans Affairs (VA) medical center from February 2013 to February 2016. We performed a Lean-based multidisciplinary initiative beginning with a rapid process improvement workshop to evaluate current processes, identify root causes of delays, and develop countermeasures. Frontline staff developed standard work for each phase of the ED stay. Units developed a daily management system to reinforce, evaluate, and refine standard work. The primary outcome was the change in ED LOS for medicine admissions pre- and postintervention. ED LOS at the intervention site was compared with other similar VA facilities as controls over the same time period using a difference-in-differences approach. ED LOS for medicine admissions reduced 26.4%, from 8.7 to 6.4 hours. Difference-in-differences analysis showed that ED LOS for combined medicine and surgical admissions decreased from 6.7 to 6.0 hours (-0.7 hours, P = .003) at the intervention site compared with no change (5.6 hours, P = .2) at the control sites. We utilized Lean management to significantly reduce ED LOS for medicine admissions. Specifically, the development and management of standard work were key to sustaining these results.

The role of charity care and primary care physician assignment on ED use in homeless patients.

PubMed

Wang, Hao; Nejtek, Vicki A; Zieger, Dawn; Robinson, Richard D; Schrader, Chet D; Phariss, Chase; Ku, Jocelyn; Zenarosa, Nestor R

2015-08-01

Homeless patients are a vulnerable population with a higher incidence of using the emergency department (ED) for noncrisis care. Multiple charity programs target their outreach toward improving the health of homeless patients, but few data are available on the effectiveness of reducing ED recidivism. The aim of this study is to determine whether inappropriate ED use for nonemergency care may be reduced by providing charity insurance and assigning homeless patients to a primary care physician (PCP) in an outpatient clinic setting. A retrospective medical records review of homeless patients presenting to the ED and receiving treatment between July 2013 and June 2014 was completed. Appropriate vs inappropriate use of the ED was determined using the New York University ED Algorithm. The association between patients with charity care coverage, PCP assignment status, and appropriate vs inappropriate ED use was analyzed and compared. Following New York University ED Algorithm standards, 76% of all ED visits were deemed inappropriate with approximately 77% of homeless patients receiving charity care and 74% of patients with no insurance seeking noncrisis health care in the ED (P=.112). About 50% of inappropriate ED visits and 43.84% of appropriate ED visits occurred in patients with a PCP assignment (P=.019). Both charity care homeless patients and those without insurance coverage tend to use the ED for noncrisis care resulting in high rates of inappropriate ED use. Simply providing charity care and/or PCP assignment does not seem to sufficiently reduce inappropriate ED use in homeless patients. Copyright © 2015 The Authors. Published by Elsevier Inc. All rights reserved.

Assessing childhood maltreatment and mental health correlates of disordered eating profiles in a nationally representative sample of English females.

PubMed

Armour, Cherie; Műllerová, Jana; Fletcher, Shelley; Lagdon, Susan; Burns, Carol Rhonda; Robinson, Martin; Robinson, Jake

2016-03-01

Previous research suggests that childhood maltreatment is associated with the onset of eating disorders (ED). In turn, EDs are associated with alternative psychopathologies such as depression and posttraumatic stress disorder (PTSD), and with suicidality. Moreover, it has been reported that various ED profiles may exist. The aim of the current study was to examine the profiles of disordered eating and the associations of these with childhood maltreatment and with mental health psychopathology. The current study utilised a representative sample of English females (N = 4206) and assessed for the presence of disordered eating profiles using Latent Class Analysis. Multinomial logistic regression was implemented to examine the associations of childhood sexual and physical abuse with the disordered eating profiles and the associations of these with PTSD, depression and suicidality. Results supported those of previous findings in that we found five latent classes of which three were regarded as disordered eating classes. Significant relationships were found between these and measures of childhood trauma and mental health outcomes. Childhood sexual and physical abuse increased the likelihood of membership in disordered eating classes and these in turn increased the likelihood of adverse mental health and suicidal outcomes.

ED-WAVE tool design approach: Case of a textile wastewater treatment plant in Blantyre, Malawi

NASA Astrophysics Data System (ADS)

Chipofya, V.; Kraslawski, A.; Avramenko, Y.

The ED-WAVE tool is a PC based package for imparting training on wastewater treatment technologies. The system consists of four modules viz. Reference Library, Process Builder, Case Study Manager, and Treatment Adviser. The principles of case-based design and case-based reasoning as applied in the ED-WAVE tool are utilised in this paper to evaluate the design approach of the wastewater treatment plant at Mapeto David Whitehead & Sons (MDW&S) textile and garments factory, Blantyre, Malawi. The case being compared with MDW&S in the ED-WAVE tool is Textile Case 4 in Sri Lanka (2003). Equalisation, coagulation and rotating biological contactors is the sequencing of treatment units at Textile Case 4 in Sri Lanka. Screening, oxidation ditches and sedimentation is the sequencing of treatment units at MDW&S textile and garments factory. The study suggests that aerobic biological treatment is necessary in the treatment of wastewater from a textile and garments factory. MDW&S incorporates a sedimentation process which is necessary for the removal of settleable matter before the effluent is discharged to the municipal wastewater treatment plant. The study confirmed the practical use of the ED-WAVE tool in the design of wastewater treatment systems, where after encountering a new situation; already collected decision scenarios (cases) are invoked and modified in order to arrive at a particular design alternative. What is necessary, however, is to appropriately modify the case arrived at through the Case Study Manager in order to come up with a design appropriate to the local situation taking into account technical, socio-economic and environmental aspects.

Influence of an elemental diet on 5-fluorouracil-induced morphological changes in the mouse salivary gland and colon.

PubMed

Kawashima, Rei; Fujimaki, Mio; Ikenoue, Yuka; Danjo, Keiko; Koizumi, Wasaburo; Ichikawa, Takafumi

2016-04-01

The elemental diet (ED) Elental® reportedly reduces adverse reactions to chemotherapy in digestive system cancer patients; however, the mechanism is unclear. Therefore, we verified the protective effect of ED against gastrointestinal disorders induced by the antineoplastic drug 5-fluorouracil (5-FU). After 5 days of tail vein injections of 40 mg/kg/day 5-FU in female BALB/c mice, the mice were given oral ED (ED group) or dextrin with the same number of calories (control group). We measured the weight of salivary glands and the PAS-positive area of colonic mucosa and verified the antitumor effect in tumor-bearing mice given 5-FU and ED. Although body weight decreased after 5-FU treatment, ED group mice weighed more than control group mice. Additionally, although control mice developed diarrhea after 5-FU treatment, the ED group showed only loose stools. The control group saliva volume was approximately one sixth of the vehicle group volume after 5-FU treatment; this was improved to approximately half in the ED group. The area ratio of PAS-positive cells in the colonic mucosa was reduced by 5-FU treatment, with the ratio being higher in the ED group than that in the control group. Similar tumor growth suppression was observed in the 5-FU and ED groups. ED alleviated adverse reactions to 5-FU without affecting antitumor activity. Protection against 5-FU-induced weight loss was potentially due to both improved nutritional support with combined ingredients and prevention of diarrhea that is associated with reduced colonic goblet cells and decreased saliva production from reduced salivary gland contraction.

Protecting the Moon for research: ILEWG report

NASA Astrophysics Data System (ADS)

Foing, Bernard H.

We give a report on recommendations with emphasis on environment protection, and since last COSPAR from ILEWG International conferences Exploration and Utilisation of the Moon on held at Cape Canaveral in 2008 (ICEUM10), and in Beijing in May 2010 with IAF (GLUC -ICEUM11). We discuss the different rationale for Moon exploration, as debated at ILEWG. ILEWG Science task group has listed priorities for scientific investigations: clues on the formation and evolution of rocky planets, accretion and bombardment in the inner solar system, comparative planetology processes (tectonic, volcanic, impact cratering, volatile delivery), records astrobiology, survival of organics; past, present and future life; sciences from a biology lunar laboratory. We discuss how to preserve Moon research potential in these areas while operating with instruments, landers, rover during a cooperative robotic village, and during the transition form lunar human outpost to permanent sustainable human base. We discuss how Moon-Mars Exploration can inspire solutions to global Earth sustained development with the trade-off of In-Situ Utilisation of resources; Establishment of permanent robotic infrastructures, Environmental and planetary protection aspects and lessons for Mars; Life sciences laboratories, and support to human exploration. Co-authors: ILEWG Task Groups on Science, Technology and Human Lunar Bases ILEWG Reference documents: http://sci.esa.int/ilewg -10th ILEWG Conference on Exploration and Utilisation of the Moon, NASA Lunar Ex-ploration Analysis Group-PSace Resources Roundtable, Cape Canaveral October 2008, pro-gramme online at http://sci.esa.int/ilewg/ -9th ILEWG Conference on Exploration and Utilisation of the Moon, ICEUM9 Sorrento 2007, programme online at http://sci.esa.int/ilewg/ -8th ILEWG Conference on Exploration and Utilisation of the Moon, Beijing July 2006, programme online at http://sci.esa.int/ilewg/ -The Moon and Near Earth Objects (P. Ehrenfreund , B.H. Foing, A. Cellino Editors), Ad-vances in Space Research, Volume 37, Issue 1, pp 1-192, 2006 -7th ILEWG Conference on Exploration and Utilisation of the Moon, Toronto Sept 2005, Programme and Proceedings on line at www.ilewg.org, R. Richards et al Editors -6th ILEWG Conference on Exploration and Utilisation of the Moon, Udaipur Nov. 2004, Proceedings ( N. Bhandari Editor), Journal Earth System Science, India, 114, No6, Dec 2005, pp. 573-841 -5th ILEWG Conference on Exploration and Utilisation of the Moon, Hawaii Nov 2003, Pro-ceedings ILC2005/ICEUM5 (S.M. Durst et al Editors), Vol 108, 1-576 pp, Science and Tech-nology Series, American Astronautical Society, 2004 -'The next steps in exploring deep space -A cosmic study by the IAA', W. Huntress, D. Stetson, R. Farquhar, J. Zimmerman, B. Clark, W. O'Neil, R. Bourke and B. Foing, Acta Astronautica, Vol 58, Issues 6-7, March-April 2006, p302-377 -IAA/ESA workshop on "Next Steps in Exploring Deep Space", ESTEC 22-23 sept. 2003 (B.H. Foing W. Huntress, conveners) Lunar Exploration, Planetary and Space Science, Vol 50, issue 14-15, Dec 2002 (B.H. Foing al) -ESLAB36 symposium on "Earth-like Planets and Moons", 2002, ESA-SP514, pp. 1-356, (B.H.Foing B. Battrick, editors) -'Lunar Exploration 2000', (B.H. Foing, D. Heather, Editors), Adv. Space Research Vol 30, Nr 8, 2002 -'Earth-Moon Relationships', Proceedings of the Conference held in Padova, Italy at the Ac-cademia Galileiana di Scienze Lettere ed Arti, Nov. 2000, (C. Barbieri and F. Rampazzi, Editors), in Earth, Moon , Planets Vol. 85-86, Nos 1-3, pp 1-575, 2001 -4th International Conference on Exploration and Utilisation of the Moon, ESTEC, 2000, ESA SP-462 (B.H. Foing M. Perry, editors) -Investing in Space: The Challenge for Europe. Long-Term Space Policy Committee, Second Report, May 1999. ESA-SP-2000 -2nd International Lunar Workshop, held at Kyoto in October 1996, Proceedings, H. Mizutani, editor, Japan Space Forum Publisher, 1997 International Lunar Workshop, 1994 May 31-June 3, Beatenberg, Switzerland. Proceedings. Ed. Balsiger, H. et al. European Space Agency, 1994. ESA-SP-1170 -Astronomy and Space Science from the Moon', Proceedings of COSPAR/IAF session at World Congress, Washington, (B.H. Foing et al editors), Advances in Space Research, Volume 14, Issue 6, 1994 -Mission to the Moon, Europe's Priorities for Scientific Exploration and Utilisation of the Moon', R.M. Bonnet et al, European Space Agency, ESA SP-1150, June 1992

Screening and brief interventions for hazardous alcohol use in accident and emergency departments: a randomised controlled trial protocol

PubMed Central

Coulton, Simon; Perryman, Katherine; Bland, Martin; Cassidy, Paul; Crawford, Mike; Deluca, Paolo; Drummond, Colin; Gilvarry, Eilish; Godfrey, Christine; Heather, Nick; Kaner, Eileen; Myles, Judy; Newbury-Birch, Dorothy; Oyefeso, Adenekan; Parrott, Steve; Phillips, Tom; Shenker, Don; Shepherd, Jonathan

2009-01-01

Background There is a wealth of evidence regarding the detrimental impact of excessive alcohol consumption on the physical, psychological and social health of the population. There also exists a substantial evidence base for the efficacy of brief interventions aimed at reducing alcohol consumption across a range of healthcare settings. Primary research conducted in emergency departments has reinforced the current evidence regarding the potential effectiveness and cost-effectiveness. Within this body of evidence there is marked variation in the intensity of brief intervention delivered, from very minimal interventions to more intensive behavioural or lifestyle counselling approaches. Further the majority of primary research has been conducted in single centre and there is little evidence of the wider issues of generalisability and implementation of brief interventions across emergency departments. Methods/design The study design is a prospective pragmatic factorial cluster randomised controlled trial. Individual Emergency Departments (ED) (n = 9) are randomised with equal probability to a combination of screening tool (M-SASQ vs FAST vs SIPS-PAT) and an intervention (Minimal intervention vs Brief advice vs Brief lifestyle counselling). The primary hypothesis is that brief lifestyle counselling delivered by an Alcohol Health Worker (AHW) is more effective than Brief Advice or a minimal intervention delivered by ED staff. Secondary hypotheses address whether short screening instruments are more acceptable and as efficient as longer screening instruments and the cost-effectiveness of screening and brief interventions in ED. Individual participants will be followed up at 6 and 12 months after consent. The primary outcome measure is performance using a gold-standard screening test (AUDIT). Secondary outcomes include; quantity and frequency of alcohol consumed, alcohol-related problems, motivation to change, health related quality of life and service utilisation. Discussion This paper presents a protocol for a large multi-centre pragmatic factorial cluster randomised trial to evaluate the effectiveness and cost-effectiveness of screening and brief interventions for hazardous alcohol users attending emergency departments. Trial Registration ISRCTN 93681536 PMID:19575791

At the crossroads of violence and aggression in the emergency department: perspectives of Australian emergency nurses.

PubMed

Morphet, Julia; Griffiths, Debra; Plummer, Virginia; Innes, Kelli; Fairhall, Robyn; Beattie, Jill

2014-05-01

Violence is widespread in Australian emergency departments (ED) and most prevalent at triage. The aim of the present study was to identify the causes and common acts of violence in the ED perceived by three distinct groups of nurses. The Delphi technique is a method for consensus-building. In the present study a three-phase Delphi technique was used to identify and compare what nurse unit managers, triage and non-triage nurses believe is the prevalence and nature of violence and aggression in the ED. Long waiting times, drugs and alcohol all contributed to ED violence. Triage nurses also indicated that ED staff, including security staff and the triage nurses themselves, can contribute to violence. Improved communication at triage and support from management to follow up episodes of violence were suggested as strategies to reduce violence in the ED CONCLUSION :There is no single solution for the management of ED violence. Needs and strategies vary because people in the waiting room have differing needs to those inside the ED. Participants agreed that the introduction and enforcement of a zero tolerance policy, including support from managers to follow up reports of violence, would reduce violence and improve safety for staff. Education of the public regarding ED processes, and the ED staff in relation to patient needs, may contribute to reducing ED violence. What is known about the topic? Violence is prevalent in Australian healthcare, and particularly in emergency departments (ED). Several organisations and government bodies have made recommendations aimed at reducing the prevalence of violence in healthcare but, to date, these have not been implemented consistently, and violence continues. What does this paper add? This study examined ED violence from the perspective of triage nurses, nurse unit managers and non-triage nurses, and revealed that violence is experienced differently by emergency nurses, depending on their area of work. Triage nurses have identified that they themselves contribute to violence in the ED by their style of communication. Nurse unit managers and non-triage nurses perceive that violence is the result of drugs and alcohol, as well as long waiting times. What are the implications for practitioners? Strategies to reduce violence must address the needs of patients and staff both within the ED and in the waiting room. Such strategies should be multifaceted and include education of ED consumers and staff, as well as support from management to respond to reports of violence.

Use of poisons information resources and satisfaction with electronic products by Victorian emergency department staff.

PubMed

Luke, Stephen; Fountain, John S; Reith, David M; Braitberg, George; Cruickshank, Jaycen

2014-10-01

ED staff use a range of poisons information resources of varying type and quality. The present study aims to identify those resources utilised in the state of Victoria, Australia, and assess opinion of the most used electronic products. A previously validated self-administered survey was conducted in 15 EDs, with 10 questionnaires sent to each. The survey was then repeated following the provision of a 4-month period of access to Toxinz™, an Internet poisons information product novel to the region. The study was conducted from December 2010 to August 2011. There were 117 (78%) and 48 (32%) responses received from the first and second surveys, respectively, a 55% overall response rate. No statistically significant differences in professional group, numbers of poisoned patients seen or resource type accessed were identified between studies. The electronic resource most used in the first survey was Poisindex® (48.68%) and Toxinz™ (64.1%) in the second. There were statistically significant (P < 0.01) improvements in satisfaction in 26 of 42 questions between surveys, and no decrements. Although the majority of responders possessed mobile devices, less than half used them for poisons information but would do so if a reputable product was available. The order of poisons information sources most utilised was: consultation with a colleague, in-house protocols and electronic resources. There was a significant difference in satisfaction with electronic poisons information resources and a movement away from existing sources when choice was provided. Interest in increased use of mobile solutions was identified. © 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

The Reduction in ED and Hospital Admissions in Medical Home Practices Is Specific to Primary Care-Sensitive Chronic Conditions.

PubMed

Green, Lee A; Chang, Hsiu-Ching; Markovitz, Amanda R; Paustian, Michael L

2018-04-01

To determine whether the Patient-Centered Medical Home (PCMH) transformation reduces hospital and ED utilization, and whether the effect is specific to chronic conditions targeted for management by the PCMH in our setting. All patients aged 18 years and older in 2,218 primary care practices participating in a statewide PCMH incentive program sponsored by Blue Cross Blue Shield of Michigan (BCBSM) in 2009-2012. Quantitative observational study, jointly modeling PCMH-targeted versus other hospital admissions and ED visits on PCMH score, patient, and practice characteristics in a hierarchical multivariate model using the generalized gamma distribution. Claims data and PCMH scores held by BCBSM. Both hospital and ED utilization were reduced proportionately to PCMH score. Hospital utilization was reduced by 13.9 percent for PCMH-targeted conditions versus only 3.8 percent for other conditions (p = .003), and ED utilization by 11.2 percent versus 3.7 percent (p = .010). Hospital PMPM cost was reduced by 17.2 percent for PCMH-targeted conditions versus only 3.1 percent for other conditions (p < .001), and ED PMPM cost by 9.4 percent versus 3.6 percent (p < .001). PCMH transformation reduces hospital and ED use, and the majority of the effect is specific to PCMH-targeted conditions. © Health Research and Educational Trust.

Electrodialytic removal of nitrate from pineapple juice: effect on selected physicochemical properties, amino acids, and aroma components of the juice.

PubMed

Ackarabanpojoue, Yuwadee; Chindapan, Nathamol; Yoovidhya, Tipaporn; Devahastin, Sakamon

2015-05-01

This study aimed at investigating the effect of nitrate removal from pineapple juice by electrodialysis (ED) on selected properties of the ED-treated juice. Single-strength pineapple juice with reduced pulp content was treated by ED to reduce the nitrate concentration to 15, 10, or 5 ppm. After ED, the removed pulp was added to the ED-treated juice and its properties, including electrical conductivity, acidity, pH, total soluble solids (TSS), color, amino acids, and selected aroma compounds, were determined and compared with those of the untreated juice. ED could reduce the nitrate content of 1 L of pineapple juice from an initial value of 50 ppm to less than 5 ppm within 30 min. A significant decrease in the electrical conductivity, acidity, pH, TSS, and yellowness, but a significant increase in the lightness, of the juice was observed upon ED. Concentrations of almost all amino acids of the ED-treated juice significantly decreased. The concentrations of 8 major compound contributors to the pineapple aroma also significantly decreased. Adding the pulp back to the ED-treated juice increased the amino acids concentrations; however, it led to a significant decrease in the concentrations of the aroma compounds. © 2015 Institute of Food Technologists®

Dedication increases productivity: an analysis of the implementation of a dedicated medical team in the emergency department.

PubMed

Ramos, Pedro; Paiva, José Artur

2017-12-01

In several European countries, emergency departments (EDs) now employ a dedicated team of full-time emergency medicine (EM) physicians, with a distinct leadership and bed-side emergency training, in all similar to other hospital departments. In Portugal, however, there are still two very different models for staffing EDs: a classic model, where EDs are mostly staffed with young inexperienced physicians from different medical departments who take turns in the ED in 12-h shifts and a dedicated model, recently implemented in some hospitals, where the ED is staffed by a team of doctors with specific medical competencies in emergency medicine that work full-time in the ED. Our study assesses the effect of an intervention in a large academic hospital ED in Portugal in 2002, and it is the first to test the hypothesis that implementing a dedicated team of doctors with EM expertise increases the productivity and reduces costs in the ED, maintaining the quality of care provided to patients. A pre-post design was used for comparing the change on the organisational model of delivering care in our medical ED. All emergency medical admissions were tracked in 2002 (classic model with 12-h shift in the ED) and 2005/2006 (dedicated team with full-time EM physicians), and productivity, costs with medical human resources and quality of care measures were compared. We found that medical productivity (number of patients treated per hour of medical work) increased dramatically after the creation of the dedicated team (X 2 KW = 31.135; N = 36; p < 0.001) and costs with ED medical work reduced both in regular hours and overtime. Moreover, hospitalisation rates decreased and the length of stay in the ED increased significantly after the creation of the dedicated team. Implementing a dedicated team of doctors increased the medical productivity and reduced costs in our ED. Our findings have straightforward implication for Portuguese policymakers aiming at reducing hospital costs while coping with increased ED demand.

Clinical- and cost-effectiveness of a nurse led self-management intervention to reduce emergency visits by people with epilepsy.

PubMed

Noble, Adam J; McCrone, Paul; Seed, Paul T; Goldstein, Laura H; Ridsdale, Leone

2014-01-01

People with chronic epilepsy (PWE) often make costly, and clinically unnecessary emergency department (ED) visits. Some do it frequently. No studies have examined interventions to reduce them. An intervention delivered by an epilepsy nurse specialist (ENS) might reduce visits. The rationale is it may optimize patients' self-management skills and knowledge of appropriate ED use. We examined such an intervention's clinical- and cost-effectiveness. Eighty-five adults with epilepsy were recruited from three London EDs with similar catchment populations. Forty-one PWE recruited from two EDs received treatment-as-usual (TAU) and formed the comparison group. The remaining 44 PWE were recruited from the ED of a hospital that had implemented a new ENS service for PWE attending ED. These participants formed the intervention group. They were offered 2 one-to-one sessions with an ENS, plus TAU. Participants completed questionnaires on health service use and psychosocial well-being at baseline, 6- and 12-month follow-up. Covariates were identified and adjustments made. Sixty-nine (81%) participants were retained at follow-up. No significant effect of the intervention on ED visits at 12 months or on other outcomes was found. However, due to less time as inpatients, the average service cost for intervention participants over follow-up was less than for TAU participants' (adjusted difference £558, 95% CI, -£2409, £648). Covariates most predictive of subsequent ED visits were patients' baseline feelings of stigmatization due to epilepsy and low confidence in managing epilepsy. The intervention did not lead to a reduction in ED use, but did not cost more, partly because those receiving the intervention had shorter hospital admissions. Our findings on long-term ED predictors clarifies what causes ED use, and suggests that future interventions might focus more on patients' perceptions of stigma and on their confidence in managing epilepsy. If addressed, ED visits might be reduced and efficiency-savings generated.

Use of the emergency department for less-urgent care among type 2 diabetics under a disease management program

PubMed Central

2009-01-01

Background This study analyzed the likelihood of less-urgent emergency department (ED) visits among type 2 diabetic patients receiving care under a diabetes disease management (DM) program offered by the Louisiana State University Health Care Services Division (LSU HCSD). Methods All ED and outpatient clinic visits made by 6,412 type 2 diabetic patients from 1999 to 2006 were extracted from the LSU HCSD Disease Management (DM) Evaluation Database. Patient ED visits were classified as either urgent or less-urgent, and the likelihood of a less-urgent ED visit was compared with outpatient clinic visits using the Generalized Estimating Equation methodology for binary response to time-dependent variables. Results Patients who adhered to regular clinic visit schedules dictated by the DM program were less likely to use the ED for less urgent care with odds ratio of 0.1585. Insured patients had 1.13 to 1.70 greater odds of a less-urgent ED visit than those who were uninsured. Patients with better-managed glycated hemoglobin (A1c or HbA1c) levels were 82 times less likely to use less-urgent ED visits. Furthermore, being older, Caucasian, or a longer participant in the DM program had a modestly lower likelihood of less-urgent ED visits. The patient's Charlson Comorbidity Index (CCI), gender, prior hospitalization, and the admitting facility showed no effect. Conclusion Patients adhering to the DM visit guidelines were less likely to use the ED for less-urgent problems. Maintaining normal A1c levels for their diabetes also has the positive impact to reduce less-urgent ED usages. It suggests that successful DM programs may reduce inappropriate ED use. In contrast to expectations, uninsured patients were less likely to use the ED for less-urgent care. Patients in the DM program with Medicaid coverage were 1.3 times more likely to seek care in the ED for non-emergencies while commercially insured patients were nearly 1.7 times more likely to do so. Further research to understand inappropriate ED use among insured patients is needed. We suggest providing visit reminders, a call centre, or case managers to reduce the likelihood of less-urgent ED visit use among DM patients. By reducing the likelihood of unnecessary ED visits, successful DM programs can improve patient care. PMID:19968871

Use of the emergency department for less-urgent care among type 2 diabetics under a disease management program.

PubMed

Chiou, Shang-Jyh; Campbell, Claudia; Horswell, Ronald; Myers, Leann; Culbertson, Richard

2009-12-07

This study analyzed the likelihood of less-urgent emergency department (ED) visits among type 2 diabetic patients receiving care under a diabetes disease management (DM) program offered by the Louisiana State University Health Care Services Division (LSU HCSD). All ED and outpatient clinic visits made by 6,412 type 2 diabetic patients from 1999 to 2006 were extracted from the LSU HCSD Disease Management (DM) Evaluation Database. Patient ED visits were classified as either urgent or less-urgent, and the likelihood of a less-urgent ED visit was compared with outpatient clinic visits using the Generalized Estimating Equation methodology for binary response to time-dependent variables. Patients who adhered to regular clinic visit schedules dictated by the DM program were less likely to use the ED for less urgent care with odds ratio of 0.1585. Insured patients had 1.13 to 1.70 greater odds of a less-urgent ED visit than those who were uninsured. Patients with better-managed glycated hemoglobin (A1c or HbA1c) levels were 82 times less likely to use less-urgent ED visits. Furthermore, being older, Caucasian, or a longer participant in the DM program had a modestly lower likelihood of less-urgent ED visits. The patient's Charlson Comorbidity Index (CCI), gender, prior hospitalization, and the admitting facility showed no effect. Patients adhering to the DM visit guidelines were less likely to use the ED for less-urgent problems. Maintaining normal A1c levels for their diabetes also has the positive impact to reduce less-urgent ED usages. It suggests that successful DM programs may reduce inappropriate ED use. In contrast to expectations, uninsured patients were less likely to use the ED for less-urgent care. Patients in the DM program with Medicaid coverage were 1.3 times more likely to seek care in the ED for non-emergencies while commercially insured patients were nearly 1.7 times more likely to do so. Further research to understand inappropriate ED use among insured patients is needed. We suggest providing visit reminders, a call centre, or case managers to reduce the likelihood of less-urgent ED visit use among DM patients. By reducing the likelihood of unnecessary ED visits, successful DM programs can improve patient care.

Physical activity and exercise dependence during inpatient treatment of longstanding eating disorders: an exploratory study of excessive and non-excessive exercisers.

PubMed

Bratland-Sanda, Solfrid; Sundgot-Borgen, Jorunn; Rø, Øyvind; Rosenvinge, Jan H; Hoffart, Asle; Martinsen, Egil W

2010-04-01

To describe changes in physical activity (PA) and exercise dependence score during treatment of eating disorders (ED), and to explore correlations among changes in PA, exercise motivation, exercise dependence score and ED psychopathology in excessive and non-excessive exercisers. Thirty-eight adult females receiving inpatient treatment for anorexia nervosa, bulimia nervosa or ED not otherwise specified participated in this prospective study. Assessments included accelerometer assessed PA, Exercise Dependence Scale, Reasons for Exercise Inventory, ED Examination, and ED Inventory. Amount of PA was significantly reduced in non-excessive exercisers during treatment, in excessive exercisers there was a trend towards reduced amount of PA from admission to discharge. In excessive exercisers, reduced ED psychopathology was correlated with reduction in exercise dependence score and perceived importance of exercise to regulate negative affects, but not with importance of exercise for weight/appearance. These associations were not found in non-excessive exercisers. Excessive exercise is an important issue in longstanding ED, and the excessive exercising patients need help to develop alternative strategies to regulate negative affects.

Stoichiometric modelling of assimilatory and dissimilatory biomass utilisation in a microbial community

PubMed Central

Hunt, Kristopher A.; Jennings, Ryan deM.; Inskeep, William P.; Carlson, Ross P.

2017-01-01

Summary Assimilatory and dissimilatory utilisation of autotroph biomass by heterotrophs is a fundamental mechanism for the transfer of nutrients and energy across trophic levels. Metagenome data from a tractable, thermoacidophilic microbial community in Yellowstone National Park was used to build an in silico model to study heterotrophic utilisation of autotroph biomass using elementary flux mode analysis and flux balance analysis. Assimilatory and dissimilatory biomass utilisation was investigated using 29 forms of biomass-derived dissolved organic carbon (DOC) including individual monomer pools, individual macromolecular pools and aggregate biomass. The simulations identified ecologically competitive strategies for utilizing DOC under conditions of varying electron donor, electron acceptor or enzyme limitation. The simulated growth environment affected which form of DOC was the most competitive use of nutrients; for instance, oxygen limitation favoured utilisation of less reduced and fermentable DOC while carbon-limited environments favoured more reduced DOC. Additionally, metabolism was studied considering two encompassing metabolic strategies: simultaneous versus sequential use of DOC. Results of this study bound the transfer of nutrients and energy through microbial food webs, providing a quantitative foundation relevant to most microbial ecosystems. PMID:27387069

Primary care professionals providing non-urgent care in hospital emergency departments.

PubMed

Gonçalves-Bradley, Daniela; Khangura, Jaspreet K; Flodgren, Gerd; Perera, Rafael; Rowe, Brian H; Shepperd, Sasha

2018-02-13

In many countries emergency departments (EDs) are facing an increase in demand for services, long waits, and severe crowding. One response to mitigate overcrowding has been to provide primary care services alongside or within hospital EDs for patients with non-urgent problems. However, it is unknown how this impacts the quality of patient care and the utilisation of hospital resources, or if it is cost-effective. This is the first update of the original Cochrane Review published in 2012. To assess the effects of locating primary care professionals in hospital EDs to provide care for patients with non-urgent health problems, compared with care provided by regularly scheduled emergency physicians (EPs). We searched the Cochrane Central Register of Controlled Trials (the Cochrane Library; 2017, Issue 4), MEDLINE, Embase, CINAHL, PsycINFO, and King's Fund, from inception until 10 May 2017. We searched ClinicalTrials.gov and the WHO ICTRP for registered clinical trials, and screened reference lists of included papers and relevant systematic reviews. Randomised trials, non-randomised trials, controlled before-after studies, and interrupted time series studies that evaluated the effectiveness of introducing primary care professionals to hospital EDs attending to patients with non-urgent conditions, as compared to the care provided by regularly scheduled EPs.  DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We identified four trials (one randomised trial and three non-randomised trials), one of which is newly identified in this update, involving a total of 11,463 patients, 16 general practitioners (GPs), 9 emergency nurse practitioners (NPs), and 69 EPs. These studies evaluated the effects of introducing GPs or emergency NPs to provide care to patients with non-urgent problems in the ED, as compared to EPs for outcomes such as resource use. The studies were conducted in Ireland, the UK, and Australia, and had an overall high or unclear risk of bias. The outcomes investigated were similar across studies, and there was considerable variation in the triage system used, the level of expertise and experience of the medical practitioners, and type of hospital (urban teaching, suburban community hospital). Main sources of funding were national or regional health authorities and a medical research funding body.There was high heterogeneity across studies, which precluded pooling data. It is uncertain whether the intervention reduces time from arrival to clinical assessment and treatment or total length of ED stay (1 study; 260 participants), admissions to hospital, diagnostic tests, treatments given, or consultations or referrals to hospital-based specialist (3 studies; 11,203 participants), as well as costs (2 studies; 9325 participants), as we assessed the evidence as being of very low-certainty for all outcomes.No data were reported on adverse events (such as ED returns and mortality). We assessed the evidence from the four included studies as of very low-certainty overall, as the results are inconsistent and safety has not been examined. The evidence is insufficient to draw conclusions for practice or policy regarding the effectiveness and safety of care provided to non-urgent patients by GPs and NPs versus EPs in the ED to mitigate problems of overcrowding, wait times, and patient flow.

Does Orthopaedic Outpatient Care Reduce Emergency Department Utilization After Total Joint Arthroplasty?

PubMed

Chaudhary, Muhammad Ali; Lange, Jeffrey K; Pak, Linda M; Blucher, Justin A; Barton, Lauren B; Sturgeon, Daniel J; Koehlmoos, Tracey; Haider, Adil H; Schoenfeld, Andrew J

2018-05-22

Emergency department (ED) visits after elective surgical procedures are a potential target for interventions to reduce healthcare costs. More than 1 million total joint arthroplasties (TJAs) are performed each year with postsurgical ED utilization estimated in the range of 10%. We asked whether (1) outpatient orthopaedic care was associated with reduced ED utilization and (2) whether there were identifiable factors associated with ED utilization within the first 30 and 90 days after TJA. An analysis of adult TRICARE beneficiaries who underwent TJA (2006-2014) was performed. TRICARE is the insurance program of the Department of Defense, covering > 9 million beneficiaries. ED use within 90 days of surgery was the primary outcome and postoperative outpatient orthopaedic care the primary explanatory variable. Patient demographics (age, sex, race, beneficiary category), clinical characteristics (length of hospital stay, prior comorbidities, complications), and environment of care were used as covariates. Logistic regression adjusted for all covariates was performed to determine factors associated with ED use. We found that orthopaedic outpatient care (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.68-0.77) was associated with lower odds of ED use within 90 days. We also found that index hospital length of stay (OR, 1.07; 95% CI, 1.04-1.10), medical comorbidities (OR, 1.16; 95% CI, 1.08-1.24), and complications (OR, 2.47; 95% CI, 2.24-2.72) were associated with higher odds of ED use. When considering that at 90 days, only 3928 patients sustained a complication, a substantial number of ED visits (11,486 of 15,414 [75%]) after TJA may be avoidable. Enhancing access to appropriate outpatient care with improved discharge planning may reduce ED use after TJA. Further research should be directed toward unpacking the situations, outside of complications, that drive patients to access the ED and devise interventions that could mitigate such behavior. Level III, therapeutic study.

Free and Reduced-Price Lunch Eligibility Data in Ed"Facts": A White Paper on Current Status and Potential Changes

ERIC Educational Resources Information Center

Hoffman, Lee

2012-01-01

ED"Facts" is an initiative of the U. S. Department of Education to base education policy on reliable performance data provided by state education agencies. Among its many data items, ED"Facts" houses school-level counts of students disaggregated by state-defined student economic status, typically free and reduced-price lunch…

Gait pattern in two rare genetic conditions characterized by muscular hypotonia: Ehlers-Danlos and Prader-Willi syndrome.

PubMed

Cimolin, Veronica; Galli, Manuela; Vismara, Luca; Grugni, Graziano; Camerota, Filippo; Celletti, Claudia; Albertini, Giorgio; Rigoldi, Chiara; Capodaglio, Paolo

2011-01-01

This study aimed to quantify and compare the gait pattern in Ehlers-Danlos (EDS) and Prader-Willi syndrome (PWS) patients to provide data for developing evidence-based rehabilitation strategies. Twenty EDS and 19 PWS adult patients were evaluated with an optoelectronic system and force platforms for measuring kinematic and kinetic parameters during walking. The results were compared with those obtained in a group of 20 normal-weight controls (CG). The results showed that PWS patients walked with longer stance duration and reduced velocity than EDS, close to CG. Both EDS and PWS showed reduced anterior step length than CG. EDS kinematics evidenced a physiological position at proximal joints (pelvis and hip joint) while some deficits were displayed at knee (reduced flexion in swing phase) and ankle level (plantar flexed position in stance and reduced dorsal flexion in swing). PWS showed a forward tilted pelvis in the sagittal plane, excessive hip flexion during the whole gait cycle and an increased hip movement in the frontal plane. Their knees were flexed at initial contact with reduced range of motion while ankle joints showed a plantar flexed position during stance. No differences were found in terms of ankle kinetics and joint stiffness. Our data showed that EDS and PWS patients were characterized by a different gait strategy: PWS showed functional limitations at every level of the lower limb joints, whereas in EDS limitations, greater than PWS, were reported mainly at the distal joints. PWS patients should be encouraged to walk for its positive impact on muscle mass and strength and energy balance. For EDS patients the rehabilitation program should be focused on ankle strategy improvement. Copyright © 2011 Elsevier Ltd. All rights reserved.

Alcohol Interventions Among Underage Drinkers in the ED: A Randomized Controlled Trial.

PubMed

Cunningham, Rebecca M; Chermack, Stephen T; Ehrlich, Peter F; Carter, Patrick M; Booth, Brenda M; Blow, Frederic C; Barry, Kristen L; Walton, Maureen A

2015-10-01

This study examined the efficacy of emergency department (ED)-based brief interventions (BIs), delivered by a computer or therapist, with and without a post-ED session, on alcohol consumption and consequences over 12 months. Patients (ages 14-20 years) screening positive for risky drinking were randomized to: BI (n = 277), therapist BI (n = 278), or control (n = 281). After the 3-month follow-up, participants were randomized to receive a post-ED BI session or control. Incorporating motivational interviewing, the BIs addressed alcohol consumption and consequences, including driving under the influence (DUI), and alcohol-related injury, as well as other concomitant drug use. The computer BI was an offline, Facebook-styled program. Among 4389 patients screened, 1054 patients reported risky drinking and 836 were enrolled in the randomized controlled trial. Regression models examined the main effects of the intervention conditions (versus control) and the interaction effects (ED condition × post-ED condition) on primary outcomes. The therapist and computer BIs significantly reduced consumption at 3 months, consequences at 3 and 12 months, and prescription drug use at 12 months; the computer BI reduced the frequency of DUI at 12 months; and the therapist BI reduced the frequency of alcohol-related injury at 12 months. The post-ED session reduced alcohol consequences at 6 months, benefiting those who had not received a BI in the ED. A single-session BI, delivered by a computer or therapist in the ED, shows promise for underage drinkers. Findings for the fully automated stand-alone computer BI are particularly appealing given the ease of future implementation. Copyright © 2015 by the American Academy of Pediatrics.

A Randomized Controlled Trial of a Citywide Emergency Department Care Coordination Program to Reduce Prescription Opioid Related ED Visits

PubMed Central

Paulozzi, Leonard J.; Howell, Donelle; McPherson, Sterling; Murphy, Sean M.; Grohs, Becky; Marsh, Linda; Lederhos, Crystal; Roll, Jon

2017-01-01

Background Increasing prescription overdose deaths have demonstrated the need for safer ED prescribing practices for patients who are frequent ED users. Objectives We hypothesized that the care of frequent ED users would improve using a citywide care coordination program combined with an ED care coordination information system, as measured by fewer ED visits by and decreased controlled substance prescribing to these patients. Methods We conducted a multi-site randomized controlled trial (RCT) across all EDs in a metropolitan area. 165 patients with the most ED visits for complaints of pain were randomized. For the treatment arm, drivers of ED use were identified by medical record review. Patients and their primary care providers were contacted by phone. Each patient was discussed at a community multidisciplinary meeting where recommendations for ED care were formed. The ED care recommendations were stored in an ED information exchange system that faxed them to the treating ED provider when the patient presented to the ED. The control arm was subjected to treatment as usual. Results The intervention arm experienced a 34% decrease (IRR = 0.66, p < 0.001; 95% CI: 0.57 – 0.78) in ED visits and an 80% decrease (OR = 0.21, p = 0.001) in the odds of receiving an opioid prescription from the ED relative to the control group. Declines of 43.7%, 53.1%, 52.9%, and 53.1% were observed in the treatment group for morphine milligram equivalents, controlled substance pills, prescriptions, and prescribers. Conclusion This RCT showed the effectiveness of a citywide ED care coordination program in reducing ED visits and controlled substance prescribing. PMID:27624507

Utilisation of antihyperglycaemic drugs in ten European countries: different developments and different levels.

PubMed

Melander, A; Folino-Gallo, P; Walley, T; Schwabe, U; Groop, P-H; Klaukka, T; Vallano, A; Laporte, J-R; Gallego, M R; Schiappa, M; Røder, M; Kampmann, J P; de Swaef, A; Aberg, M; Månsson, N-O; Lindblad, U

2006-09-01

The aim of this study was to compare developments in the utilisation of antihyperglycaemic drugs (AHGDs) in ten European countries. Data on the yearly utilisation of insulin and oral AHGDs were collected from public registers in Denmark, Finland, Norway, Sweden, Belgium, England, Germany, Italy, Portugal and Spain, and were expressed as defined daily doses per 1,000 inhabitants per day. Total AGHD utilisation increased everywhere, but at different rates and levels. Insulin utilisation doubled in England and Germany, but hardly changed in Belgium, Portugal or Italy. Sulfonylurea utilisation doubled in Spain, England and Denmark but was reduced in Germany and Sweden. Metformin utilisation increased greatly everywhere. There were two- to three-fold differences in AHGD utilisation even between neighbouring countries. In Finland, there were more users of both insulin (+120%) and oral AHGDs (+80%) than in Denmark, and the daily oral AHGD doses were higher. In Denmark and Sweden, AHGD utilisation was equal in subjects aged <45 years, but in those >or=45 years of age, both insulin and oral AHGD utilisation were twice as high in Sweden. The ubiquitous increase in AHGD utilisation, particularly metformin, seems logical, considering the increasing prevalence of type 2 diabetes and the results of the UK Prospective Diabetes Study. However, the large differences even between neighbouring countries are more difficult to explain, and suggest different habits and attitudes in terms of screening and management of type 2 diabetes.

Reducing eating disorder onset in a very high risk sample with significant comorbid depression: A randomized controlled trial.

PubMed

Taylor, C Barr; Kass, Andrea E; Trockel, Mickey; Cunning, Darby; Weisman, Hannah; Bailey, Jakki; Sinton, Meghan; Aspen, Vandana; Schecthman, Kenneth; Jacobi, Corinna; Wilfley, Denise E

2016-05-01

Eating disorders (EDs) are serious problems among college-age women and may be preventable. An indicated online eating disorder (ED) intervention, designed to reduce ED and comorbid pathology, was evaluated. 206 women (M age = 20 ± 1.8 years; 51% White/Caucasian, 11% African American, 10% Hispanic, 21% Asian/Asian American, 7% other) at very high risk for ED onset (i.e., with high weight/shape concerns plus a history of being teased, current or lifetime depression, and/or nonclinical levels of compensatory behaviors) were randomized to a 10-week, Internet-based, cognitive-behavioral intervention or waitlist control. Assessments included the Eating Disorder Examination (EDE, to assess ED onset), EDE-Questionnaire, Structured Clinical Interview for DSM Disorders, and Beck Depression Inventory-II. ED attitudes and behaviors improved more in the intervention than control group (p = .02, d = 0.31); although ED onset rate was 27% lower, this difference was not significant (p = .28, NNT = 15). In the subgroup with highest shape concerns, ED onset rate was significantly lower in the intervention than control group (20% vs. 42%, p = .025, NNT = 5). For the 27 individuals with depression at baseline, depressive symptomatology improved more in the intervention than control group (p = .016, d = 0.96); although ED onset rate was lower in the intervention than control group, this difference was not significant (25% vs. 57%, NNT = 4). An inexpensive, easily disseminated intervention might reduce ED onset among those at highest risk. Low adoption rates need to be addressed in future research. (c) 2016 APA, all rights reserved).

The relationship between dietary energy density and energy intake

PubMed Central

Rolls, Barbara J.

2014-01-01

Much of the research in ingestive behavior has focused on the macronutrient composition of foods; however, these studies are incomplete, or could be misleading, if they do not consider the energy density (ED) of the diet under investigation. Lowering the ED (kcal/g) by increasing the volume of preloads without changing macronutrient content can enhance satiety and reduce subsequent energy intake at a meal. Ad libitum intake or satiation has also been shown to be influenced by ED when the proportions of macronutrients are constant. Since people tend to eat a consistent weight of food, when the ED of the available foods is reduced, energy intake is reduced. The effects of ED have been seen in adults of different weight status, sex, and behavioral characteristics, as well as in 3- to 5-year-old children. The mechanisms underlying the response to variations in ED are not yet well understood and data from controlled studies lasting more than several days are limited. However, both population-based studies and long-term clinical trials indicate that the effects of dietary ED can be persistent. Several clinical trials have shown that reducing the ED of the diet by the addition of water-rich foods such as fruits and vegetables was associated with substantial weight loss even when patients were not told to restrict calories. Since lowering dietary energy density could provide effective strategies for the prevention and treatment of obesity, there is a need for more studies of mechanisms underlying the effect and ways to apply these findings. PMID:19303887

A Randomized Controlled Trial of a Citywide Emergency Department Care Coordination Program to Reduce Prescription Opioid Related Emergency Department Visits.

PubMed

Neven, Darin; Paulozzi, Leonard; Howell, Donelle; McPherson, Sterling; Murphy, Sean M; Grohs, Becky; Marsh, Linda; Lederhos, Crystal; Roll, John

2016-11-01

Increasing prescription overdose deaths have demonstrated the need for safer emergency department (ED) prescribing practices for patients who are frequent ED users. We hypothesized that the care of frequent ED users would improve using a citywide care coordination program combined with an ED care coordination information system, as measured by fewer ED visits by and decreased controlled substance prescribing to these patients. We conducted a multisite randomized controlled trial (RCT) across all EDs in a metropolitan area; 165 patients with the most ED visits for complaints of pain were randomized. For the treatment arm, drivers of ED use were identified by medical record review. Patients and their primary care providers were contacted by phone. Each patient was discussed at a community multidisciplinary meeting where recommendations for ED care were formed. The ED care recommendations were stored in an ED information exchange system that faxed them to the treating ED provider when the patient presented to the ED. The control arm was subjected to treatment as usual. The intervention arm experienced a 34% decrease (incident rate ratios = 0.66, p < 0.001; 95% confidence interval 0.57-0.78) in ED visits and an 80% decrease (odds ratio = 0.21, p = 0.001) in the odds of receiving an opioid prescription from the ED relative to the control group. Declines of 43.7%, 53.1%, 52.9%, and 53.1% were observed in the treatment group for morphine milligram equivalents, controlled substance pills, prescriptions, and prescribers, respectively. This RCT showed the effectiveness of a citywide ED care coordination program in reducing ED visits and controlled substance prescribing. Copyright © 2016 The Author(s). Published by Elsevier Inc. All rights reserved.

Quantitative proteomics of the human skin secretome reveal a reduction in immune defense mediators in ectodermal dysplasia patients.

PubMed

Burian, Marc; Velic, Ana; Matic, Katarina; Günther, Stephanie; Kraft, Beatrice; Gonser, Lena; Forchhammer, Stephan; Tiffert, Yvonne; Naumer, Christian; Krohn, Michael; Berneburg, Mark; Yazdi, Amir S; Maček, Boris; Schittek, Birgit

2015-03-01

In healthy human skin host defense molecules such as antimicrobial peptides (AMPs) contribute to skin immune homeostasis. In patients with the congenital disease ectodermal dysplasia (ED) skin integrity is disturbed and as a result patients have recurrent skin infections. The disease is characterized by developmental abnormalities of ectodermal derivatives and absent or reduced sweating. We hypothesized that ED patients have a reduced skin immune defense because of the reduced ability to sweat. Therefore, we performed a label-free quantitative proteome analysis of wash solution of human skin from ED patients or healthy individuals. A clear-cut difference between both cohorts could be observed in cellular processes related to immunity and host defense. In line with the extensive underrepresentation of proteins of the immune system, dermcidin, a sweat-derived AMP, was reduced in its abundance in the skin secretome of ED patients. In contrast, proteins involved in metabolic/catabolic and biosynthetic processes were enriched in the skin secretome of ED patients. In summary, our proteome profiling provides insights into the actual situation of healthy versus diseased skin. The systematic reduction in immune system and defense-related proteins may contribute to the high susceptibility of ED patients to skin infections and altered skin colonization.

Impact of season, weekends and bank holidays on emergency department transfers of nursing home residents.

PubMed

Fan, C W; Keating, T; Brazil, E; Power, D; Duggan, J

2016-08-01

For urgent, unexpected clinical events, nursing home (NH) residents are transferred to the acute hospital emergency department (ED). A previous study showed that a third of transfers occurred during working hours. Our aims were to profile a one-year NH transfers to the ED and to examine the re-presentation, patient-oriented outcome and the impact of season, weekends and bank holidays on NH transfers. All NH transfers from a catchment to an ED over one year were identified using electronic patient record. Age, gender, reason for presentation, patient-oriented outcome and date and time of presentation were recorded. Representation and the interval between transfers were calculated. Number of transfers was calculated for season, weekdays/weekends and bank holidays. Student t test, Chi-square statistics and one-way ANOVA were used. Significance was set at 0.05. There were 802 transfers from 465 NH residents over a year; 501 (62.5 %) resulted in admissions, 189 (40.6 %) residents represent to the service and 80 episodes occurred within a fortnight of the last attendance. The highest transfers occurred in May (2.81 patients/day), during working hours and on Wednesdays and Thursdays (>2.5 transfers/day). 'Unwell adult' and 'falls' were the two commonest reasons for presentation. Our study showed that NH transfers occurred mainly within working hours and during weekdays. Insights into the transfer pattern and the reasons for NH patients to utilise ED will facilitate improved design and operation of the department by creating care pathways for these patients.

Depression Prevention for Early Adolescent Girls

PubMed Central

Chaplin, Tara M.; Gillham, Jane E.; Reivich, Karen; Elkon, Andrea G. L.; Samuels, Barbra; Freres, Derek R.; Winder, Breanna; Seligman, Martin E. P.

2015-01-01

Given the dramatic increase in depression that occurs during early adolescence in girls, interventions must address the needs of girls. The authors examined whether a depression prevention program, the Penn Resiliency Program, was more effective for girls in all-girls groups than in co-ed groups. Within co-ed groups, the authors also tested whether there were greater effects for boys than for girls. Participants were 208 11- to 14-year-olds. Girls were randomly assigned to all-girls groups, co-ed groups, or control. Boys were assigned to co-ed groups or control. Students completed questionnaires on depressive symptoms, hopelessness, and explanatory style before and after the intervention. Girls groups were better than co-ed groups in reducing girls’hopelessness and for session attendance rates but were similar to co-ed groups in reducing depressive symptoms. Co-ed groups decreased depressive symptoms, but this did not differ by gender. Findings support prevention programs and suggest additional benefits of girls groups. PMID:26139955

Offering within-category food swaps to reduce energy density of food purchases: a study using an experimental online supermarket.

PubMed

Forwood, Suzanna E; Ahern, Amy L; Marteau, Theresa M; Jebb, Susan A

2015-06-25

Swaps are often used to encourage healthier food choices, but there is little evidence of their effectiveness. The current study assessed the impact of offering swaps on groceries purchased within a bespoke online supermarket; specifically the objective was to measure the impact on energy density (ED) of food purchases following the offer of lower ED alternatives (a) at point of selection or at checkout, and (b) with or without explicit consent to receive swap prompts. Participants were asked to complete a 12-item shopping task within an online shopping platform, developed for studying food purchasing. 1610 adults were randomly assigned to a no swap control condition or to one of four interventions: consented swaps at selection; consented swaps at checkout; imposed swaps at selection; or imposed swaps at checkout. Each swap presented two lower ED options from the same category as the participant's chosen food. Swap acceptance rate and purchased food ED were the primary outcomes. Of the mean 12.36 (SD 1.26) foods purchased, intervention participants were offered a mean of 4.1 (SD 1.68) swaps, with the potential to reduce the ED of purchased food (effect (95% CI): -83 kJ/100 g (-110 - -56), p = <0.0001). A median of one swap (IQR 0 to 2) was accepted, not significantly reducing the purchased food ED (effect (95% CI): -24 kJ/100 g (4 - -52), p = 0.094). More swaps were accepted when offered at selection than at checkout (OR (95% CI) = 1.224 (1.11 - 1.35), p < 0.0001), but no differences were seen with consent. Purchased food ED was unaffected by point of swap or consent, but reduced with number of swaps accepted (effect per swap (95% CI) = -24 kJ/100 g (-35 - -14), p < 0.0001). Within category swaps did not reduce the ED of food purchases reflecting the observation that the use of swaps within an on-line shopping platform offered small potential gains in ED and a minority was accepted.

Benchmarks for Reducing Emergency Department Visits and Hospitalizations Through Community Health Workers Integrated Into Primary Care: A Cost-Benefit Analysis.

PubMed

Basu, Sanjay; Jack, Helen E; Arabadjis, Sophia D; Phillips, Russell S

2017-02-01

Uncertainty about the financial costs and benefits of community health worker (CHW) programs remains a barrier to their adoption. To determine how much CHWs would need to reduce emergency department (ED) visits and associated hospitalizations among their assigned patients to be cost-neutral from a payer's perspective. Using a microsimulation of patient health care utilization, costs, and revenues, we estimated what portion of ED visits and hospitalizations for different conditions would need to be prevented by a CHW program to fully pay for the program's expenses. The model simulated CHW programs enrolling patients with a history of at least 1 ED visit for a chronic condition in the prior year, utilizing data on utilization and cost from national sources. CHWs assigned to patients with uncontrolled hypertension and congestive heart failure, as compared with other common conditions, achieve cost-neutrality with the lowest number of averted visits to the ED. To achieve cost-neutrality, 4-5 visits to the ED would need to be averted per year by a CHW assigned a panel of 70 patients with uncontrolled hypertension or congestive heart failure-approximately 3%-4% of typical ED visits among such patients, respectively. Most other chronic conditions would require between 7% and 12% of ED visits to be averted to achieve cost-savings. Offsetting costs of a CHW program is theoretically feasible for many common conditions. Yet the benchmark for reducing ED visits and associated hospitalizations varies substantially by a patient's primary diagnosis.

Smoothing inpatient discharges decreases emergency department congestion: a system dynamics simulation model.

PubMed

Wong, Hannah J; Wu, Robert C; Caesar, Michael; Abrams, Howard; Morra, Dante

2010-08-01

Timely access to emergency patient care is an important quality and efficiency issue. Reduced discharges of inpatients at weekends are a reality to many hospitals and may reduce hospital efficiency and contribute to emergency department (ED) congestion. To evaluate the daily number of ED beds occupied by inpatients after evenly distributing inpatient discharges over the course of the week using a computer simulation model. Simulation modelling study from an academic care hospital in Toronto, Canada. Daily historical data from the general internal medicine (GIM) department between 15 January and 15 December for two years, 2005 and 2006, were used for model building and validation, respectively. There was good agreement between model simulations and historical data for both ED and ward censuses and their respective lengths of stay (LOS), with the greatest difference being +7.8% for GIM ward LOS (model: 9.3 days vs historical: 8.7 days). When discharges were smoothed across the 7 days, the number of ED beds occupied by GIM patients decreased by approximately 27-57% while ED LOS decreased 7-14 hours. The model also demonstrated that patients occupying hospital beds who no longer require acute care have a considerable impact on ED and ward beds. Smoothing out inpatient discharges over the course of a week had a positive effect on decreasing the number of ED beds occupied by inpatients. Despite the particular challenges associated with weekend discharges, simulation experiments suggest that discharges evenly spread across the week may significantly reduce bed requirements and ED LOS.

Combining presentation high-sensitivity cardiac troponin I and glucose measurements to rule-out an acute myocardial infarction in patients presenting to emergency department with chest pain.

PubMed

Greenslade, J H; Kavsak, P; Parsonage, W; Shortt, C; Than, M; Pickering, J W; Aldous, S; Cullen, L

2015-03-01

The use of high sensitivity troponin (hs-Tn) may enable early rule out of acute myocardial infarction (AMI) for patients presenting to the emergency department (ED) with chest pain. This study evaluated two approaches to the early rule out of AMI; a combination of a presentation hs-Tn <4ng/L and normal glucose at presentation (dual testing) and a presentation hs-Tn troponin below the limit of detection (LoD). We utilised prospectively collected data on adult patients presenting with suspected ACS in two EDs in Australia and New Zealand. Blood samples were taken on presentation and tested for glucose and high sensitivity troponin I. The primary endpoint was index AMI and the secondary endpoint was 30-day acute coronary syndrome (ACS). Sensitivity, specificity, positive and negative predictive values were used to assess the diagnostic accuracy of the dual testing and LoD approaches. Of the 1412 participants, 182 (12.9%) had index AMI. The LoD and the dual testing approach were 100% sensitive for index AMI. The specificity of the dual testing approach (25.2%) was slightly higher than that of the LoD (20.4%). Sensitivity for ACS was similar for the two approaches (96.5% for dual testing and 98.1% for the LoD). The dual testing and LoD approach identified all patients with index AMI and could be used to reduce the proportion of patients requiring lengthy assessment and inpatient admission. Further investigation is still required to rule out unstable angina pectoris in patients identified as low risk. Copyright © 2014 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.

Does family-centred neonatal discharge planning reduce healthcare usage? A before and after study in South West England.

PubMed

Ingram, Jenny C; Powell, Jane E; Blair, Peter S; Pontin, David; Redshaw, Maggie; Manns, Sarah; Beasant, Lucy; Burden, Heather; Johnson, Debbie; Rose, Claire; Fleming, Peter J

2016-03-10

To implement parent-oriented discharge planning (Train-to-Home) for preterm infants in neonatal care. Before and after study, investigating the effects of the intervention during two 11-month periods before and after implementation. Four local neonatal units (LNUs) in South West England. Infants without major anomalies born at 27-33 weeks' gestation admitted to participating units, and their parents. A family-centred discharge package to increase parents' involvement and understanding of their baby's needs, comprising a train graphic and supporting care pathways to facilitate parents' understanding of their baby's progress and physiological maturation, combined with improved estimation of the likely discharge date. Perceived Maternal Parenting Self-Efficacy (PMP S-E) scores, infant length of stay (LOS) and healthcare utilisation for 8 weeks following discharge. Parents reported that the Train-to-Home improved understanding of their baby's progress and their preparedness for discharge. Despite a lack of change in PMP S-E scores with the intervention, the number of post-discharge visits to emergency departments (EDs) fell from 31 to 20 (p<0.05), with a significant reduction in associated healthcare costs (£3400 to £2200; p<0.05) after discharge. In both study phases, over 50% of infants went home more than 3 weeks before their estimated date of delivery (EDD), though no reduction in LOS occurred. Despite the lack of measurable effect on the parental self-efficacy scores, the reduction in ED attendances and associated costs supports the potential value of this approach. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Towards valid 'serious non-fatal injury' indicators for international comparisons based on probability of admission estimates.

PubMed

Cryer, Colin; Miller, Ted R; Lyons, Ronan A; Macpherson, Alison K; Pérez, Katherine; Petridou, Eleni Th; Dessypris, Nick; Davie, Gabrielle S; Gulliver, Pauline J; Lauritsen, Jens; Boufous, Soufiane; Lawrence, Bruce; de Graaf, Brandon; Steiner, Claudia A

2017-02-01

Governments wish to compare their performance in preventing serious injury. International comparisons based on hospital inpatient records are typically contaminated by variations in health services utilisation. To reduce these effects, a serious injury case definition has been proposed based on diagnoses with a high probability of inpatient admission (PrA). The aim of this paper was to identify diagnoses with estimated high PrA for selected developed countries. The study population was injured persons of all ages who attended emergency department (ED) for their injury in regions of Canada, Denmark, Greece, Spain and the USA. International Classification of Diseases (ICD)-9 or ICD-10 4-digit/character injury diagnosis-specific ED attendance and inpatient admission counts were provided, based on a common protocol. Diagnosis-specific and region-specific PrAs with 95% CIs were calculated. The results confirmed that femoral fractures have high PrA across all countries studied. Strong evidence for high PrA also exists for fracture of base of skull with cerebral laceration and contusion; intracranial haemorrhage; open fracture of radius, ulna, tibia and fibula; pneumohaemothorax and injury to the liver and spleen. Slightly weaker evidence exists for cerebellar or brain stem laceration; closed fracture of the tibia and fibula; open and closed fracture of the ankle; haemothorax and injury to the heart and lung. Using a large study size, we identified injury diagnoses with high estimated PrAs. These diagnoses can be used as the basis for more valid international comparisons of life-threatening injury, based on hospital discharge data, for countries with well-developed healthcare and data collection systems. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Do palliative care interventions reduce emergency department visits among patients with cancer at the end of life? A systematic review.

PubMed

DiMartino, Lisa D; Weiner, Bryan J; Mayer, Deborah K; Jackson, George L; Biddle, Andrea K

2014-12-01

Frequent emergency department (ED) visits are an indicator of poor quality of cancer care. Coordination of care through the use of palliative care teams may limit aggressive care and improve outcomes for patients with cancer at the end of life. To systematically review the literature to determine whether palliative care interventions implemented in the hospital, home, or outpatient clinic are more effective than usual care in reducing ED visits among patients with cancer at the end of life. PubMed, EMBASE, and CINAHL databases were searched from database inception to May 7, 2014. Only randomized/non-randomized controlled trials (RCTs) and observational studies examining the effect of palliative care interventions on ED visits among adult patients with cancer with advanced disease were considered. Data were abstracted from the articles that met all the inclusion criteria. A second reviewer independently abstracted data from 2 articles and discrepancies were resolved. From 464 abstracts, 2 RCTs, 10 observational studies, and 1 non-RCT/quasi-experimental study were included. Overall there is limited evidence to support the use of palliative care interventions to reduce ED visits, although studies examining effect of hospice care and those conducted outside of the United States reported a statistically significant reduction in ED visits. Evidence regarding whether palliative care interventions implemented in the hospital, home or outpatient clinic are more effective than usual care at reducing ED visits is not strongly substantiated based on the literature reviewed. Improvements in the quality of reporting for studies examining the effect of palliative care interventions on ED use are needed.

Processing of a porous titanium alloy from elemental powders using a solid state isothermal foaming technique.

PubMed

Nugroho, Aris W; Leadbeater, Garry; Davies, Ian J

2010-12-01

The authors have conducted a preliminary investigation with regard to the potential to manufacture porous titanium alloys for biomedical applications using toxic-free elemental powders, i.e., Ti, Nb, Ta, Zr, in combination with the pressurised gas bubble entrapment method and in contrast to standard processing routes that generally utilise prealloyed powder containing potentially toxic elements. Elemental powder compacts were either hot isostatic pressed (HIP-ed) at 1000°C and then foamed at 1150°C or else HIP-ed at 1100°C and foamed at 1350°C. Porous α + β alloys containing up to 45 vol% of porosity in the size range 20-200 μm were successfully produced, thus highlighting the potential of this manufacturing route. It was expected that further optimisation of the processing route would allow full development of the preferred β-Ti phase (from the point of view of elastic modulus compatibility between implant and bone) with this being the subject of future work by the authors.

Solving the worldwide emergency department crowding problem - what can we learn from an Israeli ED?

PubMed

Pines, Jesse M; Bernstein, Steven L

2015-01-01

ED crowding is a prevalent and important issue facing hospitals in Israel and around the world, including North and South America, Europe, Australia, Asia and Africa. ED crowding is associated with poorer quality of care and poorer health outcomes, along with extended waits for care. Crowding is caused by a periodic mismatch between the supply of ED and hospital resources and the demand for patient care. In a recent article in the Israel Journal of Health Policy Research, Bashkin et al. present an Ishikawa diagram describing several factors related to longer length of stay (LOS), and higher levels of ED crowding, including management, process, environmental, human factors, and resource issues. Several solutions exist to reduce ED crowding, which involve addressing several of the issues identified by Bashkin et al. This includes reducing the demand for and variation in care, and better matching the supply of resources to demands in care in real time. However, what is needed to reduce crowding is an institutional imperative from senior leadership, implemented by engaged ED and hospital leadership with multi-disciplinary cross-unit collaboration, sufficient resources to implement effective interventions, access to data, and a sustained commitment over time. This may move the culture of a hospital to facilitate improved flow within and across units and ultimately improve quality and safety over the long-term.

An analysis of partial efficiencies of energy utilisation of different macronutrients by barramundi (Lates calcarifer) shows that starch restricts protein utilisation in carnivorous fish.

PubMed

Glencross, Brett D; Blyth, David; Bourne, Nicholas; Cheers, Susan; Irvin, Simon; Wade, Nicholas M

2017-02-01

This study examined the effect of including different dietary proportions of starch, protein and lipid, in diets balanced for digestible energy, on the utilisation efficiencies of dietary energy by barramundi (Lates calcarifer). Each diet was fed at one of three ration levels (satiety, 80 % of initial satiety and 60 % of initial satiety) for a 42-d period. Fish performance measures (weight gain, feed intake and feed conversion ratio) were all affected by dietary energy source. The efficiency of energy utilisation was significantly reduced in fish fed the starch diet relative to the other diets, but there were no significant effects between the other macronutrients. This reduction in efficiency of utilisation was derived from a multifactorial change in both protein and lipid utilisation. The rate of protein utilisation deteriorated as the amount of starch included in the diet increased. Lipid utilisation was most dramatically affected by inclusion levels of lipid in the diet, with diets low in lipid producing component lipid utilisation rates well above 1·3, which indicates substantial lipid synthesis from other energy sources. However, the energetic cost of lipid gain was as low as 0·65 kJ per kJ of lipid deposited, indicating that barramundi very efficiently store energy in the form of lipid, particularly from dietary starch energy. This study defines how the utilisation efficiency of dietary digestible energy by barramundi is influenced by the macronutrient source providing that energy, and that the inclusion of starch causes problems with protein utilisation in this species.

Impact of an ABCDE team triage process combined with public guidance on the division of work in an emergency department.

PubMed

Kantonen, Jarmo; Lloyd, Robert; Mattila, Juho; Kauppila, Timo; Menezes, Ricardo

2015-06-01

To study the effects of applying an emergency department (ED) triage system, combined with extensive publicity in local media about the "right" use of emergency services, on the division of work between ED nurses and general practitioners (GPs). An observational and quasi-experimental study based on before-after comparisons. Implementation of the ABCDE triage system in a Finnish combined ED where secondary care is adjacent, and in a traditional primary care ED where secondary care is located elsewhere. GPs and nurses from two different primary care EDs. Numbers of monthly visits to different professional groups before and after intervention in the studied primary care EDs and numbers of monthly visits to doctors in the local secondary care ED. The beginning of the triage process increased temporarily the number of independent consultations and patient record entries by ED nurses in both types of studied primary care EDs and reduced the number of patient visits to a doctor compared with previous years but had no effect on doctor visits in the adjacent secondary care ED. No further decrease in the number of nurse or GP visits was observed by inhibiting the entrance of non-urgent patients. The ABCDE triage system combined with public guidance may reduce non-urgent patient visits to doctors in different kinds of primary care EDs without increasing visits in the secondary care ED. However, the additional work to implement the ABCDE system is mainly directed to nurses, which may pose a challenge for staffing.

Analysis of patient flow in the emergency department and the effect of an extensive reorganisation

PubMed Central

Miro, O; Sanchez, M; Espinosa, G; Coll-Vinent, B; Bragulat, E; Milla, J; Wardrope, J

2003-01-01

Objectives: To evaluate the different internal factors influencing patient flow, effectiveness, and overcrowding in the emergency department (ED), as well as the effects of ED reorganisation on these indicators. Methods: The study compared measurements at regular intervals of three hours of patient arrivals and patient flow between two comparable periods (from 10 February to 2 March) of 1999 and 2000. In between, a structural and staff reorganisation of ED was undertaken. The main reason for each patient remaining in ED was recorded and allocated to one of four groups: (1) factors related to ED itself ; (2) factors related to ED-hospital interrelation; (3) factors related to hospital itself; and (4) factors related to neither ED nor hospital. The study measured the number of patients waiting to be seen and the waiting time to be seen as effectiveness markers, as well as the percentage of time that ED was overcrowded, as judged by numerical and functional criteria. Results: Effectiveness of ED was closely related with some ED related and hospital related factors. After the reorganisation, patients who remained in ED because of hospital related or non-ED-non-hospital related factors decreased. ED reorganisation reduced the number of patients waiting to be seen from 5.8 to 2.5 (p<0.001) and waiting time from 87 to 24 minutes (p<0.001). Before the reorganisation, 31% and 48% of the time was considered to be overcrowded in numerical and functional terms respectively. After the reorganisation, these figures were reduced to 8% and 15% respectively (p<0.001 for both). Conclusions: ED effectiveness and overcrowding are not only determined by external pressure, but also by internal factors. Measurement of patient flow across ED has proved useful in detecting these factors and in being used to plan an ED reorganisation. PMID:12642527

Peripheral nerve block in patients with Ehlers-Danlos syndrome, hypermobility type: a case series.

PubMed

Neice, Andrew E; Stubblefield, Eryn E; Woodworth, Glenn E; Aziz, Michael F

2016-09-01

Ehlers-Danlos syndrome (EDS) is an inherited disease characterized by defects in various collagens or their post translational modification, with an incidence estimated at 1 in 5000. Performance of peripheral nerve block in patients with EDS is controversial, due to easy bruising and hematoma formation after injections as well as reports of reduced block efficacy. The objective of this study was to review the charts of EDS patients who had received peripheral nerve block for any evidence of complications or reduced efficacy. Case series, chart review. Academic medical center. Patients with a confirmed or probable diagnosis of EDS who had received a peripheral nerve block in the last 3 years were identified by searching our institutions electronic medical record system. The patients were classified by their subtype of EDS. Patients with no diagnosed subtype were given a probable subtype based on a chart review of the patient's symptoms. Patient charts were reviewed for any evidence of complications or reduced block efficacy. A total of 21 regional anesthetics, on 16 unique patients were identified, 10 of which had a EDS subtype diagnosis. The majority of these patients had a diagnosis of hypermobility-type EDS. No block complications were noted in any patients. Two block failures requiring repeat block were noted, and four patients reported uncontrolled pain on postoperative day one despite successful placement of a peripheral nerve catheter. Additionally, blocks were performed without incident in patients with classical-type and vascular-type EDS although the number was so small that no conclusions can be drawn about relative safety of regional anesthesia in these groups. This series fails to show an increased risk of complications of peripheral nerve blockade in patients with hypermobility-type EDS. Copyright © 2016 Elsevier Inc. All rights reserved.

Cerebro- and Cardio-vascular Responses to Energy Drink in Young Adults: Is there a Gender Effect?

PubMed

Monnard, Cathríona R; Montani, Jean-Pierre; Grasser, Erik K

2016-01-01

Energy drinks (EDs) are suspected to induce potential adverse cardiovascular effects and have recently been shown to reduce cerebral blood flow velocity (CBFV) in young, healthy subjects. Gender differences in CBFV in response to EDs have not previously been investigated, despite the fact that women are more prone to cardiovascular disturbances such as neurocardiogenic syncope than men. Therefore, the aim of this study was to explore gender differences in cerebrovascular and cardiovascular responses to EDs. We included 45 subjects in a retrospective analysis of pooled data from two previous randomized trials carried out in our laboratory with similar protocols. Beat-to-beat blood pressure, impedance cardiography, transcranial Doppler, and end-tidal carbon dioxide (etCO2) measurements were made for at least 20 min baseline and for 80 min following the ingestion of 355 mL of a sugar-sweetened ED. Gender and time differences in cerebrovascular and cardiovascular parameters were investigated. CBFV was significantly reduced in response to ED, with the greatest reduction observed in women compared with men (-12.3 ± 0.8 vs. -9.7 ± 0.8%, P < 0.05). Analysis of variance indicated significant time (P < 0.01) and gender × time (P < 0.01) effects. The percentage change in CBFV in response to ED was independent of body weight and etCO2. No significant gender difference in major cardiovascular parameters in response to ED was observed. ED ingestion reduced CBFV over time, with a greater reduction observed in women compared with men. Our results have potential implications for women ED consumers, as well as high-risk individuals.

X-Ray Fluorescence Determination of Sulphur in Oils by a Thin Film Method.

DTIC Science & Technology

1983-09-01

thickness. The procedure utilises a mixture of samp and an alkyd resin to improve adhesion to a Mylar substrate and to reduce sample flow during...thickness. The procedure utilises a mixture of sample and an alkyd resin to improve adhesion to a Mylar substrate and to reduce sample flow during...film. By incorporating an alkyd resin into the sample mixture the adhesion of the oil film to the Mylar sheet substrate is improved to the extent that

Evaluating the effect of clinical decision units on patient flow in seven Canadian emergency departments.

PubMed

Schull, Michael J; Vermeulen, Marian J; Stukel, Therese A; Guttmann, Astrid; Leaver, Chad A; Rowe, Brian H; Sales, Anne

2012-07-01

To evaluate the effect of emergency department (ED) clinical decision units (CDUs) on overall ED patient flow in a pilot project funded in 2008 by the Ontario Ministry of Health and Long-Term Care (MOHLTC). A retrospective analysis of unscheduled ED visits at seven CDU pilot and nine control sites was conducted using administrative data. The authors examined trends in CDU utilization and compared outcomes between pilot-CDU and control sites 1 year prior to implementation, with the first 18 months of CDU operation. Sites that were unsuccessful in their applications for CDU program funding served as controls. Outcomes included ED length of stay (LOS), admission rates, and ED revisit rates. At CDU sites, roughly 4% of ED patients were admitted to CDUs. The presence of a pilot-CDU was independently associated with a small reduction in ED LOS for all low-acuity patients (-0.14 hour, 95% confidence interval [CI]=-0.22 to -0.07) and nonadmitted patients (-0.11 hour, 95% CI=-0.16 to -0.07). A small independent effect on absolute hospital admission rate for all high-acuity patients (-0.8%, 95% CI=-1.5% to -0.03%) and moderate-acuity patients (-0.6%, 95% CI=-1.1% to -0.2%) was also observed. Pilot-CDUs were not associated with changes in ED revisit rates. With only 4% of ED patients admitted to CDUs, the potential for efficiency gains in these EDs was limited. Nonetheless, these findings suggest small improvements in the operation of the ED through CDU implementation. Although marginal, the observed effects of CDU operation were in the desired direction of reduced ED LOS, reduced admission rate, and no increase in ED revisit rate. © 2012 by the Society for Academic Emergency Medicine.

Improving ED efficiency to capture additional revenue.

PubMed

Mandavia, Sujal; Samaniego, Loretta

2016-06-01

An increase in the number of patients visiting emergency departments (EDs) presents an opportunity for additional revenue if hospitals take four steps to optimize resources: Streamline the patient pathway and reduce the amount of time each patient occupies a bed in the ED. Schedule staff according to the busy and light times for patient arrivals. Perform registration and triage bedside, reducing initial wait times. Create an area for patients to wait for test results so beds can be freed up for new arrivals.

Effect of sulfate and nitrate on acetate conversion by anaerobic microorganisms in a freshwater sediment.

PubMed

Scholten, Johannes C M; Bodegom, Peter M; Vogelaar, Jaap; Ittersum, Alexander; Hordijk, Kees; Roelofsen, Wim; Stams, Alfons J M

2002-12-01

Acetate is quantitatively the most important substrate for methane production in a freshwater sediment in The Netherlands. In the presence of alternative electron acceptors the conversion of acetate by methanogens was strongly inhibited. By modelling the results, obtained in experiments with and without (13)C-labelled acetate, we could show that the competition for acetate between methanogens and sulfate reducers is the main cause of inhibition of methanogenesis in the sediment. Although nitrate led to a complete inhibition of methanogenesis, acetate-utilising nitrate-reducing bacteria hardly competed with methanogens for the available acetate in the presence of nitrate. Most-probable-number enumerations showed that methanogens (2x10(8) cells cm(-3) sediment) and sulfate reducers (2x10(8) cells cm(-3) sediment) were the dominant acetate-utilising organisms in the sediment, while numbers of acetate-utilising nitrate reducers were very low (5x10(5) cells cm(-3) sediment). However, high numbers of sulfide-oxidising nitrate reducers were detected. Denitrification might result in the formation of toxic products. We speculate that the accumulation of low concentrations of NO (<0.2 mM) may result in an inhibition of methanogenesis.

Eating disorder-specific health-related quality of life and exercise in college females.

PubMed

Cook, Brian J; Hausenblas, Heather A

2011-11-01

Although eating disorder (ED) symptoms result in reduced quality of life (QOL), research is needed to examine variables that influence this relationship. The purpose of our study was to conceptually examine the relationship among ED-specific QOL, ED symptoms, and exercise behavior. Female university students (N = 387) completed ED-specific QOL, exercise behavior, ED symptoms, and exercise dependence symptoms measures. We found support for the beneficial association of psychological QOL on ED symptoms as well as the detrimental association of exercise dependence on ED symptoms. Our results suggest that improvements in psychological aspects of QOL resulting from exercise may mediate ED symptoms when exercise motivations are not pathological. We discuss further research and intervention implications of our findings.

Opportunistic pathology-based screening for diabetes

PubMed Central

Simpson, Aaron J; Krowka, Renata; Kerrigan, Jennifer L; Southcott, Emma K; Wilson, J Dennis; Potter, Julia M; Nolan, Christopher J; Hickman, Peter E

2013-01-01

Objective To determine the potential of opportunistic glycated haemoglobin (HbA1c) testing of pathology samples to detect previously unknown diabetes. Design Pathology samples from participants collected for other reasons and suitable for HbA1c testing were utilised for opportunistic diabetes screening. HbA1c was measured with a Biorad Variant II turbo analyser and HbA1c levels of ≥6.5% (48 mmol/mol) were considered diagnostic for diabetes. Confirmation of previously unknown diabetes status was obtained by a review of hospital medical records and phone calls to general practitioners. Setting Hospital pathology laboratory receiving samples from hospital-based and community-based (CB) settings. Participants Participants were identified based on the blood sample collection location in the CB, emergency department (ED) and inpatient (IP) groups. Exclusions pretesting were made based on the electronic patient history of: age <18 years, previous diabetes diagnosis, query for diabetes status in the past 12 months, evidence of pregnancy and sample collected postsurgery or transfusion. Only one sample per individual participant was tested. Results Of the 22 396 blood samples collected, 4505 (1142 CB, 1113 ED, 2250 IP) were tested of which 327 (7.3%) had HbA1c levels ≥6.5% (48 mmol/mol). Of these 120 (2.7%) were determined to have previously unknown diabetes (11 (1%) CB, 21 (1.9%) ED, 88 (3.9%) IP). The prevalence of previously unknown diabetes was substantially higher (5.4%) in hospital-based (ED and IP) participants aged over 54 years. Conclusions Opportunistic testing of referred pathology samples can be an effective method of screening for diabetes, especially in hospital-based and older persons. PMID:24065696

Systemic inflammatory response syndrome-based severe sepsis screening algorithms in emergency department patients with suspected sepsis.

PubMed

Shetty, Amith L; Brown, Tristam; Booth, Tarra; Van, Kim Linh; Dor-Shiffer, Daphna E; Vaghasiya, Milan R; Eccleston, Cassanne E; Iredell, Jonathan

2016-06-01

Systemic inflammatory response syndrome (SIRS)-based severe sepsis screening algorithms have been utilised in stratification and initiation of early broad spectrum antibiotics for patients presenting to EDs with suspected sepsis. We aimed to investigate the performance of some of these algorithms on a cohort of suspected sepsis patients. We conducted a retrospective analysis on an ED-based prospective sepsis registry at a tertiary Sydney hospital, Australia. Definitions for sepsis were based on the 2012 Surviving Sepsis Campaign guidelines. Numerical values for SIRS criteria and ED investigation results were recorded at the trigger of sepsis pathway on the registry. Performance of specific SIRS-based screening algorithms at sites from USA, Canada, UK, Australia and Ireland health institutions were investigated. Severe sepsis screening algorithms' performance was measured on 747 patients presenting with suspected sepsis (401 with severe sepsis, prevalence 53.7%). Sensitivity and specificity of algorithms to flag severe sepsis ranged from 20.2% (95% CI 16.4-24.5%) to 82.3% (95% CI 78.2-85.9%) and 57.8% (95% CI 52.4-63.1%) to 94.8% (95% CI 91.9-96.9%), respectively. Variations in SIRS values between uncomplicated and severe sepsis cohorts were only minor, except a higher mean lactate (>1.6 mmol/L, P < 0.01). We found the Ireland and JFK Medical Center sepsis algorithms performed modestly in stratifying suspected sepsis patients into high-risk groups. Algorithms with lactate levels thresholds of >2 mmol/L rather than >4 mmol/L performed better. ED sepsis registry-based characterisation of patients may help further refine sepsis definitions of the future. © 2016 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Development of an electronic emergency department-based geo-information injury surveillance system in Hong Kong.

PubMed

Chow, C B; Leung, M; Lai, Adela; Chow, Y H; Chung, Joanne; Tong, K M; Lit, Albert

2012-06-01

To describe the experience in the development of an electronic emergency department (ED)-based injury surveillance (IS) system in Hong Kong using data-mining and geo-spatial information technology (IT) for a Safe Community setup. This paper described the phased development of an emergency department-based IS system based on World Health Organization (WHO) injury surveillance Guideline to support safety promotion and injury prevention in a Safe Community in Hong Kong starting 2002. The initial ED data-based only collected data on name, sex, age, address, eight general categories of injury types (traffic, domestic, common assault, indecent assault, batter, industrial, self-harm and sports) and disposal from ED. Phase 1--manual data collection on International Classification of External Causes of Injury pre-event data; Phase 2--manual form was converted to electronic format using web-based data mining technology with built in data quality monitoring mechanism; Phase 3--integration of injury surveillance-data with in-patient hospital information; and Phase 4--geo-spatial information and body mapping were introduced to geo-code exact place of injury in an electronic map and site of injury on body map. It was feasible to develop a geo-spatial IS system at busy ED to collect valuable information for safety promotion and injury prevention at Safe Community setting. The keys for successful development and implementation involves engagement of all stakeholders at design and implementation of the system with injury prevention as ultimate goal, detail workflow planning at front end, support from the management, building on exiting system and appropriate utilisation of modern technology. Copyright © 2011 Elsevier Ltd. All rights reserved.

Ghrelin and peptide YY increase with weight loss during a 12-month intervention to reduce dietary energy density in obese women

PubMed Central

Hill, Brenna R.; Rolls, Barbara J.; Roe, Liane S.; De Souza, Mary Jane; Williams, Nancy I.

2013-01-01

Reducing dietary energy density (ED) promotes weight loss; however, underlying mechanisms are not well understood. The purpose of this study was to determine if low-ED diets facilitate weight loss through actions on ghrelin and peptide YY (PYY), independent of influences of psychosocial measures. Seventy-one obese women (BMI 30–40kg/m2) ages 22–60y received counseling to reduce ED. Fasting blood samples were analyzed for total ghrelin and total PYY by radioimmunoassay at mo 0, 3, 6, and 12. Restraint, disinhibition, and hunger were assessed by the Eating Inventory. Body weight (−7.8 ± 0.5kg), BMI (−2.9 ± 0.2kg/m2), body fat (−3.0 ± 0.3%), and ED (−0.47 ± 0.05kcal/g or −1.97 ± 0.21kJ/g) decreased from mo 0 to 6 (p<0.05) after which no change occurred from mo 6 to 12. Ghrelin increased in a curvilinear fashion (mo 0: 973 ± 39, mo 3: 1024 ± 37, mo 6: 1109 ± 44, and mo 12: 1063 ± 45pg/ml, p<0.001) and PYY increased linearly (mo 0: 74.2 ± 3.1, mo 3: 76.4 ± 3.2, mo 6: 77.2 ± 3.0, mo 12: 82.8 ± 3.2pg/ml, p<0.001). ED, body weight, and hunger predicted ghrelin, with ED being the strongest predictor (ghrelin = 2674.8 + 291.6 × ED − 19.2 × BW − 15 × H; p<0.05). There was a trend toward a significant association between ED and PYY (PYY = 115.0 − 43.1 × ED; p=0.05). Reductions in ED may promote weight loss and weight loss maintenance by opposing increases in ghrelin and promoting increases in PYY. PMID:24076434

Lean intervention improves patient discharge times, improves emergency department throughput and reduces congestion.

PubMed

Beck, Michael J; Okerblom, Davin; Kumar, Anika; Bandyopadhyay, Subhankar; Scalzi, Lisabeth V

2016-12-01

To determine if a lean intervention improved emergency department (ED) throughput and reduced ED boarding by improving patient discharge efficiency from a tertiary care children's hospital. The study was conducted at a tertiary care children's hospital to study the impact lean that changes made to an inpatient pediatric service line had on ED efficiency. Discharge times from the general pediatrics' service were compared to patients discharged from all other pediatric subspecialty services. The intervention was multifaceted. First, team staffing reconfiguration permitted all discharge work to be done at the patient's bedside using a new discharge checklist. The intervention also incorporated an afternoon interdisciplinary huddle to work on the following day's discharges. Retrospectively, we determined the impact this had on median times of discharge order entry, patient discharge, and percent of patients discharged before noon. As a marker of ED throughput, we determined median hour of day that admitted patients left the ED to move to their hospital bed. As marker of ED congestion we determined median boarding times. For the general pediatrics service line, the median discharge order entry time decreased from 1:43pm to 11:28am (p < 0.0001) and the median time of discharge decreased from 3:25pm to 2:25pm (p < 0.0001). The percent of patients discharged before noon increased from 14.0% to 26.0% (p < 0.0001). The discharge metrics remained unchanged for the pediatric subspecialty services group. Median ED boarding time decreased by 49 minutes (p < 0.0001). As a result, the median time of day admitted patients were discharged from the ED was advanced from 5 PM to 4 PM. Lean principles implemented by one hospital service line improved patient discharge times enhanced patient ED throughput, and reduced ED boarding times.

A novel approach to reducing admissions for children with sickle cell disease in pain crisis through individualization and standardization in the emergency department.

PubMed

Schefft, Matthew R; Swaffar, Caitlan; Newlin, Jennifer; Noda, Cady; Sisler, India

2018-06-01

Vaso-occlusive crisis (VOC) is frequent in children with sickle cell disease (SCD) creating significant burden on patients, families, and emergency departments (ED). The objective of the project was to reduce the admission rate for children with SCD presenting to our ED with VOC by >20% within 6 months of initiating individualized pain plans (IPP). A multi-disciplinary quality improvement team was assembled. A Plan-Do-Study-Act (PDSA) format was employed. The IPP document was created in a unique folder within the electronic medical record. IPPs were created through retrospective chart review for our 80 highest resource users. Pediatric residents, ED residents, and ED attending physicians were instructed on use of the IPPs. Our study measured the presence of an IPP, adherence to the IPP, and time to opiate administration. Our primary outcome was admission rate. Length of stay and 72-hr return to the ED were assessed as balancing measures. Overall, admission rate decreased by 24% following implementation compared with the previous 5 years (P = 0.046). IPPs were created for 78% of patients and followed by ED staff in 86% of visits. Admission rate was significantly lower for patients receiving a second opiate dose within 45 min of the first dose (P < 0.01). There was no difference in readmission rate or 72-hr return rate to ED. This study presents an effective strategy to reduce admission rate for children with SCD presenting with VOC. Shorter time to second opiate dosing was also associated with reduced risk of admission. © 2018 Wiley Periodicals, Inc.

Bacterial pathogen indicators regrowth and reduced sulphur compounds' emissions during storage of electro-dewatered biosolids.

PubMed

Navab-Daneshmand, Tala; Enayet, Samia; Gehr, Ronald; Frigon, Dominic

2014-10-01

Electro-dewatering (ED) increases biosolids dryness from 10-15 to 30-50%, which helps wastewater treatment facilities control disposal costs. Previous work showed that high temperatures due to Joule heating during ED inactivate total coliforms to meet USEPA Class A biosolids requirements. This allows biosolids land application if the requirements are still met after the storage period between production and application. In this study, we examined bacterial regrowth and odour emissions during the storage of ED biosolids. No regrowth of total coliforms was observed in ED biosolids over 7d under aerobic or anaerobic incubations. To mimic on-site contamination during storage or transport, ED samples were seeded with untreated sludge. Total coliform counts decreased to detection limits after 4d in inoculated samples. Olfactometric analysis of ED biosolids odours showed that odour concentrations were lower compared to the untreated and heat-treated control biosolids. Furthermore, under anaerobic conditions, odorous reduced sulphur compounds (methanethiol, dimethyl sulphide and dimethyl disulphide) were produced by untreated and heat-treated biosolids, but were not detected in the headspaces above ED samples. The data demonstrate that ED provides advantages not only as a dewatering technique, but also for producing biosolids with lower microbial counts and odour levels. Copyright © 2014 Elsevier Ltd. All rights reserved.

The effective mitigation of greenhouse gas emissions from rice paddies without compromising yield by early-season drainage.

PubMed

Islam, Syed Faiz-Ul; van Groenigen, Jan Willem; Jensen, Lars Stoumann; Sander, Bjoern Ole; de Neergaard, Andreas

2018-01-15

Global rice production systems face two opposing challenges: the need to increase production to accommodate the world's growing population while simultaneously reducing greenhouse gas (GHG) emissions. Adaptations to drainage regimes are one of the most promising options for methane mitigation in rice production. Whereas several studies have focused on mid-season drainage (MD) to mitigate GHG emissions, early-season drainage (ED) varying in timing and duration has not been extensively studied. However, such ED periods could potentially be very effective since initial available C levels (and thereby the potential for methanogenesis) can be very high in paddy systems with rice straw incorporation. This study tested the effectiveness of seven drainage regimes varying in their timing and duration (combinations of ED and MD) to mitigate CH 4 and N 2 O emissions in a 101-day growth chamber experiment. Emissions were considerably reduced by early-season drainage compared to both conventional continuous flooding (CF) and the MD drainage regime. The results suggest that ED+MD drainage may have the potential to reduce CH 4 emissions and yield-scaled GWP by 85-90% compared to CF and by 75-77% compared to MD only. A combination of (short or long) ED drainage and one MD drainage episode was found to be the most effective in mitigating CH 4 emissions without negatively affecting yield. In particular, compared with CF, the long early-season drainage treatments LE+SM and LE+LM significantly (p<0.01) decreased yield-scaled GWP by 85% and 87% respectively. This was associated with carbon being stabilised early in the season, thereby reducing available C for methanogenesis. Overall N 2 O emissions were small and not significantly affected by ED. It is concluded that ED+MD drainage might be an effective low-tech option for small-scale farmers to reduce GHG emissions and save water while maintaining yield. Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.

Utilising flags to reduce drag around a short finite circular cylinder

NASA Astrophysics Data System (ADS)

Javadi, Kh.; Kiani, F.; Tahaye Abadi, M.

2018-03-01

This paper utilises flags to decrease the drag around a short finite circular cylinder. Wall-adapted large eddy simulation and two-way fluid-structure interaction methods were applied to resolve unsteady turbulent flow structure. The far-field Reynolds number of the current configuration based on the cylinder diameter was chosen to be 20,000. In addition, the length-to-diameter ratio of the cylinder was assumed to be L/D = 2 whereas the flexible flag had a width-to-diameter ratio of W/D = 1.5. The results were compared with the regular short finite circular cylinder and the rigid flagged cylinder in our previous work. The results indicate that utilising flags inside the near-wake region of the cylinder reduces the pressure drag. The physical mechanism of this drag reduction is presented.

Modelling Pasture-based Automatic Milking System Herds: The Impact of Large Herd on Milk Yield and Economics.

PubMed

Islam, M R; Clark, C E F; Garcia, S C; Kerrisk, K L

2015-07-01

The aim of this modelling study was to investigate the effect of large herd size (and land areas) on walking distances and milking interval (MI), and their impact on milk yield and economic penalties when 50% of the total diets were provided from home grown feed either as pasture or grazeable complementary forage rotation (CFR) in an automatic milking system (AMS). Twelve scenarios consisting of 3 AMS herds (400, 600, 800 cows), 2 levels of pasture utilisation (current AMS utilisation of 15.0 t dry matter [DM]/ha, termed as 'moderate'; optimum pasture utilisation of 19.7 t DM/ha, termed as 'high') and 2 rates of incorporation of grazeable complementary forage system (CFS: 0, 30%; CFS = 65% farm is CFR and 35% of farm is pasture) were investigated. Walking distances, energy loss due to walking, MI, reduction in milk yield and income loss were calculated for each treatment based on information available in the literature. With moderate pasture utilisation and 0% CFR, increasing the herd size from 400 to 800 cows resulted in an increase in total walking distances between the parlour and the paddock from 3.5 to 6.3 km. Consequently, MI increased from 15.2 to 16.4 h with increased herd size from 400 to 800 cows. High pasture utilisation (allowing for an increased stocking density) reduced the total walking distances up to 1 km, thus reduced the MI by up to 0.5 h compared to the moderate pasture, 800 cow herd combination. The high pasture utilisation combined with 30% of the farm in CFR in the farm reduced the total walking distances by up to 1.7 km and MI by up to 0.8 h compared to the moderate pasture and 800 cow herd combination. For moderate pasture utilisation, increasing the herd size from 400 to 800 cows resulted in more dramatic milk yield penalty as yield increasing from c.f. 2.6 and 5.1 kg/cow/d respectively, which incurred a loss of up to $AU 1.9/cow/d. Milk yield losses of 0.61 kg and 0.25 kg for every km increase in total walking distance (voluntary return trip from parlour to paddock) and every one hour increase in MI, respectively. The high pasture utilisation combined with 30% of the farm in CFR in the farm increased milk yield by up to 1.5 kg/cow/d, thereby reducing loss by up to $0.5/cow/d (c.f. the moderate pasture and 800 cow herd scenario). Thus, it was concluded that the successful integration of grazeable CFS with pasture has the potential to improve financial performance compared to the pasture only, large herd, AMS.

Emergency medicine: an operations management view.

PubMed

Soremekun, Olan A; Terwiesch, Christian; Pines, Jesse M

2011-12-01

Operations management (OM) is the science of understanding and improving business processes. For the emergency department (ED), OM principles can be used to reduce and alleviate the effects of crowding. A fundamental principle of OM is the waiting time formula, which has clear implications in the ED given that waiting time is fundamental to patient-centered emergency care. The waiting time formula consists of the activity time (how long it takes to complete a process), the utilization rate (the proportion of time a particular resource such a staff is working), and two measures of variation: the variation in patient interarrival times and the variation in patient processing times. Understanding the waiting time formula is important because it presents the fundamental parameters that can be managed to reduce waiting times and length of stay. An additional useful OM principle that is applicable to the ED is the efficient frontier. The efficient frontier compares the performance of EDs with respect to two dimensions: responsiveness (i.e., 1/wait time) and utilization rates. Some EDs may be "on the frontier," maximizing their responsiveness at their given utilization rates. However, most EDs likely have opportunities to move toward the frontier. Increasing capacity is a movement along the frontier and to truly move toward the frontier (i.e., improving responsiveness at a fixed capacity), we articulate three possible options: eliminating waste, reducing variability, or increasing flexibility. When conceptualizing ED crowding interventions, these are the major strategies to consider. © 2011 by the Society for Academic Emergency Medicine.

Use of knowledge-sharing web-based portal in gross and microscopic anatomy.

PubMed

Durosaro, Olayemi; Lachman, Nirusha; Pawlina, Wojciech

2008-12-01

Changes in worldwide healthcare delivery require review of current medical school curricula structure to develop learning outcomes that ensures mastery of knowledge and clinical competency. In the last 3 years, Mayo Medical School implemented outcomes-based curriculum to encompass new graduate outcomes. Standard courses were replaced by 6-week clinically-integrated didactic blocks separated by student-self selected academic enrichment activities. Gross and microscopic anatomy was integrated with radiology and genetics respectively. Laboratory components include virtual microscopy and anatomical dissection. Students assigned to teams utilise computer portals to share learning experiences. High-resolution computed tomographic (CT) scans of cadavers prior to dissection were made available for correlative learning between the cadaveric material and radiologic images. Students work in teams on assigned presentations that include histology, cell and molecular biology, genetics and genomic using the Nexus Portal, based on DrupalEd, to share their observations, reflections and dissection findings. New generation of medical students are clearly comfortable utilising web-based programmes that maximise their learning potential of conceptually difficult and labor intensive courses. Team-based learning approach emphasising the use of knowledge-sharing computer portals maximises opportunities for students to master their knowledge and improve cognitive skills to ensure clinical competency.

Coordination Program Reduced Acute Care Use And Increased Primary Care Visits Among Frequent Emergency Care Users.

PubMed

Capp, Roberta; Misky, Gregory J; Lindrooth, Richard C; Honigman, Benjamin; Logan, Heather; Hardy, Rose; Nguyen, Dong Q; Wiler, Jennifer L

2017-10-01

Many high utilizers of the emergency department (ED) have public insurance, especially through Medicaid. We evaluated how participation in Bridges to Care (B2C)-an ED-initiated, multidisciplinary, community-based program-affected subsequent ED use, hospital admissions, and primary care use among publicly insured or Medicaid-eligible high ED utilizers. During the six months after the B2C intervention was completed, participants had significantly fewer ED visits (a reduction of 27.9 percent) and significantly more primary care visits (an increase of 114.0 percent), compared to patients in the control group. In a subanalysis of patients with mental health comorbidities, we found that recipients of B2C services had significantly fewer ED visits (a reduction of 29.7 percent) and hospitalizations (30.0 percent), and significantly more primary care visits (an increase of 123.2 percent), again compared to patients in the control group. The B2C program reduced acute care use and increased the number of primary care visits among high ED utilizers, including those with mental health comorbidities. Project HOPE—The People-to-People Health Foundation, Inc.

Mesophilic and thermophilic anaerobic digestion of sulphate-containing wastewaters.

PubMed

Colleran, E; Pender, S

2002-01-01

The effect of sulphate at an influent chemical oxygen demand (COD):sulphate ratio of 4 on the operational performance of anaerobic hybrid reactors treating molasses wastewater was investigated under mesophilic and thermophilic conditions in a long-term laboratory-scale study over a 1,081 day period. The presence of sulphate reduced the COD removal efficiency under both mesophilic and thermophilic conditions. At 55 degrees C, effluent acetate levels were consistently greater than 4000 mg l(-1) indicating that thermophilic acetate-utilising methane-producing bacteria (MPB) or sulphate-reducing bacteria (SRB) had not developed in the reactor under the conditions applied. At 37 degrees C, acetate was exclusively utilised by acetoclastic methanogens, whereas H2-utilising SRB predominated over H2-utilising MPB in the competition for hydrogen. By contrast, hydrogenotrophic MPB were shown to outcompete H2-utilising SRB during long-term thermophilic operation. 16SrDNA analysis of the seed sludge and reactor biomass on conclusion of the 37 degrees C and 55 degrees C trials illustrated that the dominant methanogen present on conclusion of the thermophilic trial in the absence of influent sulphate was related to Methanocorpusculum parvuum, and was capable of growth on both acetate and hydrogen. By contrast, an organism closely related to Methanobacterium thermoautotrophicum was the dominant methanogen present in the sulphate-fed reactor on completion of the thermophilic trial.

Impact of a bronchiolitis guideline on ED resource use and cost: a segmented time-series analysis.

PubMed

Akenroye, Ayobami T; Baskin, Marc N; Samnaliev, Mihail; Stack, Anne M

2014-01-01

Bronchiolitis is a major cause of infant morbidity and contributes to millions of dollars in health care costs. Care guidelines may cut costs by reducing unnecessary resource utilization. Through the implementation of a guideline, we sought to reduce unnecessary resource utilization and improve the value of care provided to infants with bronchiolitis in a pediatric emergency department (ED). We conducted an interrupted time series that examined ED visits of 2929 patients with bronchiolitis, aged 1 to 12 months old, seen between November 2007 and April 2013. Outcomes were proportion having a chest radiograph (CXR), respiratory syncytial virus (RSV) testing, albuterol or antibiotic administration, and the total cost of care. Balancing measures included admission rate, returns to the ED resulting in admission within 72 hours of discharge, and ED length of stay (LOS). There were no significant preexisting trends in the outcomes. After guideline implementation, there was an absolute reduction of 23% in CXR (95% confidence interval [CI]: 11% to 34%), 11% in RSV testing (95% CI: 6% to 17%), 7% in albuterol use (95% CI: 0.2% to 13%), and 41 minutes in ED LOS (95% CI: 16 to 65 minutes). Mean cost per patient was reduced by $197 (95% CI: $136 to $259). Total cost savings was $196,409 (95% CI: $135,592 to $258,223) over the 2 bronchiolitis seasons after guideline implementation. There were no significant differences in antibiotic use, admission rates, or returns resulting in admission within 72 hours of discharge. A bronchiolitis guideline was associated with reductions in CXR, RSV testing, albuterol use, ED LOS, and total costs in a pediatric ED.

Gender differences in excessive daytime sleepiness among Japanese workers.

PubMed

Doi, Yuriko; Minowa, Masumi

2003-02-01

Excessive daytime sleepiness (EDS) is serious concern in the workplace with respect to errors, accidents, absenteeism, reduced productivity and impaired personal or professional life. Previous community studies found a female preponderance of EDS, however, there is little research on EDS and gender in occupational settings. We examined the gender differences in prevalence and risk factors of EDS among employees working at a telecommunications company in the Tokyo metropolitan area. Our outcome measure of EDS was the Epworth Sleepiness Scale (ESS). A self-administered questionnaire on health and sleep including ESS was distributed to 5,571 workers between December 1999 and January 2000, and 5,072 responses were returned (91.0%). A total of 4,722 full-time, non-manual and non-shift employees aged 20-59 were used for analysis (3,909 men and 813 women). Chi-squared tests and multiple logistic regression analyses were applied for examining the gender differences in the prevalence and risk factors of EDS. The prevalence rates of EDS were 13.3% for women and 7.2% for men (P<0.001). We identified that deprived nocturnal sleep, an irregular sleep-wake schedule and depression were the risk factors of EDS for both genders, and being married worked as a protective factor against EDS for men alone. It is obvious that a ban on overtime work and a provision of mental health hygiene are the general strategies for reducing EDS at worksites. In the case of women, we suggest the formation of effective strategies for improving women's status at home and in the workplace must also be a solution for the prevention of EDS (e.g. promoting gender equality in the division of labor at home and strengthening family care policies for working women).

Energy drink use frequency among an international sample of people who use drugs: Associations with other substance use and well-being.

PubMed

Peacock, Amy; Bruno, Raimondo; Ferris, Jason; Winstock, Adam

2017-05-01

The study aims were to identify: i.) energy drink (ED), caffeine tablet, and caffeine intranasal spray use amongst a sample who report drug use, and ii.) the association between ED use frequency and demographic profile, drug use, hazardous drinking, and wellbeing. Participants (n=74,864) who reported drug use completed the online 2014 Global Drug Survey. They provided data on demographics, ED use, and alcohol and drug use, completed the Alcohol Use Disorders Identification Test (AUDIT) and Personal Wellbeing Index (PWI), and reported whether they wished to reduce alcohol use. Lifetime ED, caffeine tablet and intranasal caffeine spray use were reported by 69.2%, 24.5% and 4.9%. Median age of ED initiation was 16 years. For those aged 16-37, median years using EDs increased from 4 to 17 years of consumption, where it declined thereafter. Greater ED use frequency was associated with: being male; under 21 years of age; studying; and past year caffeine tablet/intranasal spray, tobacco, cannabis, amphetamine, MDMA, and cocaine use. Past year, infrequent (1-4days) and frequent (≥5days) past month ED consumers reported higher AUDIT scores and lower PWI scores than lifetime abstainers; past month consumers were less likely to report a desire to reduce alcohol use. ED use is part of a complex interplay of drug use, alcohol problems, and poorer personal wellbeing, and ED use frequency may be a flag for current/future problems. Prospective research is required exploring where ED use fits within the trajectory of other alcohol and drug use. Copyright © 2017 Elsevier B.V. All rights reserved.

Evaluating the impact of a partnership for creating change in substance misuse practice in St. Petersburg, Russia.

PubMed

Green, Anita J; Holloway, David G

2005-11-01

This paper reports on an evaluation of an innovative education and training programme for nurses and narcologists in St. Petersburg, Russia. The aims of the evaluation were: first, to evaluate the effect of the education and training programme on the clinical practice of doctors and nurses who have had direct contact with the programme and, second, to evaluate the influence of the education and training programme on city-wide drug and alcohol policy and practice. Brief contextual information regarding the programme is provided prior to an account of the qualitative methodology. Particular attention was paid to the work of Patton [Utilisation-focused evaluation, second ed., Sage, London, 1986; Qualitative research and evaluation methods, third ed., Sage, London, 2002] for the theoretical framework and to Hantais and Mangen [Cross-national research methods in the social sciences, Pinter, London, 1996] regarding the methodological issues that surround international and cross-cultural research projects. Data collection was carried out in St. Petersburg and in the United Kingdom, which involved key participants in the programme. The data analysis followed Miles and Huberman [Qualitative data analysis. An expanded sourcebook, second ed. Sage, Thousand Oaks, 1994] which yielded six major themes: rehabilitation, the role and continuing professional development of the trained nurse; the status of the nurse training-college and the staff, small scale projects and their significance; sharing experiences/networking/face-to-face meetings; and, lack of resistance. The findings are discussed and recommendations for further involvement are identified.

Two-Step Process for ED UTI Screening in Febrile Young Children: Reducing Catheterization Rates.

PubMed

Lavelle, Jane M; Blackstone, Mercedes M; Funari, Mary Kate; Roper, Christine; Lopez, Patricia; Schast, Aileen; Taylor, April M; Voorhis, Catherine B; Henien, Mira; Shaw, Kathy N

2016-07-01

Urinary tract infection (UTI) screening in febrile young children can be painful and time consuming. We implemented a screening protocol for UTI in a high-volume pediatric emergency department (ED) to reduce urethral catheterization, limiting catheterization to children with positive screens from urine bag specimens. This quality-improvement initiative was implemented using 3 Plan-Do-Study-Act cycles, beginning with a small test of the proposed change in 1 ED area. To ensure appropriate patients received timely screening, care teams discussed patient risk factors and created patient-specific, appropriate procedures. The intervention was extended to the entire ED after providing education. Finally, visual cues were added into the electronic health record, and nursing scripts were developed to enlist family participation. A time-series design was used to study the impact of the 6-month intervention by using a p-chart to determine special cause variation. The primary outcome measure for the study was defined as the catheterization rate in febrile children ages 6 to 24 months. The ED reduced catheterization rates among febrile young children from 63% to <30% over a 6-month period with sustained results. More than 350 patients were spared catheterization without prolonging ED length of stay. Additionally, there was no change in the revisit rate or missed UTIs among those followed within the hospital's network. A 2-step less-invasive process for screening febrile young children for UTI can be instituted in a high-volume ED without increasing length of stay or missing cases of UTI. Copyright © 2016 by the American Academy of Pediatrics.

Disease management program for chronic obstructive pulmonary disease: a randomized controlled trial.

PubMed

Rice, Kathryn L; Dewan, Naresh; Bloomfield, Hanna E; Grill, Joseph; Schult, Tamara M; Nelson, David B; Kumari, Sarita; Thomas, Mel; Geist, Lois J; Beaner, Caroline; Caldwell, Michael; Niewoehner, Dennis E

2010-10-01

The effect of disease management for chronic obstructive pulmonary disease (COPD) is not well established. To determine whether a simplified disease management program reduces hospital admissions and emergency department (ED) visits due to COPD. We performed a randomized, adjudicator-blinded, controlled, 1-year trial at five Veterans Affairs medical centers of 743 patients with severe COPD and one or more of the following during the previous year: hospital admission or ED visit for COPD, chronic home oxygen use, or course of systemic corticosteroids for COPD. Control group patients received usual care. Intervention group patients received a single 1- to 1.5-hour education session, an action plan for self-treatment of exacerbations, and monthly follow-up calls from a case manager. We determined the combined number of COPD-related hospitalizations and ED visits per patient. Secondary outcomes included hospitalizations and ED visits for all causes, respiratory medication use, mortality, and change in Saint George's Respiratory Questionnaire. After 1 year, the mean cumulative frequency of COPD-related hospitalizations and ED visits was 0.82 per patient in usual care and 0.48 per patient in disease management (difference, 0.34; 95% confidence interval, 0.15-0.52; P < 0.001). Disease management reduced hospitalizations for cardiac or pulmonary conditions other than COPD by 49%, hospitalizations for all causes by 28%, and ED visits for all causes by 27% (P < 0.05 for all). A relatively simple disease management program reduced hospitalizations and ED visits for COPD. Clinical trial registered with www.clinicaltrials.gov (NCT00126776).

Methylphenidate and the risk of trauma.

PubMed

Man, Kenneth K C; Chan, Esther W; Coghill, David; Douglas, Ian; Ip, Patrick; Leung, Ling-Pong; Tsui, Matthew S H; Wong, Wilfred H S; Wong, Ian C K

2015-01-01

Children and adolescents with attention-deficit/hyperactivity disorder (ADHD) are prone to sustaining trauma that requires emergency department (ED) admission. Methylphenidate (MPH) can reduce ADHD symptoms and may thus theoretically reduce the risk of trauma-related ED admission, but previous studies do not make this association clear. This study examines this association. A total of 17 381 patients aged 6 to 19 years who received MPH prescriptions were identified by using the Clinical Data Analysis & Reporting System (2001-2013). Using a self-controlled case series study design, the relative incidence of trauma-related ED admissions was compared with periods of patient exposure and nonexposure to MPH. Among 17 381 patients prescribed MPH, 4934 had at least 1 trauma-related ED admission. The rate of trauma-related ED admission was lower during exposed periods compared with nonexposed periods (incidence rate ratio [IRR]: 0.91 [95% confidence interval (CI): 0.86-0.97]). The findings were similar only when the incident trauma episode was assessed (IRR: 0.89 [95% CI: 0.82-0.96]). A similar protective association was found in both genders. In validation analysis using nontrauma-related ED admissions as a negative control outcome, no statistically significant association was found (IRR: 0.99 [95% CI: 0.95-1.02]). All sensitivity analyses demonstrated consistent results. This study supports the hypothesis that MPH is associated with a reduced risk of trauma-related ED admission in children and adolescents. A similar protective association was found in both male and female patients. This protective association should be considered in clinical practice. Copyright © 2015 by the American Academy of Pediatrics.

Does charging different user fees for primary and secondary care affect first-contacts with primary healthcare? A systematic review

PubMed Central

Hone, Thomas; Lee, John Tayu; Majeed, Azeem; Conteh, Lesong; Millett, Christopher

2017-01-01

Abstract Policy-makers are increasingly considering charging users different fees between primary and secondary care (differential user charges) to encourage utilisation of primary health care in health systems with limited gate keeping. A systematic review was conducted to evaluate the impact of introducing differential user charges on service utilisation. We reviewed studies published in MEDLINE, EMBASE, the Cochrane library, EconLIT, HMIC, and WHO library databases from January 1990 until June 2015. We extracted data from the studies meeting defined eligibility criteria and assessed study quality using an established checklist. We synthesized evidence narratively. Eight studies from six countries met our eligibility criteria. The overall study quality was low, with diversity in populations, interventions, settings, and methods. Five studies examined the introduction of or increase in user charges for secondary care, with four showing decreased secondary care utilisation, and three showing increased primary care utilisation. One study identified an increase in primary care utilisation after primary care user charges were reduced. The introduction of a non-referral charge in secondary care was associated with lower primary care utilisation in one study. One study compared user charges across insurance plans, associating higher charges in secondary care with higher utilisation in both primary and secondary care. Overall, the impact of introducing differential user-charges on primary care utilisation remains uncertain. Further research is required to understand their impact as a demand side intervention, including implications for health system costs and on utilisation among low-income patients. PMID:28453713

Solar cells based on electrodeposited thin films of ZnS, CdS, CdSSe and CdTe

NASA Astrophysics Data System (ADS)

Weerasinghe, Ajith R.

The motivations of this research were to produce increased efficiency and low-cost solar cells. The production efficiency of Si solar cells has almost reached their theoretical limit, and reducing the manufacturing cost of Si solar cells is difficult to achieve due to the high-energy usage in material purifying and processing stages. Due to the low usage of materials and input energy, thin film solar cells have the potential to reduce the costs. CdS/CdTe thin film solar cells are already the cheapest on $/W basis. The cost of CdTe solar cells can be further reduced if all the semiconducting layers are fabricated using the electrodeposition (ED) method. ED method is scalable, low in the usage of energy and raw materials. These benefits lead to the cost effective production of semiconductors. The conventional method of fabricating CdS layers produces Cd containing waste solutions routinely, which adds to the cost of solar cells.ZnS, CdS and CdS(i-X)Sex buffer and window layers and CdTe absorber layers have been successfully electrodeposited and explored under this research investigation. These layers were fully characterised using complementary techniques to evaluate the material properties. Photoelectrochemical (PEC) studies, optical absorption, X-ray diffraction (XRD), X-ray fluorescence (XRF), scanning electron microscopy (SEM), energy-dispersive X-ray (EDX) spectroscopy, atomic force microscopy (AFM) and Raman spectroscopy were utilised to evaluate the material properties of these solid thin film layers. ZnS and CdS thin film layers were electrodeposited from Na-free chemical precursors to avoid the group I element (Na) to reduce deterioration of CdTe devices. Deposition parameters such as, growth substrates, temperature, pH, growth cathodic voltage, stirring rate, time and chemical concentrations were identified to fabricate the above semiconductors. To further optimise these layers, a heat treatment process specific to the material was developed. In addition, the deposition parameters of CdTe layers were further optimised. This research programme has demonstrated that electrodeposited ZnS, CdS and CdTe thin film layers have material characteristics comparable with those of the materials reported in the literature and can be used in thin film solar cell devices. Furthermore, the electrolytes were used for up to two years, reducing the wastage even further, in comparison to other fabrication methods, such as chemical bath deposition. Several large-area semiconducting layers were successfully fabricated to test the scalability of the method. Nano-rods perpendicular to the glass/FTO surface with gaps among grains in CdS layers were observed. In order to reduce the possible pinholes due the gaps, a deposition of a semiconducting layer to cover completely the substrate was investigated. CdS(i-X)Sex layers were investigated to produce a layer-by-layer deposition of the material. However it was observed the surface morphology of CdS(j.X)Sex is a function of the growth parameters which produced nano-wires, nano-tubes and nano-sheets. This is the first recording of this effect for a low temperature deposition method, minimising the cost of producing this highly photosensitive material for use in various nano technology applications.The basic structure experimented was glass/conducting-glass/buffer layer/window material/absorber material/metal. By utilising all the semiconducting layers developed, several solar cell device structures were designed, fabricated and tested. This included a novel all-electrodeposited multi-layer graded bandgap device, to enhance the absorption of solar photons. The device efficiencies varied from batch to batch, and efficiencies in the range (3-7)% were observed. The variations in chemical concentrations, surface states and the presence of pin-hole defects in CdS were the main reasons for the range of efficiencies obtained. In the future work section, ways to avoid these variations and to increase efficiencies are identified and presented.

Human endometrial cell coculture reduces the endocrine disruptor toxicity on mouse embryo development

PubMed Central

2012-01-01

Backgrounds Previous studies suggested that endocrine disruptors (ED) are toxic on preimplantation embryos and inhibit development of embryos in vitro culture. However, information about the toxicity of endocrine disruptors on preimplantation development of embryo in human reproductive environment is lacking. Methods Bisphenol A (BPA) and Aroclor 1254 (polychlorinated biphenyls) were used as endocrine disruptors in this study. Mouse 2-cell embryos were cultured in medium alone or vehicle or co-cultured with human endometrial epithelial layers in increasing ED concentrations. Results At 72 hours the percentage of normal blastocyst were decreased by ED in a dose-dependent manner while the co-culture system significantly enhanced the rate and reduced the toxicity of endocrine disruptors on the embryonic development in vitro. Conclusions In conclusion, although EDs have the toxic effect on embryo development, the co-culture with human endometrial cell reduced the preimplantation embryo from it thereby making human reproductive environment protective to preimplantation embryo from the toxicity of endocrine disruptors. PMID:22546201

Transfer of care and offload delay: continued resistance or integrative thinking?

PubMed

Schwartz, Brian

2015-11-01

The disciplines of paramedicine and emergency medicine have evolved synchronously over the past four decades, linked by emergency physicians with expertise in prehospital care. Ambulance offload delay (OD) is an inevitable consequence of emergency department overcrowding (EDOC) and compromises the care of the patient on the ambulance stretcher in the emergency department (ED), as well as paramedic emergency medical service response in the community. Efforts to define transfer of care from paramedics to ED staff with a view to reducing offload time have met with resistance from both sides with different agendas. These include the need to return paramedics to serve the community versus the lack of ED capacity to manage the patient. Innovative solutions to other system issues, such as rapid access to trauma teams, reducing door-to-needle time, and improving throughput in the ED to reduce EDOC, have been achieved by involving all stakeholders in an integrative thinking process. Only by addressing this issue in a similar integrative process will solutions to OD be realized.

The effects and outcomes of electrolyte disturbances and asphyxia on newborns hearing

PubMed Central

Liang, Chun; Hong, Qi; Jiang, Tao-Tao; Gao, Yan; Yao, Xiao-Fang; Luo, Xiao-Xing; Zhuo, Xiu-Hui; Shinn, Jennifer B.; Jones, Raleigh O.; Zhao, Hong-Bo; Lu, Guang-Jin

2013-01-01

Objective To determine the effect of electrolyte disturbances (ED) and asphyxia on infant hearing and hearing outcomes. Study Design We conducted newborn hearing screening with transient evoked otoacoustic emission (TEOAE) test on a large scale (>5,000 infants). The effects of ED and asphyxia on infant hearing and hearing outcomes were evaluated. Result The pass rate of TEOAE test was significantly reduced in preterm infants with ED (83.1%, multiple logistic regression analysis: P<0.01) but not in full-term infants with ED (93.6%, P=0.41). However, there was no significant reduction in the pass rate in infants with asphyxia (P=0.85). We further found that hypocalcaemia significantly reduced the pass rate of TEOAE test (86.8%, P<0.01). In the follow-up recheck at 3 months of age, the pass rate remained low (44.4%, P<0.01). Conclusion ED is a high-risk factor for preterm infant hearing. Hypocalcaemia can produce more significant impairment with a low recovery rate. PMID:23648318

Does the Broad Categories for the Diagnosis of Eating Disorders (BCD-ED) Scheme Reduce the Frequency of Eating Disorder not Otherwise Specified?

PubMed Central

Sysko, Robyn; Walsh, B. Timothy

2010-01-01

Objective This study evaluated whether the Broad Categories for the Diagnosis of Eating Disorders (BCD-ED) proposal (Walsh & Sysko, 2009) reduces the number of individuals who receive a DSM-IV eating disorder not otherwise specified (EDNOS) diagnosis. Method Individuals calling a tertiary care facility completed a brief telephone interview and were classified into a DSM-IV eating disorder category (anorexia nervosa, bulimia nervosa, EDNOS). Subsequently, the proposed DSM-5 criteria for eating disorders and the BCD-ED scheme were also applied. Results A total of 247 individuals with telephone interview data met criteria for an eating disorder, including 97 (39.3%) with an EDNOS. Of patients with an EDNOS diagnosis, 97.6% were re-classified using the BCD-ED scheme. Discussion The BCD-ED scheme has the potential to virtually eliminate the use of DSM-IV EDNOS; however, additional data are needed to document its validity and clinical utility. PMID:21997426

The use of hospital emergency departments for nonurgent health problems: a national perspective.

PubMed

Cunningham, P J; Clancy, C M; Cohen, J W; Wilets, M

1995-11-01

The use of the hospital emergency department (ED) for nonurgent health problems has been a subject of considerable controversy, in part because there is no widely accepted definition of "nonurgent." Elimination or substantial reduction in nonurgent ED use is frequently offered as a strategy for reducing health expenditures. Previous studies, often limited to individual hospitals or communities, have limited generalizability and do not permit examination of multiple factors likely to influence nonurgent ED utilization or examination of ED use for nonurgent problems in the context of overall outpatient utilization. This analysis of the 1987 National Medical Expenditure Survey (NMES) provides a nationally representative examination of nonurgent ED utilization that describes the frequency of ED use for nonurgent problems, characteristics of individuals that are associated with an increased likelihood of nonurgent ED use, the use of other outpatient physician services, and expenditures associated with nonurgent ED visits.

The role of training dose in drug discrimination: a review

PubMed Central

Stolerman, Ian P; Childs, Emma; Ford, Matthew M; Grant, Kathleen A

2011-01-01

Drug discrimination has been an important technique in behavioural pharmacology for at least 40 years. The characteristics of drug-produced discriminative stimuli are influenced by behavioural and pharmacological variables, including the doses used to establish discriminations. This review covers studies on the effects of varying the training dose of a drug in a search for general principles that are applicable across different drug classes and methodological approaches. With respect to quantitative changes, relationships between training dose and rate of acquisition or magnitude of stimulus control were found for most drug classes. Acquisition accelerated with dose up to a point beyond which drug-induced impairments of performance had a deleterious impact. Sensitivity to the training drug as measured by ED50 values typically increased when the training dose was reduced. Qualitative changes were more complex and appeared to fall into three categories: (i) changes in profiles of generalisation between partial and full agonists; (ii) reduced specificity of some discriminations at small training doses and (iii) changes in the relative salience of actions mediated through different neurotransmitter systems or from central and peripheral sites. Three-lever discrimination procedures incorporating ‘drug versus drug’ or “dose versus dose” contingencies enabled detection of more subtle differences than the simple ‘drug versus no drug’ approach when applied to the opioid, hallucinogen and barbiturate classes of drugs. These conclusions have implications for the interpretation of data from studies that utilise either within- or between-subject designs for studying the discriminative stimulus effects of drugs. PMID:21808191

Epilepsy - overview

MedlinePlus

... or antiepileptic drugs), may reduce the number of future seizures: These drugs are taken by mouth. Which ... 23986299 . Wiebe S. The epilepsies. In: Goldman L, Schafer AI, eds. Goldman's Cecil Medicine . 25th ed. Philadelphia, PA: ...

Applying Systems Engineering Reduces Radiology Transport Cycle Times in the Emergency Department.

PubMed

White, Benjamin A; Yun, Brian J; Lev, Michael H; Raja, Ali S

2017-04-01

Emergency department (ED) crowding is widespread, and can result in care delays, medical errors, increased costs, and decreased patient satisfaction. Simultaneously, while capacity constraints on EDs are worsening, contributing factors such as patient volume and inpatient bed capacity are often outside the influence of ED administrators. Therefore, systems engineering approaches that improve throughput and reduce waste may hold the most readily available gains. Decreasing radiology turnaround times improves ED patient throughput and decreases patient waiting time. We sought to investigate the impact of systems engineering science targeting ED radiology transport delays and determine the most effective techniques. This prospective, before-and-after analysis of radiology process flow improvements in an academic hospital ED was exempt from institutional review board review as a quality improvement initiative. We hypothesized that reorganization of radiology transport would improve radiology cycle time and reduce waste. The intervention included systems engineering science-based reorganization of ED radiology transport processes, largely using Lean methodologies, and adding no resources. The primary outcome was average transport time between study order and complete time. All patients presenting between 8/2013-3/2016 and requiring plain film imaging were included. We analyzed electronic medical record data using Microsoft Excel and SAS version 9.4, and we used a two-sample t-test to compare data from the pre- and post-intervention periods. Following the intervention, average transport time decreased significantly and sustainably. Average radiology transport time was 28.7 ± 4.2 minutes during the three months pre-intervention. It was reduced by 15% in the first three months (4.4 minutes [95% confidence interval [CI] 1.5-7.3]; to 24.3 ± 3.3 min, P=0.021), 19% in the following six months (5.4 minutes, 95% CI [2.7-8.2]; to 23.3 ± 3.5 min, P=0.003), and 26% one year following the intervention (7.4 minutes, 95% CI [4.8-9.9]; to 21.3 ± 3.1 min, P=0.0001). This result was achieved without any additional resources, and demonstrated a continual trend towards improvement. This innovation demonstrates the value of systems engineering science to increase efficiency in ED radiology processes. In this study, reorganization of the ED radiology transport process using systems engineering science significantly increased process efficiency without additional resource use.

Increasing low-energy-dense foods and decreasing high-energy-dense foods differently influence weight loss trial outcomes

PubMed Central

Vadiveloo, M; Parker, H; Raynor, H

2018-01-01

BACKGROUND/OBJECTIVE Although reducing energy density (ED) enhances weight loss, it is unclear whether all dietary strategies that reduce ED are comparable, hindering effective ED guidelines for obesity treatment. This study examined how changes in number of low-energy-dense (LED) (<4.186 kJ/1.0 kcal g−1) and high-energy-dense (HED) (>12.56 kJ/3.0 kcal g−1) foods consumed affected dietary ED and weight loss within an 18-month weight loss trial. METHODS This secondary analysis examined data from participants randomized to an energy-restricted lifestyle intervention or lifestyle intervention plus limited non-nutrient dense, energy-dense food variety (n = 183). Number of daily LED and HED foods consumed was calculated from three, 24-h dietary recalls and anthropometrics were measured at 0, 6 and 18 months. Multivariable-adjusted generalized linear models and repeated-measures mixed linear models examined associations between 6-month changes in number of LED and HED foods and changes in ED, body mass index (BMI), and percent weight loss at 6 and 18 months. RESULTS Among mostly female (58%), White (92%) participants aged 51.9 years following an energy-restricted diet, increasing number of LED foods or decreasing number of HED foods consumed was associated with 6- and 18-month reductions in ED (β = − 0.25 to − 0.38 kJ g−1 (−0.06 to − 0.09 kcal g−1), P<0.001). Only increasing number of LED foods consumed was associated with 6- and 18-month reductions in BMI (β = − 0.16 to − 0.2 kg m−2, P<0.05) and 6-month reductions in percent weight loss (β = − 0.5%, P<0.05). Participants consuming ≤2 HED foods per day and ≥6.6 LED foods per day experienced better weight loss outcomes at 6- and 18-month than participants only consuming ≤2 HED foods per day. CONCLUSION Despite similar reductions in ED from reducing number of HED foods or increasing number of LED foods consumed, only increasing number of LED foods related to weight loss. This provides preliminary evidence that methods used to reduce dietary ED may differentially influence weight loss trajectories. Randomized controlled trials are needed to inform ED recommendations for weight loss. PMID:29406521

Applying Systems Engineering Reduces Radiology Transport Cycle Times in the Emergency Department

PubMed Central

White, Benjamin A.; Yun, Brian J.; Lev, Michael H.; Raja, Ali S.

2017-01-01

Introduction Emergency department (ED) crowding is widespread, and can result in care delays, medical errors, increased costs, and decreased patient satisfaction. Simultaneously, while capacity constraints on EDs are worsening, contributing factors such as patient volume and inpatient bed capacity are often outside the influence of ED administrators. Therefore, systems engineering approaches that improve throughput and reduce waste may hold the most readily available gains. Decreasing radiology turnaround times improves ED patient throughput and decreases patient waiting time. We sought to investigate the impact of systems engineering science targeting ED radiology transport delays and determine the most effective techniques. Methods This prospective, before-and-after analysis of radiology process flow improvements in an academic hospital ED was exempt from institutional review board review as a quality improvement initiative. We hypothesized that reorganization of radiology transport would improve radiology cycle time and reduce waste. The intervention included systems engineering science-based reorganization of ED radiology transport processes, largely using Lean methodologies, and adding no resources. The primary outcome was average transport time between study order and complete time. All patients presenting between 8/2013–3/2016 and requiring plain film imaging were included. We analyzed electronic medical record data using Microsoft Excel and SAS version 9.4, and we used a two-sample t-test to compare data from the pre- and post-intervention periods. Results Following the intervention, average transport time decreased significantly and sustainably. Average radiology transport time was 28.7 ± 4.2 minutes during the three months pre-intervention. It was reduced by 15% in the first three months (4.4 minutes [95% confidence interval [CI] 1.5–7.3]; to 24.3 ± 3.3 min, P=0.021), 19% in the following six months (5.4 minutes, 95% CI [2.7–8.2]; to 23.3 ± 3.5 min, P=0.003), and 26% one year following the intervention (7.4 minutes, 95% CI [4.8–9.9]; to 21.3 ± 3.1 min, P=0.0001). This result was achieved without any additional resources, and demonstrated a continual trend towards improvement. This innovation demonstrates the value of systems engineering science to increase efficiency in ED radiology processes. Conclusion In this study, reorganization of the ED radiology transport process using systems engineering science significantly increased process efficiency without additional resource use. PMID:28435492

The impact of reducing financial barriers on utilisation of a primary health care facility in Rwanda.

PubMed

Dhillon, Ranu S; Bonds, Matthew H; Fraden, Max; Ndahiro, Donald; Ruxin, Josh

2012-01-01

This study investigates the impact of subsidising community-based health insurance (mutuelle) enrolment, removing point-of-service co-payments, and improving service delivery on health facility utilisation rates in Mayange, a sector of rural Rwanda of approximately 25,000 people divided among five 'imidugudu' or small villages. While comprehensive service upgrades were introduced in the Mayange Health Centre between April 2006 and February 2007, utilisation rates remained similar to comparison sites. Between February 2007 and April 2007, subsidies for mutuelle enrolment established virtually 100% coverage. Immediately after co-payments were eliminated in February 2007, patient visits levelled at a rate triple the previous value. Regression analyses using data from Mayange and two comparison sites indicate that removing financial barriers resulted in about 0.6 additional annual visits for curative care per capita. Although based on a single local pilot, these findings suggest that in order to achieve improved health outcomes, key short-term objectives include improved service delivery and reduced financial barriers. Based on this pilot, higher utilisation rates may be affected if broader swaths of the population are enrolled in mutuelle and co-payments are eliminated. Health leaders in Rwanda should consider further studies to determine if the impact of eliminating co-payments and increasing subsidies for mutuelle enrolment as seen in Mayange holds at greater levels of scale. Broader studies to better elucidate the impact of enrolment subsidies and co-payment subsidies on utilisation, health outcomes, and costs would also provide policy insights.

Energy Density, Energy Intake, and Body Weight Regulation in Adults12345

PubMed Central

Karl, J. Philip; Roberts, Susan B.

2014-01-01

The role of dietary energy density (ED) in the regulation of energy intake (EI) is controversial. Methodologically, there is also debate about whether beverages should be included in dietary ED calculations. To address these issues, studies examining the effects of ED on EI or body weight in nonelderly adults were reviewed. Different approaches to calculating dietary ED do not appear to alter the direction of reported relations between ED and body weight. Evidence that lowering dietary ED reduces EI in short-term studies is convincing, but there are currently insufficient data to determine long-term effectiveness for weight loss. The review also identified key barriers to progress in understanding the role of ED in energy regulation, in particular the absence of a standard definition of ED, and the lack of data from multiple long-term clinical trials examining the effectiveness of low-ED diet recommendations for preventing both primary weight gain and weight regain in nonobese individuals. Long-term clinical trials designed to examine the impact of dietary ED on energy regulation, and including multiple ED calculation methods within the same study, are still needed to determine the importance of ED in the regulation of EI and body weight. PMID:25398750

Influence of Price and Labeling on Energy Drink Purchasing in an Experimental Convenience Store.

PubMed

Temple, Jennifer L; Ziegler, Amanda M; Epstein, Leonard H

2016-01-01

To examine the impact of energy drink (ED) pricing and labeling on the purchase of EDs. Participants visited a laboratory-based convenience store 3 times and purchased a beverage under different ED labeling (none, caffeine content, and warning labels) and pricing conditions. The 36 participants (aged 15-30 years) were classified as energy drink consumers (≥ 2 energy drinks/wk) and nonconsumers (< 1 energy drink/mo). Data were log transformed to generate elasticity coefficients. The authors analyzed changes in elasticity as a function of price and labeling using mixed-effects regression models. Increasing the price of EDs reduced ED purchases and increased purchasing of other caffeinated beverages among ED consumers. Energy drink labels affected ED sales in adolescents. These data suggest that ED pricing and labeling may influence the purchasing of ED, especially in adolescent consumers. Copyright © 2016 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved.

Reductions in entrée energy density increase children's vegetable intake and reduce energy intake.

PubMed

Leahy, Kathleen E; Birch, Leann L; Fisher, Jennifer O; Rolls, Barbara J

2008-07-01

The energy density (ED; kcal/g) of an entrée influences children's energy intake (EI), but the effect of simultaneously changing both ED and portion size of an entrée on preschool children's EI is unknown. In this within-subject crossover study, 3- to 5-year-old children (30 boys, 31 girls) in a daycare facility were served a test lunch once/week for 4 weeks. The amount and type of vegetables and cheeses incorporated into the sauce of a pasta entrée were manipulated to create two versions that varied in ED by 25% (1.6 or 1.2 kcal/g). Across the weeks, each version of the entrée was served to the children in each of two portion sizes (400 or 300 g). Lunch, consumed ad libitum, also included carrots, applesauce, and milk. Decreasing ED of the entrée by 25% significantly (P<0.0001) reduced children's EI of the entrée by 25% (63.1+/-8.3 kcal) and EI at lunch by 17% (60.7+/-8.9 kcal). Increasing the proportion of vegetables in the pasta entrée increased children's vegetable intake at lunch by half of a serving of vegetables (P<0.01). Decreasing portion size of the entrée by 25% did not significantly affect children's total food intake or EI at lunch. Therefore, reducing the ED of a lunch entrée resulted in a reduction in children's EI from the entrée and from the meal in both portion size conditions. Decreasing ED by incorporating more vegetables into recipes is an effective way of reducing children's EI while increasing their vegetable intake.

Effects of energy content and energy density of pre-portioned entrées on energy intake.

PubMed

Blatt, Alexandria D; Williams, Rachel A; Roe, Liane S; Rolls, Barbara J

2012-10-01

Pre-portioned entrées are commonly consumed to help control portion size and limit energy intake. The influence of entrée characteristics on energy intake, however, has not been well studied. We determined how the effects of energy content and energy density (ED, kcal/g) of pre-portioned entrées combine to influence daily energy intake. In a crossover design, 68 non-dieting adults (28 men and 40 women) were provided with breakfast, lunch, and dinner on 1 day a week for 4 weeks. Each meal included a compulsory, manipulated pre-portioned entrée followed by a variety of unmanipulated discretionary foods that were consumed ad libitum. Across conditions, the entrées were varied in both energy content and ED between a standard level (100%) and a reduced level (64%). Results showed that in men, decreases in the energy content and ED of pre-portioned entrées acted independently and added together to reduce daily energy intake (both P < 0.01). Simultaneously decreasing the energy content and ED reduced total energy intake in men by 16% (445 ± 47 kcal/day; P < 0.0001). In women, the entrée factors also had independent effects on energy intake at breakfast and lunch, but at dinner and for the entire day the effects depended on the interaction of the two factors (P < 0.01). Simultaneously decreasing the energy content and ED reduced daily energy intake in women by 14% (289 ± 35 kcal/day; P < 0.0001). Both the energy content and ED of pre-portioned entrées affect daily energy intake and could influence the effectiveness of such foods for weight management.

Testing the effects of educational toilet posters: a novel way of reducing haemolysis of blood samples within ED.

PubMed

Corkill, David

2012-02-01

Haemolysed blood samples are an unnecessary burden on Emergency Departments (ED) as they increase workloads and drive down efficiencies. Little empirical data exists that demonstrates the effectiveness of educational posters displayed in staff toilet cubicles. This study explored the impact educational toilet posters have on reducing haemolysis rates within the ED. A time series study of the clinical effect of educational toilet posters on reducing haemolysis rates throughout a 12 month period at the Gold Coast Hospital ED was undertaken. The GCH ED is a tertiary emergency service that has approximately 66,000 patient presentations per year. Data was collected prospectively. Analysis was undertaken to investigate the effects on total number of haemolysed samples and those clinically significant samples with a haemolytic index >3. Further investigation explored the specific effects on medical and nursing staff. Analysis undertaken using an independent t-test found that the pre-intervention data demonstrates a medium haemolysis rate of 4.92% (SD=1.04). This is a statistically significantly different (t=3.56, df=50, p=0.001) from the median post intervention data of 3.95% (SD=0.84). The difference of 0.97% (95%CI=0.42, 1.52) represents a 19.72% reduction in clinically significant haemolysed samples over the study period. This study reveals that the use of educational toilet posters had a positive impact on reducing the rates of haemolysed samples collected within the ED. This simple and cost effective educational initiative changed the behaviour of clinical staff. Further investigation is warranted to examine the impact of educational toilet posters on additional clinical scenarios. Crown Copyright © 2011. Published by Elsevier Ltd. All rights reserved.

Interventions to reduce the stigma of eating disorders: A systematic review and meta-analysis.

PubMed

Doley, Joanna R; Hart, Laura M; Stukas, Arthur A; Petrovic, Katja; Bouguettaya, Ayoub; Paxton, Susan J

2017-03-01

Stigma is a problem for individuals with eating disorders (EDs), forming a barrier to disclosure and help-seeking. Interventions to reduce ED stigma may help remove these barriers; however, it is not known which strategies (e.g., explaining etiology to reduce blame, contact with a person with an ED, or educating about ED) are effective in reducing stigma and related outcomes. This review described effectiveness of intervention strategies, and identified gaps in the literature. A search of four databases was performed using the terms (eating disorder* OR bulimi* OR anorexi* OR binge-eating disorder) AND (stigma* OR stereotyp* OR beliefs OR negative attitudes) AND (program OR experiment OR intervention OR education), with additional texts sought through LISTSERVs. Two raters screened papers, extracted data, and assessed quality. Stigma reduction strategies and study characteristics were examined in critical narrative synthesis. Exploratory meta-analysis compared the effects of biological and sociocultural explanations of EDs on attitudinal stigma. Eighteen papers were eligible for narrative synthesis, with four also eligible for inclusion in a meta-analysis. Biological explanations reduced stigma relative to other explanations, including sociocultural explanations in meta-analysis (g = .47, p < .001). Combined education and contact interventions improved stigma relative to control groups or over time. Most studies examined Anorexia Nervosa (AN) stigma and had mostly female, undergraduate participants. Despite apparent effectiveness, research should verify that biological explanations do not cause unintentional harm. Future research should evaluate in vivo contact, directly compare education and contact strategies, and aim to generalize findings across community populations. © 2017 Wiley Periodicals, Inc.

Mentoring from Different Social Spheres: How Can Multiple Mentors Help in Doctoral Student Success in Ed.D Programs?

ERIC Educational Resources Information Center

Terry, Tarae; Ghosh, Rajashi

2015-01-01

Doctoral students leave their programs early due to lack of mentoring relationships needed to support degree completion and success. However, how mentoring contributes to Ed.D degree completion is not widely studied. In this qualitative narrative study, we sought to explore how multiple mentoring relationships reduced attrition in an Ed.D program.…

Emergency Department Visits for Nontraumatic Dental Problems: A Mixed-Methods Study

PubMed Central

Chi, Donald L.; Schwarz, Eli; Milgrom, Peter; Yagapen, Annick; Malveau, Susan; Chen, Zunqui; Chan, Ben; Danner, Sankirtana; Owen, Erin; Morton, Vickie; Lowe, Robert A.

2015-01-01

Objectives. We documented emergency department (ED) visits for nontraumatic dental problems and identified strategies to reduce ED dental visits. Methods. We used mixed methods to analyze claims in 2010 from a purposive sample of 25 Oregon hospitals and Oregon’s All Payer All Claims data set and interviewed 51 ED dental visitors and stakeholders from 6 communities. Results. Dental visits accounted for 2.5% of ED visits and represented the second-most-common discharge diagnosis in adults aged 20 to 39 years, were associated with being uninsured (odds ratio [OR] = 5.2 [reference: commercial insurance]; 95% confidence interval [CI] = 4.8, 5.5) or having Medicaid insurance (OR = 4.0; 95% CI = 3.7, 4.2), resulted in opioid (56%) and antibiotic (56%) prescriptions, and generated $402 (95% CI = $396, $408) in hospital costs per visit. Interviews revealed health system, community, provider, and patient contributors to ED dental visits. Potential solutions provided by interviewees included Medicaid benefit expansion, care coordination, water fluoridation, and patient education. Conclusions. Emergency department dental visits are a significant and costly public health problem for vulnerable individuals. Future efforts should focus on implementing multilevel interventions to reduce ED dental visits. PMID:25790415

Utilization of physiotherapy in the continuum of stroke care at a tertiary hospital in Ibadan, Nigeria.

PubMed

Olaleye, Olubukola Adebisi; Lawal, Zainab Iyabo

2017-03-01

To investigate the pattern of referral for and utilisation of physiotherapy in the continuum of stroke care at a tertiary hospital in Ibadan, Nigeria. Referral notes and medical records of patients admitted in the University College Hospital, Ibadan with a clinical diagnosis of stroke between January, 2009 and December, 2013 were retrospectively reviewed. Information on age, sex, type of stroke, length of hospital stay, referral for physiotherapy and utilisation of physiotherapy were retrieved. Data were summarised using descriptive statistics and analysed using Chi-square test. A total of 783 patients with stroke were admitted in the hospital during the period under study. The in-patient mortality rate was 37.2%. The mean Length of Hospital Stay (LoHS) was 16.17±12.34 days. Referral rate for physiotherapy was high (75.8%) and the mean time from admission to referral for physiotherapy was three days. Majority of patients referred utilised physiotherapy (63.4%) and mean number of physiotherapy sessions received during in-patient care was 8.69±6.45. There was a significant association between LoHS and utilisation of in-patientphysiotherapy (p=0.02). The referral rate of stroke patients for physiotherapy was relatively high. Utilisation of in-patient physiotherapy reduced length of hospital stay among patients with stroke. Utilisation of out-patient physiotherapy was low. Strategies to enhance out-patient utilisation should be explored.

Applying the Lean principles of the Toyota Production System to reduce wait times in the emergency department.

PubMed

Ng, David; Vail, Gord; Thomas, Sophia; Schmidt, Nicki

2010-01-01

In recognition of patient wait times, and deteriorating patient and staff satisfaction, we set out to improve these measures in our emergency department (ED) without adding any new funding or beds. In 2005 all staff in the ED at Hôtel-Dieu Grace Hospital began a transformation, employing Toyota Lean manufacturing principles to improve ED wait times and quality of care. Lean techniques such as value-stream mapping, just-in-time delivery techniques, workplace organization, reduction of systemic wastes, use of the worker as the source of quality improvement and ongoing refinement of our process steps formed the basis of our project. Our ED has achieved major improvements in departmental flow without adding any additional ED or inpatient beds. The mean registration to physician time has decreased from 111 minutes to 78 minutes. The number of patients who left without being seen has decreased from 7.1% to 4.3%. The length of stay (LOS) for discharged patients has decreased from a mean of 3.6 to 2.8 hours, with the largest decrease seen in our patients triaged at levels 4 or 5 using the Canadian Emergency Department Triage and Acuity Scale. We noted an improvement in ED patient satisfaction scores following the implementation of Lean principles. Lean manufacturing principles can improve the flow of patients through the ED, resulting in greater patient satisfaction along with reduced time spent by the patient in the ED.

Cardiology Consultation in the Emergency Department Reduces Re-hospitalizations for Low-Socioeconomic Patients with Acute Decompensated Heart Failure.

PubMed

Tabit, Corey E; Coplan, Mitchell J; Spencer, Kirk T; Alcain, Charina F; Spiegel, Thomas; Vohra, Adam S; Adelman, Daniel; Liao, James K; Sanghani, Rupa Mehta

2017-09-01

Re-hospitalization after discharge for acute decompensated heart failure is a common problem. Low-socioeconomic urban patients suffer high rates of re-hospitalization and often over-utilize the emergency department (ED) for their care. We hypothesized that early consultation with a cardiologist in the ED can reduce re-hospitalization and health care costs for low-socioeconomic urban patients with acute decompensated heart failure. There were 392 patients treated at our center for acute decompensated heart failure who received standardized education and follow-up. Patients who returned to the ED received early consultation with a cardiologist; 392 patients who received usual care served as controls. Thirty- and 90-day re-hospitalization, ED re-visits, heart failure symptoms, mortality, and health care costs were recorded. Despite guideline-based education and follow-up, the rate of ED re-visits was not different between the groups. However, the rate of re-hospitalization was significantly lower in patients receiving the intervention compared with controls (odds ratio 0.592), driven by a reduction in the risk of readmission from the ED (0.56 vs 0.79, respectively). Patients receiving the intervention accumulated 14% fewer re-hospitalized days than controls and 57% lower 30-day total health care cost. Despite the reduction in health care resource consumption, mortality was unchanged. After accounting for the total cost of intervention delivery, the health care cost savings was substantially greater than the cost of intervention delivery. Early consultation with a cardiologist in the ED as an adjunct to guideline-based follow-up is associated with reduced re-hospitalization and health care cost for low-socioeconomic urban patients with acute decompensated heart failure. Copyright © 2017 Elsevier Inc. All rights reserved.

Administration of the non-steroidal anti-inflammatory drug ibuprofen increases macrophage concentrations but reduces necrosis during modified muscle use

NASA Technical Reports Server (NTRS)

Cheung, E. V.; Tidball, J. G.

2003-01-01

OBJECTIVE: To test the hypothesis that ibuprofen administration during modified muscle use reduces muscle necrosis and invasion by select myeloid cell populations. METHODS: Rats were subjected to hindlimb unloading for 10 days, after which they experienced muscle reloading by normal weight-bearing to induce muscle inflammation and necrosis. Some animals received ibuprofen by intraperitoneal injection 8 h prior to the onset of muscle reloading, and then again at 8 and 16 h following the onset of reloading. Other animals received buffer injection at 8 h prior to reloading and then ibuprofen at 8 and 16 h following the onset of reloading. Control animals received buffer only at each time point. Quantitative immunohistochemical analysis was used to assess the presence of necrotic muscle fibers, total inflammatory infiltrate, neutrophils, ED1+ macrophages and ED2+ macrophages at 24 h following the onset of reloading. RESULT: Administration of ibuprofen beginning 8 h prior to reloading caused significant reduction in the concentration of necrotic fibers, but increased the concentration of inflammatory cells in muscle. The increase in inflammatory cells was attributable to a 2.6-fold increase in the concentration of ED2+ macrophages. Animals treated with ibuprofen 8 h following the onset of reloading showed no decrease in muscle necrosis or increase in ED2+ macrophage concentrations. CONCLUSION: Administration of ibuprofen prior to increased muscle loading reduces muscle damage, but increases the concentration of macrophages that express the ED2 antigen. The increase in ED2+ macrophage concentration and decrease in necrosis may be mechanistically related because ED2+ macrophages have been associated with muscle regeneration and repair.

Hospital in the Nursing Home program reduces emergency department presentations and hospital admissions from residential aged care facilities in Queensland, Australia: a quasi-experimental study.

PubMed

Fan, Lijun; Hou, Xiang-Yu; Zhao, Jingzhou; Sun, Jiandong; Dingle, Kaeleen; Purtill, Rhonda; Tapp, Sam; Lukin, Bill

2016-02-09

There has been considerable publicity regarding population ageing and hospital emergency department (ED) overcrowding. Our study aims to investigate impact of one intervention piloted in Queensland Australia, the Hospital in the Nursing Home (HiNH) program, on reducing ED and hospital attendances from residential aged care facilities (RACFs). A quasi-experimental study was conducted at an intervention hospital undertaking the program and a control hospital with normal practice. Routine Queensland health information system data were extracted for analysis. Significant reductions in the number of ED presentations per 1000 RACF beds (rate ratio (95 % CI): 0.78 (0.67-0.92); p = 0.002), number of hospital admissions per 1000 RACF beds (0.62 (0.50-0.76); p < 0.0001), and number of hospital admissions per 100 ED presentations (0.61 (0.43-0.85); p = 0.004) were noticed in the experimental hospital after the intervention; while there were no significant differences between intervention and control hospitals before the intervention. Pre-test and post-test comparison in the intervention hospital also presented significant decreases in ED presentation rate (0.75 (0.65-0.86); p < 0.0001) and hospital admission rate per RACF bed (0.66 (0.54-0.79); p < 0.0001), and a non-significant reduction in hospital admission rate per ED presentation (0.82 (0.61-1.11); p = 0.196). Hospital in the Nursing Home program could be effective in reducing ED presentations and hospital admissions from RACF residents. Implementation of the program across a variety of settings is preferred to fully assess the ongoing benefits for patients and any possible cost-savings.

Implementation of an opioid detoxification management pathway reduces emergency department length of stay.

PubMed

Bellew, Shawna D; Collins, Sean P; Barrett, Tyler W; Russ, Stephan E; Jones, Ian D; Slovis, Corey M; Self, Wesley H

2018-05-25

With the rise of opioid use in the United States, the increasing demand for treatment for opioid use disorders presents both a challenge and an opportunity to develop new care pathways for ED patients seeking opioid detoxification. We set out to improve the care of patients presenting to our ED seeking opioid detoxification by implementing a standardized management pathway and to measure the effects of this intervention. We conducted a before-after study of the effects of an opioid detoxification management pathway on ED length of stay, use of resources (social worker consultation, laboratory tests obtained), and return visits to the same ED within 30 days of discharge. All data were collected retrospectively by review of the electronic health record. Ultimately, 107 patients presented to the ED that met criteria, 52 in the intervention period and 55 in the pre-intervention period. Median ED length of stay in the intervention period was 152 (IQR 93-237) minutes compared to 312 (IQR 187-468) minutes in the pre-intervention period (p<0.001). Patients in the intervention period less frequently had a social work consultation (32.7% vs. 83.6%, p<0.001) or had laboratory tests obtained (32.7% vs 74.5%, p<0.001) and more frequently were prescribed a medication for withdrawal symptoms (57.7% vs. 29.1%, p=0.003). Implementation of an opioid detoxification management pathway reduced ED length of stay, reduced utilization of resources, and increased the proportion of patients prescribed medications for symptom relief. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Brief emergency department interventions for youth who use alcohol and other drugs: a systematic review.

PubMed

Newton, Amanda S; Dong, Kathryn; Mabood, Neelam; Ata, Nicole; Ali, Samina; Gokiert, Rebecca; Vandermeer, Ben; Tjosvold, Lisa; Hartling, Lisa; Wild, T Cameron

2013-05-01

Brief intervention (BI) is recommended for use with youth who use alcohol and other drugs. Emergency departments (EDs) can provide BIs at a time directly linked to harmful and hazardous use. The objective of this systematic review was to determine the effectiveness of ED-based BIs. We searched 14 electronic databases, a clinical trial registry, conference proceedings, and study references. We included randomized controlled trials with youth 21 years or younger. Two reviewers independently selected studies and assessed methodological quality. One reviewer extracted and a second verified data. We summarized findings qualitatively. Two trials with low risk of bias, 2 trials with unclear risk of bias, and 5 trials with high risk of bias were included. Trials evaluated targeted BIs for alcohol-positive (n = 3) and alcohol/other drug-positive youth (n = 1) and universal BIs for youth reporting recent alcohol (n = 4) or cannabis use (n = 1). Few differences were found in favor of ED-based BIs, and variation in outcome measurement and poor study quality precluded firm conclusions for many comparisons. Universal and targeted BIs did not significantly reduce alcohol use more than other care. In one targeted BI trial with high risk of bias, motivational interviewing (MI) that involved parents reduced drinking quantity per occasion and high-volume alcohol use compared with MI that was delivered to youth only. Another trial with high risk of bias reported an increase in abstinence and reduction in physical altercations when youth received peer-delivered universal MI for cannabis use. In 2 trials with unclear risk of bias, MI reduced drinking and driving and alcohol-related injuries after the ED visit. Computer-based MI delivered universally in 1 trial with low risk of bias reduced alcohol-related consequences 6 months after the ED visit. Clear benefits of using ED-based BI to reduce alcohol and other drug use and associated injuries or high-risk behaviours remain inconclusive because of variation in assessing outcomes and poor study quality.

Does charging different user fees for primary and secondary care affect first-contacts with primary healthcare? A systematic review.

PubMed

Hone, Thomas; Lee, John Tayu; Majeed, Azeem; Conteh, Lesong; Millett, Christopher

2017-06-01

Policy-makers are increasingly considering charging users different fees between primary and secondary care (differential user charges) to encourage utilisation of primary health care in health systems with limited gate keeping. A systematic review was conducted to evaluate the impact of introducing differential user charges on service utilisation. We reviewed studies published in MEDLINE, EMBASE, the Cochrane library, EconLIT, HMIC, and WHO library databases from January 1990 until June 2015. We extracted data from the studies meeting defined eligibility criteria and assessed study quality using an established checklist. We synthesized evidence narratively. Eight studies from six countries met our eligibility criteria. The overall study quality was low, with diversity in populations, interventions, settings, and methods. Five studies examined the introduction of or increase in user charges for secondary care, with four showing decreased secondary care utilisation, and three showing increased primary care utilisation. One study identified an increase in primary care utilisation after primary care user charges were reduced. The introduction of a non-referral charge in secondary care was associated with lower primary care utilisation in one study. One study compared user charges across insurance plans, associating higher charges in secondary care with higher utilisation in both primary and secondary care. Overall, the impact of introducing differential user-charges on primary care utilisation remains uncertain. Further research is required to understand their impact as a demand side intervention, including implications for health system costs and on utilisation among low-income patients. © The Author 2017. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Cigarette Smoking and Erectile Dysfunction: Focus on NO Bioavailability and ROS Generation

PubMed Central

Tostes, Rita C.; Carneiro, Fernando S.; Lee, Anthony J.; Giachini, Fernanda R.C.; Leite, Romulo; Osawa, Yoichi; Webb, R. Clinton

2010-01-01

Introduction Thirty million men in the United States suffer from erectile dysfunction (ED) and this number is expected to double by 2025. Considered a major public health problem, which seriously affects the quality of life of patients and their partners, ED becomes increasingly prevalent with age and chronic smoking is a major risk factor in the development of ED. Aim To review available evidence concerning the effects of cigarette smoking on vascular changes associated with decreased nitric oxide (NO) bioavailability and increased reactive oxygen species (ROS) generation. Methods We examined epidemiological and clinical data linking cigarette smoking and ED, and the effects of smoking on vascular NO bioavailability and ROS generation. Main Outcome Measures There are strong parallels between smoking and ED and considerable evidence supporting the concept that smoking-related ED is associated with reduced bioavailability of NO because of increased ROS. Results Cigarette smoking-induced ED in human and animal models is associated with impaired arterial flow to the penis or acute vasospasm of the penile arteries. Long-term smoking produces detrimental effects on the vascular endothelium and peripheral nerves and also causes ultrastructural damage to the corporal tissue, all considered to play a role in chronic smoking-induced ED. Clinical and basic science studies provide strong indirect evidence that smoking may affect penile erection by the impairment of endothelium-dependent smooth muscle relaxation or more specifically by affecting NO production via increased ROS generation. Whether nicotine or other products of cigarette smoke mediate all effects related to vascular damage is still unknown. Conclusions Smoking prevention represents an important approach for reducing the risk of ED. The characterization of the components of cigarette smoke leading to ED and the mechanisms by which these components alter signaling pathways activated in erectile responses are necessary for a complete comprehension of cigarette smoking-associated ED. PMID:18331273

Deer Velvet

MedlinePlus

... activity (as an aphrodisiac), and treat male sexual performance problems (erectile dysfunction, ED). Women use deer velvet to reduce the dose of ... combinations, deer velvet is used to improve athletic performance; to improve ... reproductive disorders including premenstrual syndrome (PMS), ED, and ...

Principles of capacity management, applied in the mental health context.

PubMed

Zeitz, Kathryn; Watson, Darryl

2017-06-22

Objective The aim of the paper was to describe a suite of capacity management principles that have been applied in the mental health setting that resulted in a significant reduction in time spent in two emergency departments (ED) and improved throughput. Methods The project consisted of a multifocal change approach over three phases that included: (1) the implementation of a suite of fundamental capacity management activities led by the service and clinical director; (2) a targeted Winter Demand Plan supported by McKinsey and Co.; and (3) a sustainability of change phase. Descriptive statistics was used to analyse the performance data that was collected through-out the project. Results This capacity management project has resulted in sustained patient flow improvement. There was a reduction in the average length of stay (LOS) in the ED for consumers with mental health presentations to the ED. At the commencement of the project, in July 2014, the average LOS was 20.5h compared with 8.5h in December 2015 post the sustainability phase. In July 2014, the percentage of consumers staying longer than 24h was 26% (n=112); in November and December 2015, this had reduced to 6% and 7 5% respectively (less than one consumer per day). Conclusion Improving patient flow is multifactorial. Increased attendances in public EDs by people with mental health problems and the lengthening boarding in the ED affect the overall ED throughput. Key strategies to improve mental health consumer flow need to focus on engagement, leadership, embedding fundamentals, managing and target setting. What is known about the topic? Improving patient flow in the acute sector is an emerging topic in the health literature in response to increasing pressures of access block in EDs. What does this paper add? This paper describes the application of a suite of patient flow improvement principles that were applied in the mental health setting that significantly reduced the waiting time for consumers in two EDs. What are the implications for practitioners? No single improvement will reduce access block in the ED for mental health consumers. Reductions in waiting times require a concerted, multifocal approach across all components of the acute mental health journey.

Who uses alcohol mixed with energy drinks? Characteristics of college student users.

PubMed

Patrick, Megan E; Macuada, Carlos; Maggs, Jennifer L

2016-01-01

To examine characteristics associated with alcohol mixed with energy drink (AmED) use in a sample of college students. College students (N = 614, 53% female) in their second year of college participated during the fall of 2008. Students completed a cross-sectional survey with questions regarding AmED use. AmED use in the last 30 days was reported by 27% of participants. Logistic regression analyses found that risk factors for AmED included participating in a fraternity/sorority; participating in athletics; living off-campus; having greater fun/social, relax, and image motives for alcohol consumption; and binge drinking. Protective factors included early morning classes, honors program participation, and greater physical/behavioral motives for not drinking. Risk factors for AmED use can identify college students most likely to consume AmEDs and thereby inform screening and intervention efforts to reduce negative AmED-related consequences.

Retarded head growth and neurocognitive development in infants of mothers with a history of eating disorders: longitudinal cohort study.

PubMed

Koubaa, S; Hällström, T; Hagenäs, L; Hirschberg, A L

2013-10-01

To characterise early growth and neurocognitive development in children of mothers with a history of eating disorders (ED). A longitudinal cohort study. Child-care centres in Stockholm, Sweden. Children born to mothers with previous ED (n = 47) (24 anorexia nervosa, 20 bulimia nervosa, 3 unspecified ED), and controls (n = 65). Mean values and standard deviation scores of weight and height from birth to 5 years of age and head circumference up to 18 months of age were compared between groups. Neurocognitive development was studied at the age of 5 years by the validated parent questionnaire Five to Fifteen. Head growth and neurocognitive development. We previously reported that mothers with a history of ED conceived infants with lower birthweight and head circumference than controls. At 3 months of age, body mass index (BMI) was no longer reduced but mean head circumferences of the children born to mothers with ED were smaller throughout the observation period. Similarly, the longitudinal results of the standard deviation scores of head circumference showed a significant overall group effect with lower levels in both subgroups of ED (anorexia nervosa and bulimia nervosa). The children of the ED mothers also had significantly higher Five to Fifteen scores than controls, reflecting difficulties in language skills. Head circumference at birth correlated with language skills in the children of mothers with ED. Children of mothers with previous ED demonstrated an early catch-up in BMI, but the average head circumference continued to be delayed until at least 18 months of age. The reduced head growth was related to delayed neurocognitive development. © 2013 RCOG.

Effect of an emergency department-based electronic system for musculoskeletal consultation on facilitating care for common injuries.

PubMed

Mears, Simon C; Pantle, Hardin A; Bessman, Edward S; Lifchez, Scott D

2015-05-01

Access to musculoskeletal consultation in the emergency department (ED) is a nationwide problem. In addition, consultation from a subspecialist may be delayed or may not be available, which can slow down the ED flow and reduce patient satisfaction. The purpose of this study was to review the 1-year results of a change in the authors' institutional practice to reduce subspecialty consultation for select musculoskeletal problems while still ensuring adequate patient follow-up in orthopedic or plastic surgery clinics for patients not seen by these services in the ED. The authors hypothesized that select injuries could be safely managed in the ED by using an electronic system to ensure appropriate follow-up care. Using Kaizen methodology, a multidisciplinary group (including ED staff, orthopedics, plastic surgery, pediatrics, nursing, radiology, therapy, and administration) met to improve care for select musculoskeletal injuries. A system was agreed on in which ED providers managed select musculoskeletal injuries without subspecialist consultation. Follow-up was organized using an electronic system, which facilitated communication between the ED staff and the secretarial staff of the subspecialist departments. Over a 1-year period, 150 patients were treated using this system. Charts and radiographs were reviewed for missed injuries. Radiographic review revealed 2 missed injuries. One patient had additional back pain and a lumbar spine fracture was found during the subspecialist follow-up visit; it was treated nonoperatively. Another patient appeared to have scapholunate widening on the injury radiograph that was not appreciated in the ED. Of the 150 patients, 51 were seen in follow-up by a subspecialist at the authors' institution. An electronic system to organize follow-up with a subspecialist allowed the ED providers to deliver safe and effective care for simple musculoskeletal injuries. Copyright 2015, SLACK Incorporated.

Examining the sources of occupational stress in an emergency department.

PubMed

Basu, S; Yap, C; Mason, S

2016-12-01

Previous work has established that health care staff, in particular emergency department (ED) personnel, experience significant occupational stress but the underlying stressors have not been well quantified. Such data inform interventions that can reduce cases of occupational mental illness, burnout, staff turnover and early retirement associated with cumulative stress. To develop, implement and evaluate a questionnaire examining the origins of occupational stress in the ED. A questionnaire co-designed by an occupational health practitioner and ED management administered to nursing, medical and support staff in the ED of a large English teaching hospital in 2015. The questionnaire assessed participants' demographic characteristics and perceptions of stress across three dimensions (demand-control-support, effort-reward and organizational justice). Work-related stressors in ED staff were compared with those of an unmatched control group from the acute ear, nose and throat (ENT) and neurology directorate. A total of 104 (59%) ED staff returned questionnaires compared to 72 staff (67%) from the acute ENT/neurology directorate. The ED respondents indicated lower levels of job autonomy, management support and involvement in organizational change, but not work demand. High levels of effort-reward imbalance and organizational injustice were reported by both groups. Our findings suggest that internal ED interventions to improve workers' job control, increase support from management and involvement in organizational change may reduce work stress. The high levels of effort-reward imbalance and organizational injustice reported by both groups may indicate that wider interventions beyond the ED are also needed to address these issues. © The Author 2016. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

A flexible simulation platform to quantify and manage emergency department crowding.

PubMed

Hurwitz, Joshua E; Lee, Jo Ann; Lopiano, Kenneth K; McKinley, Scott A; Keesling, James; Tyndall, Joseph A

2014-06-09

Hospital-based Emergency Departments are struggling to provide timely care to a steadily increasing number of unscheduled ED visits. Dwindling compensation and rising ED closures dictate that meeting this challenge demands greater operational efficiency. Using techniques from operations research theory, as well as a novel event-driven algorithm for processing priority queues, we developed a flexible simulation platform for hospital-based EDs. We tuned the parameters of the system to mimic U.S. nationally average and average academic hospital-based ED performance metrics and are able to assess a variety of patient flow outcomes including patient door-to-event times, propensity to leave without being seen, ED occupancy level, and dynamic staffing and resource use. The causes of ED crowding are variable and require site-specific solutions. For example, in a nationally average ED environment, provider availability is a surprising, but persistent bottleneck in patient flow. As a result, resources expended in reducing boarding times may not have the expected impact on patient throughput. On the other hand, reallocating resources into alternate care pathways can dramatically expedite care for lower acuity patients without delaying care for higher acuity patients. In an average academic ED environment, bed availability is the primary bottleneck in patient flow. Consequently, adjustments to provider scheduling have a limited effect on the timeliness of care delivery, while shorter boarding times significantly reduce crowding. An online version of the simulation platform is available at http://spark.rstudio.com/klopiano/EDsimulation/. In building this robust simulation framework, we have created a novel decision-support tool that ED and hospital managers can use to quantify the impact of proposed changes to patient flow prior to implementation.

Antidepressive and BDNF effects of enriched environment treatment across ages in mice lacking BDNF expression through promoter IV

PubMed Central

Jha, S; Dong, B E; Xue, Y; Delotterie, D F; Vail, M G; Sakata, K

2016-01-01

Reduced promoter IV-driven expression of brain-derived neurotrophic factor (BDNF) is implicated in stress and major depression. We previously reported that defective promoter IV (KIV) caused depression-like behavior in young adult mice, which was reversed more effectively by enriched environment treatment (EET) than antidepressants. The effects of promoter IV-BDNF deficiency and EET over the life stages remain unknown. Since early-life development (ED) involves dynamic epigenetic processes, we hypothesized that EET during ED would provide maximum antidepressive effects that would persist later in life due to enhanced, long-lasting BDNF induction. We tested this hypothesis by determining EET effects across three life stages: ED (0–2 months), young adult (2–4 months), and old adult (12–14 months). KIV mice at all life stages showed depression-like behavior in the open-field and tail-suspension tests compared with wild-type mice. Two months of EET reduced depression-like behavior in ED and young adult, but not old adult mice, with the largest effect in ED KIV mice. This effect lasted for 1 month after discontinuance of EET only in ED mice. BDNF protein induction by EET in the hippocampus and frontal cortex was also the largest in ED mice and persisted only in the hippocampus of ED KIV mice after discontinuance of EET. No gender-specific effects were observed. The results suggest that defective promoter IV causes depression-like behavior, regardless of age and gender, and that EET during ED is particularly beneficial to individuals with promoter IV-BDNF deficiency, while additional treatment may be needed for older adults. PMID:27648918

Emergency Department Utilization Report to Decrease Visits by Pediatric Gastroenterology Patients.

PubMed

Lee, Jarone; Greenspan, Peter T; Israel, Esther; Katz, Aubrey; Fasano, Alessio; Kaafarani, Haytham M A; Linov, Pamela L; Raja, Ali S; Rao, Sandhya K

2016-07-01

Emergency department (ED) utilization is a major driver of health care costs. Specialist physicians have an important role in addressing ED utilization, especially at highly specialized, academic medical centers. We sought to investigate whether reporting of ED utilization to specialist physicians can decrease ED visits. This study analyzed an intervention to reduce ED utilization among ED patients who were followed by pediatric gastroenterologists. In May 2013, each pediatric gastroenterologist began receiving reports with rates of ED use by their patients. The reports generated discussion that resulted in a cultural and process change in which patients with urgent gastrointestinal (GI)-related complaints were preferentially seen in the office. Using control charts, we examined GI-related and all-diagnoses ED use over a 2-year period. The rate of GI-related ED visits decreased by 60% after the intervention, from 4.89 to 1.95 per 1000 office visits (P < .001). Similarly, rates of GI-related ED visits during office hours decreased by 59% from 2.19 to 0.89 per 1000 (P < .001). Rates of all-diagnoses ED visits did not change. Physician-level reporting of ED utilization to pediatric gastroenterologists was associated with physician engagement and a cultural and process change to preferentially treat patients with urgent issues in the office. Copyright © 2016 by the American Academy of Pediatrics.

Availability and use of capnography for in-hospital cardiac arrests in the United Kingdom.

PubMed

Turle, Sarah; Sherren, Peter B; Nicholson, Stuart; Callaghan, Thomas; Shepherd, Stephen J

2015-09-01

Airway complications occur more frequently outside the operating theatre and in emergency situations. Capnography remains the gold standard for confirming correct endotracheal tube placement, retaining high sensitivity and specificity in cardiac arrest. The 2010 European Resuscitation Council guidelines for adult advanced life support recommended waveform capnography in this setting. We investigated current UK practice relating to the availability and use of this technology during cardiac arrest. Between June and November 2014, a study was conducted of all UK acute hospitals with both a level three adult intensive care unit (ICU) and an emergency department (ED). A telephone questionnaire was administered examining intubation practice and utilisation of capnography within the ED, ICU and general wards. Two hundred and eleven hospitals met the inclusion criteria. The response rate was 100%. Arrests were mainly attended by anaesthesia (48%) and ICU physicians (38%) of registrar grade (56%). The ability to measure end tidal carbon dioxide (ETCO2) was available in all but 4 EDs; most used in waveform devices. Most ICUs were similar. However, in 67% of hospitals surveyed, it was not possible to measure ETCO2 in general wards. Where available, 87% used capnography to confirm ETT placement with less than 50% using ETCO2 to determine CPR effectiveness and 8% to prognosticate. We believe this is the first study of its kind to fully investigate the availability and use of capnography during cardiac arrest throughout the hospital. Whilst equipment provision appears adequate in critical care areas, it is insufficient in general wards. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Process improvement to enhance existing stroke team activity toward more timely thrombolytic treatment.

PubMed

Cho, Han-Jin; Lee, Kyung Yul; Nam, Hyo Suk; Kim, Young Dae; Song, Tae-Jin; Jung, Yo Han; Choi, Hye-Yeon; Heo, Ji Hoe

2014-10-01

Process improvement (PI) is an approach for enhancing the existing quality improvement process by making changes while keeping the existing process. We have shown that implementation of a stroke code program using a computerized physician order entry system is effective in reducing the in-hospital time delay to thrombolysis in acute stroke patients. We investigated whether implementation of this PI could further reduce the time delays by continuous improvement of the existing process. After determining a key indicator [time interval from emergency department (ED) arrival to intravenous (IV) thrombolysis] and conducting data analysis, the target time from ED arrival to IV thrombolysis in acute stroke patients was set at 40 min. The key indicator was monitored continuously at a weekly stroke conference. The possible reasons for the delay were determined in cases for which IV thrombolysis was not administered within the target time and, where possible, the problems were corrected. The time intervals from ED arrival to the various evaluation steps and treatment before and after implementation of the PI were compared. The median time interval from ED arrival to IV thrombolysis in acute stroke patients was significantly reduced after implementation of the PI (from 63.5 to 45 min, p=0.001). The variation in the time interval was also reduced. A reduction in the evaluation time intervals was achieved after the PI [from 23 to 17 min for computed tomography scanning (p=0.003) and from 35 to 29 min for complete blood counts (p=0.006)]. PI is effective for continuous improvement of the existing process by reducing the time delays between ED arrival and IV thrombolysis in acute stroke patients.

Intraoral Laser Welding (ILW): ultrastructural and mechanical analysis

NASA Astrophysics Data System (ADS)

Fornaini, Carlo; Passaretti, Francesca; Villa, Elena; Nammour, Samir

2010-05-01

Nd:YAG, currently used since 1970 in dental laboratories to weld metals on dental prostheses has some limits such great dimensions, high costs and fixed delivery system. Recently it was proposed the possibility to use the Nd:YAG laser device commonly utilised in dental office, to repair broken fixed, removable and orthodontic prostheses and to weld metals directly into the mouth. The aim of this work is to value, through SEM (Scanning Electron Microscope), EDS (Energy Dispersive X-Ray Spectroscopy) and DMA (Dynamic Mechanical Analysis), quality and mechanical strength of the welding process comparing a device normally used in dental lab and a device normally used in dental office for oral surgery. Sixteen CoCrMo metal plates and twenty steel orthodontic wires were divided in four groups: one was welded without metal apposition by laboratory laser, one was welded with metal apposition by laboratory laser, one was welded without metal apposition by office laser and one was welded with metal apposition by office laser. The welding process was analysed by SEM, EDS and DMA to compare the differences between the different samples. By SEM analysis it was seen that the plates welded by office laser without apposition metal showed a greater number of fissurations compared with the other samples. By EDS analysis it was seen a homogeneous composition of the metals in all the samples. The mechanical tests showed a similar elastic behaviour of the samples, with minimal differences between the two devices. No wire broke even under the maximum strength by the Analyser. This study seems to demonstrate that the welding process by office Nd:YAG laser device and the welding process by laboratory Nd:YAG laser device, analysed by SEM, EDS and DMA, showed minimal and not significant differences even if these data will be confirmed by a greater number of samples.

Presenting characteristics and processing times for culturally and linguistically diverse (CALD) patients with chest pain in an emergency department: Time, Ethnicity, and Delay (TED) Study II.

PubMed

Wechkunanukul, Kannikar; Grantham, Hugh; Teubner, David; Hyun, Karice K; Clark, Robyn A

2016-10-01

To date there has been limited published data presenting the characteristics and timeliness of the management in an Emergency Department (ED) for culturally and linguistically diverse (CALD) patients presenting with chest pain. This study aimed to describe the presenting characteristics and processing times for CALD patients with chest pain compared to the Australian-born population, and current guidelines. This study was a cross sectional analysis of a cohort of patients who presented with chest pain to the metropolitan hospital between 1 July 2012 and 30 June 2014. Of the total study population (n=6640), 1241 (18.7%) were CALD and 5399 (81.3%) were Australian-born. CALD patients were significantly older than Australian-born patients (mean age 62 vs 56years, p<0.001). There were no differences in the proportion of patients who had central chest pain (74.9% vs 75.7%, p=0.526); ambulance utilisation (41.7% vs 41.1%, p=0.697); and time to initial treatment in ED (21 vs 22min, p=0.375). However, CALD patients spent a significantly longer total time in ED (5.4 vs 4.3h, p<0.001). There was no difference in guideline concordance between the two groups with low rates of 12.5% vs 13%, p=0.556. Nonetheless, CALD patients were 22% (95% CI, 0.65, 0.95, p=0.015) less likely to receive the guideline management for chest pain. The initial emergency care was equally provided to all patients in the context of a low rate of concordance with three chest pain related standards from the two guidelines. Nonetheless, CALD patients spent a longer time in ED compared to the Australian-born group. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Does vitamin D deficiency contribute to erectile dysfunction?

PubMed Central

Sorenson, Marc; Grant, William B.

2012-01-01

Erectile dysfunction (ED) is a multifactorial disease, and its causes can be neurogenic, psychogenic, hormonal and vascular. ED is often an important indicator of cardiovascular disease (CVD) and a powerful early marker for asymptomatic CVD. Erection is a vascular event, and ED is often a vascular disease caused by endothelial damage and subsequent inhibition of vasodilation. We show here that risk factors associated with a higher CVD risk also associate with a higher ED risk. Such factors include diabetes mellitus, hypertension, arterial calcification and Inflammation in the vascular endothelium. Vitamin D deficiency is one of several dynamics that associates with increased CVD risk, but to our knowledge, it has not been studied as a possible contributor to ED. Here we examine research linking ED and CVD and discuss how vitamin D influences CVD and its classic risk factors—factors that also associate to increased ED risk. We also summarize research indicating that vitamin D associates with reduced risk of several nonvascular contributing factors for ED. We conclude that VDD contributes to ED. This hypothesis should be tested through observational and intervention studies. PMID:22928068

Effects of drug price reduction and prescribing restrictions on expenditures and utilisation of antihypertensive drugs in Korea

PubMed Central

Yoo, Ki-Bong; Lee, Sang Gyu; Park, Sohee; Kim, Tae Hyun; Ahn, Jeonghoon; Cho, Mee-Hyun; Park, Eun-Cheol

2015-01-01

Objectives To evaluate the quantitative effects of the drug price reduction on pharmaceutical expenditures and the new guidelines to restrict prescribing on drug utilisation for antihypertensive drugs. Design We used an interrupted time series design with the National patient sample data of Health Insurance Review and Assessment Service in South Korea. Methods 54 295 participants who were with primary hypertension from the National patient sample data of Health Insurance Review and Assessment Service were included. The study period was from March 2011 to December 2013. The dependent variables were antihypertensive drug costs, antihypertensive drug cost per prescribing day, daily drug utilisation, average number of drugs per month, percentage of original drugs per prescription, drug overutilisation and prohibited combinations. Segmented regression analysis was used. Results The drug price reduction reduced expenditure (US$−1.51, −10.2%), and the new guidelines reduced expenditures even more (US$−2.13; −16.2%). These policies saved US$4.22 (28%) of antihypertensive drug costs per patient in December 2013 compared to March 2012. Drug price reduction policy was introduced in April 2012. We established the policy effect by comparing it before (March 2012) with after(21 months later-December 2012). The effects of the guidelines decreased expenditures, daily drug utilisation and the average number of drugs per month more than did the drug price reduction. Conclusions Both policies saved money. The guidelines were more effective over time and had fewer side effects such as increasing daily drug utilisation and number of drugs than the effects of drug price reduction. PMID:26179644

The impact of reducing financial barriers on utilisation of a primary health care facility in Rwanda

PubMed Central

Dhillon, Ranu S.; Bonds, Matthew H.; Fraden, Max; Ndahiro, Donald; Ruxin, Josh

2011-01-01

This study investigates the impact of subsidising community-based health insurance (mutuelle) enrolment, removing point-of-service co-payments, and improving service delivery on health facility utilisation rates in Mayange, a sector of rural Rwanda of approximately 25,000 people divided among five ‘imidugudu’ or small villages. While comprehensive service upgrades were introduced in the Mayange Health Centre between April 2006 and February 2007, utilisation rates remained similar to comparison sites. Between February 2007 and April 2007, subsidies for mutuelle enrolment established virtually 100% coverage. Immediately after co-payments were eliminated in February 2007, patient visits levelled at a rate triple the previous value. Regression analyses using data from Mayange and two comparison sites indicate that removing financial barriers resulted in about 0.6 additional annual visits for curative care per capita. Although based on a single local pilot, these findings suggest that in order to achieve improved health outcomes, key short-term objectives include improved service delivery and reduced financial barriers. Based on this pilot, higher utilisation rates may be affected if broader swaths of the population are enrolled in mutuelle and co-payments are eliminated. Health leaders in Rwanda should consider further studies to determine if the impact of eliminating co-payments and increasing subsidies for mutuelle enrolment as seen in Mayange holds at greater levels of scale. Broader studies to better elucidate the impact of enrolment subsidies and co-payment subsidies on utilisation, health outcomes, and costs would also provide policy insights. PMID:21732708

Gender confirming medical interventions and eating disorder symptoms among transgender individuals.

PubMed

Testa, Rylan J; Rider, G Nicole; Haug, Nancy A; Balsam, Kimberly F

2017-10-01

Studies indicate that transgender individuals may be at risk of developing eating disorder symptoms (EDS). Elevated risk may be attributed to body dissatisfaction and/or societal reactions to nonconforming gender expression, such as nonaffirmation of a person's gender identity (e.g., using incorrect pronouns). Limited research suggests that gender-confirming medical interventions (GCMIs) may prevent or reduce EDS among transgender people. Participants included 154 transfeminine spectrum (TFS) and 288 transmasculine spectrum (TMS) individuals who completed the Trans Health Survey. Serial multiple mediation analyses controlling for age, education, and income were used to examine whether body satisfaction and nonaffirmation mediate any found relationships between various GCMIs (genital surgery, chest surgery, hormone use, hysterectomy, and hair removal) and EDS. For TFS individuals, the nonaffirmation to body satisfaction path mediated relationships between all GCMIs and EDS, although body satisfaction alone accounted for more of the indirect effects than this path for chest surgery. For TMS individuals, relationships between all GCMIs and EDS were mediated by the nonaffirmation to body satisfaction path. Findings support the hypothesis that GCMIs reduce experiences of nonaffirmation, which increases body satisfaction and thus decreases EDS. Among TFS participants, the relationship between chest surgery and lower levels of EDS was mediated most strongly by body satisfaction alone, suggesting that satisfaction with one's body may result in lower EDS even if affirmation from the external world is unchanged. Implications of these findings for intervention, policy, and legal efforts are discussed, and future research recommendations are provided. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

Code Help: Can This Unique State Regulatory Intervention Improve Emergency Department Crowding?

PubMed

Michael, Sean S; Broach, John P; Kotkowski, Kevin A; Brush, D Eric; Volturo, Gregory A; Reznek, Martin A

2018-05-01

Emergency department (ED) crowding adversely affects multiple facets of high-quality care. The Commonwealth of Massachusetts mandates specific, hospital action plans to reduce ED boarding via a mechanism termed "Code Help." Because implementation appears inconsistent even when hospital conditions should have triggered its activation, we hypothesized that compliance with the Code Help policy would be associated with reduction in ED boarding time and total ED length of stay (LOS) for admitted patients, compared to patients seen when the Code Help policy was not followed. This was a retrospective analysis of data collected from electronic, patient-care, timestamp events and from a prospective Code Help registry for consecutive adult patients admitted from the ED at a single academic center during a 15-month period. For each patient, we determined whether the concurrent hospital status complied with the Code Help policy or violated it at the time of admission decision. We then compared ED boarding time and overall ED LOS for patients cared for during periods of Code Help policy compliance and during periods of Code Help policy violation, both with reference to patients cared for during normal operations. Of 89,587 adult patients who presented to the ED during the study period, 24,017 (26.8%) were admitted to an acute care or critical care bed. Boarding time ranged from zero to 67 hours 30 minutes (median 4 hours 31 minutes). Total ED LOS for admitted patients ranged from 11 minutes to 85 hours 25 minutes (median nine hours). Patients admitted during periods of Code Help policy violation experienced significantly longer boarding times (median 20 minutes longer) and total ED LOS (median 46 minutes longer), compared to patients admitted under normal operations. However, patients admitted during Code Help policy compliance did not experience a significant increase in either metric, compared to normal operations. In this single-center experience, implementation of the Massachusetts Code Help regulation was associated with reduced ED boarding time and ED LOS when the policy was consistently followed, but there were adverse effects on both metrics during violations of the policy.

Emergency department throughput, crowding, and financial outcomes for hospitals.

PubMed

Handel, Daniel A; Hilton, Joshua A; Ward, Michael J; Rabin, Elaine; Zwemer, Frank L; Pines, Jesse M

2010-08-01

Emergency department (ED) crowding has been identified as a major public health problem in the United States by the Institute of Medicine. ED crowding not only is associated with poorer patient outcomes, but it also contributes to lost demand for ED services when patients leave without being seen and hospitals must go on ambulance diversion. However, somewhat paradoxically, ED crowding may financially benefit hospitals. This is because ED crowding allows hospitals to maximize occupancy with well-insured, elective patients while patients wait in the ED. In this article, the authors propose a more holistic model of hospital flow and revenue that contradicts this notion and offer suggestions for improvements in ED and hospital management that may not only reduce crowding and improve quality, but also increase hospital revenues. Also proposed is that increased efficiency and quality in U.S. hospitals will require changes in systematic microeconomic and macroeconomic incentives that drive the delivery of health services in the United States. Finally, the authors address several questions to propose mutually beneficial solutions to ED crowding that include the realignment of hospital incentives, changing culture to promote flow, and several ED-based strategies to improve ED efficiency.

The effect of lifestyle choices on emergency department use in Australia.

PubMed

Johar, Meliyanni; Jones, Glenn; Savage, Elizabeth

2013-05-01

Much attention has been paid to patient access to emergency services, focusing on hospital reforms, yet very little is known about the characteristics of those presenting to emergency departments. By exploiting linkage of emergency records and a representative survey of the 45 and older population in Australia, we provide unique insights into the role of lifestyle in predicting emergency presentations. A generalized linear regression model is used to estimate the impact of lifestyles on emergency presentations one year ahead. We control for extensive individual characteristics and area fixed-effects. Not smoking, having healthy body weight, taking vitamins, and exercising vigorously and regularly can reduce emergency presentations and also prevent subsequent admissions from emergency. There is no evidence that heavy drinking leads to more frequent emergency visits, but we find a high tendency for heavy drinkers to smoke and be in poor health, which are both major predictors of emergency visits. Targeted public health interventions on smoking, body mass and exercise may reduce emergency visits. Effective public health interventions which target body mass, exercise, current smoking and smoking initiation, may have the effect of reducing ED usage and subsequent admission. Individual-level data linking a survey of the population 45 and older in Australia with their emergency department (ED) records is exploited to provide unique insights into the role of lifestyle in predicting emergency care. Controlling for demographic and socioeconomic characteristics, as well as chronic conditions, we find that being a non-smoker, having a healthy body weight, taking vitamins, and doing a vigorous exercise at least once a week can prevent ED presentations. Being a non-smoker, taking vitamins and exercising also prevent subsequent admissions from ED. We do not find a similar protective effect from complying with dietary recommendations. There is no evidence that heavy drinking alone leads to more frequent ED visits, but we find a high tendency for heavy drinkers to smoke and be in poor health, which are both major predictors of ED visits. These results suggest that targeted public health interventions on smoking, body mass and exercise can reduce ED visits. The use of linked data provides important insight into the characteristics of potential ED users which in turn is valuable for the planning of health services. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Process-Improvement Cost Model for the Emergency Department.

PubMed

Dyas, Sheila R; Greenfield, Eric; Messimer, Sherri; Thotakura, Swati; Gholston, Sampson; Doughty, Tracy; Hays, Mary; Ivey, Richard; Spalding, Joseph; Phillips, Robin

2015-01-01

The objective of this report is to present a simplified, activity-based costing approach for hospital emergency departments (EDs) to use with Lean Six Sigma cost-benefit analyses. The cost model complexity is reduced by removing diagnostic and condition-specific costs, thereby revealing the underlying process activities' cost inefficiencies. Examples are provided for evaluating the cost savings from reducing discharge delays and the cost impact of keeping patients in the ED (boarding) after the decision to admit has been made. The process-improvement cost model provides a needed tool in selecting, prioritizing, and validating Lean process-improvement projects in the ED and other areas of patient care that involve multiple dissimilar diagnoses.

The impact of walk-in centres and GP co-operatives on emergency department presentations: A systematic review of the literature.

PubMed

Crawford, Jessica; Cooper, Simon; Cant, Robyn; DeSouza, Ruth

2017-09-01

Internationally, non-urgent presentations are increasing the pressure on Emergency Department (ED) staff and resources. This systematic review aims to identify the impact of alternative emergency care pathways on ED presentations - specifically GP cooperatives and walk-in clinics. Based on a structured PICO enquiry with either walk-in clinic or GP cooperative as the intervention, a search was made for peer-reviewed publications in English, between 2000 and 2014. Medline plus, OVID, PubMed, and Google Scholar were searched. The Critical Appraisal Skills Program (CASP) guidelines were used to assess study quality and data was extracted using an adapted JBI Qualitative Assessment and Review Instrument (QARI). Subsequent reporting followed the PRISMA guideline. Eleven high quality quantitative studies met the inclusion criteria. Walk-in clinics do have the potential to reduce non-urgent emergency department presentations, however evidence of this effect is low. GP cooperatives offer an alternative care stream for patients presenting to the ED and do significantly reduce local ED attendances. Community members need to be made aware of these options in order to make informed treatment choices. GP cooperatives in particular do have the potential to reduce ED workload. Further research is required to uncover recent trends and patient outcomes for walk-in clinics and GP cooperatives. Copyright © 2017 Elsevier Ltd. All rights reserved.

Occupational stress and coping strategies among emergency department nurses of China.

PubMed

Lu, Dong-Mei; Sun, Ning; Hong, Su; Fan, Yu-ying; Kong, Fan-ying; Li, Qiu-jie

2015-08-01

Emergency department(ED) nurses work in a rapidly changing environment with patients that have wide variety of conditions. Occupational stress in emergency department nurses is a common problem. The purpose of this study was to describe the relationship between coping strategies and occupational stress among ED nurses in China. A correlational, cross-sectional design was adopted. Two questionnaires were given to a random sample of 127 ED nurses registered at the Heilongjiang Nurses' Association. Data were collected from the nurses that worked in the ED of five general hospitals in Harbin China. Occupational stress and coping strategies were measured by two questionnaires. A multiple regression model was applied to analyze the relationship between stress and coping strategies. The stressors of ED nurses mainly come from the ED specialty of nursing (2.97±0.55), workload and time distribution (2.97±0.58). The mean score of positive coping strategies was 2.19±0.35, higher than the norm (1.78±0.52). The mean score of negative coping strategies was 1.20±0.61, lower than the norm (1.59±0.66), both had significant statistical difference (P<0.001). Too much documents work, criticism, instrument equipment shortage, night shift, rank of professional were the influence factors about occupational stress to positive coping styles. Too much documents work, and medical insurance for ED nurses were the influential factors on occupational stress to negative coping styles. This study identified several factors associated with occupational stress in ED nurses. These results could be used to guide nurse managers of ED nurses to reduce work stress. The managers could pay more attention to the ED nurse's coping strategies which can further influence their health state and quality of nursing care. Reducing occupational stress and enhancing coping strategies are vital not only for encouraging nurses but also for the future of nursing development. Copyright © 2015. Published by Elsevier Inc.

A Consultation Phone Service for Patients With Total Joint Arthroplasty May Reduce Unnecessary Emergency Department Visits.

PubMed

Hällfors, Eerik; Saku, Sami A; Mäkinen, Tatu J; Madanat, Rami

2018-03-01

Different measures for reducing costs after total joint arthroplasty (TJA) have gained attention lately. At our institution, a free-of-charge consultation phone service was initiated that targeted patients with TJA. This service aimed at reducing unnecessary emergency department (ED) visits and, thus, potentially improving the cost-effectiveness of TJAs. To our knowledge, a similar consultation service had not been described previously. We aimed at examining the rates and reasons for early postdischarge phone calls and evaluating the efficacy of this consultation service. During a 2-month period, we gathered information on every call received by the consultation phone service from patients with TJAs within 90 days of the index TJA procedure. Patients were followed for 2 weeks after making a call to detect major complications and self-initiated ED visits. Data were collected from electronic medical charts regarding age, gender, type of surgery, date of discharge, and length of hospital stay. We analyzed 288 phone calls. Calls were mostly related to medication (41%), wound complications (17%), and mobilization issues (15%). Most calls were resolved in the phone consultation. Few patients (13%) required further evaluation in the ED. The consultation service failed to detect the need for an ED visit in 2 cases (0.7%) that required further care. The consultation phone service clearly benefitted patients with TJAs. The service reduced the number of unnecessary ED visits and functioned well in detecting patients who required further care. Most postoperative concerns were related to prescribed medications, wound complications, and mobilization issues. Copyright © 2017 Elsevier Inc. All rights reserved.

Stress in emergency departments: experiences of nurses and doctors.

PubMed

Healy, Sonya; Tyrrell, Mark

2011-07-01

The effects of stressful incidents on emergency department (ED) staff can be profound. Witnessing aggression, violence or the death of patients, or participating in resuscitation, can be emotionally and physically demanding. Despite the frequency of these events, ED staff do not become immune to the stress they cause, and are often ill prepared and under supported to cope with them. This article reports on a study of nurses' and doctors' attitudes to, and experiences of, workplace stress in three EDs in Ireland, and offers some suggestions on how stress among ED staff can be reduced.

Molecular cloning and characterization of enhanced disease susceptibility 1 (EDS1) from Gossypium barbadense.

PubMed

Su, Xiaofeng; Qi, Xiliang; Cheng, Hongmei

2014-06-01

Arabidopsis enhanced disease susceptibility 1 (EDS1) plays an important role in plant defense against biotrophic and necrotrophic pathogens. The necrotrophic pathogen Verticillium dahliae infection of Gossypium barbadense could lead to Verticillium wilt which seriously reduces the cotton production. Here, we cloned and characterized a G. barbadense homolog of EDS1, designated as GbEDS1. The full-length cDNA of the GbEDS1 gene was obtained by the technique of rapid-amplification of cDNA ends. The open reading frame of the GbEDS1 gene was 1,647 bp long and encoded a protein of 548 amino acids residues. Comparison of the cDNA and genomic DNA sequence of GbEDS1 indicated that this gene contained a single intron and two exons. Like other EDS1s, GbEDS1 contained a conserved N-terminal lipase domain and an EDS1-specific KNEDT motif. Subcellular localization assay revealed that GbEDS1-green fluorescence protein fusion protein was localized in both cytosol and nucleus. Interestingly, the transcript levels of GbEDS1 were dramatically increased in response to pathogen V. dahliae infection. To investigate the role of GbEDS1 in plant resistance against V. dahliae, a conserved fragment derived from GbEDS1 was used to knockdown the endogenous EDS1 in Nicotiana benthamiana by heterologous virus-induced gene silencing. Our data showed that silencing of NbEDS1 resulted in increased susceptibility to V. dahliae infection in N. benthamiana, suggesting a possible involvement of the novelly isolated GbEDS1 in the regulation of plant defense against V. dahliae.

Contextual and individual factors associated with dental services utilisation by Brazilian adults: A multilevel analysis

PubMed Central

2018-01-01

Background Inequalities in the utilisation of dental services in Brazil are remarkable. The aim of this study was to evaluate the association of contextual and individual factors with the utilisation of dental services by Brazilian adults using the Andersen’s behavioural model. Methods Individual-level data from 27,017 adults residents in the State capitals who were interviewed in the 2013 Brazilian National Health Survey were pooled with contextual city-level data. The outcomes were non-utilisation of dental services and last dental visit over 12 months ago. Individual predisposing variables were age, sex, race/skin colour, schooling and social network. Individual enabling variables included income, health insurance and registration in primary health care. Individual need variables were self-perceived dental health and self-reported missing teeth. Multilevel logistic regression models were performed to estimate odds ratio (OR) and 95% confidence intervals (95% CIs) of the association of contextual and individual predisposing, enabling and need-related variables with dental services outcomes. Results Predisposing (OR = 0.89; 95% CI 0.81–0.97) and enabling (OR = 0.90; 95% CI 0.85–0.96) contextual factors were associated with non-utilisation of dental services. Individual predisposing (sex, race/skin colour, schooling), enabling (income, health insurance) and need (self-perceived oral health, missing teeth) were associated with non-utilisation of dental services and last dental visit over 12 months ago. The latter was also associated with other individual predisposing (age, social network) and need (eating difficulties due to oral problems) characteristics. Conclusions Individual and contextual determinants influenced dental services utilisation in Brazilian adults. These factors should be on the policy agenda and considered in the organisation of health services aiming to reduce oral health inequalities related to access and utilisation of dental services. PMID:29420660

Contextual and individual factors associated with dental services utilisation by Brazilian adults: A multilevel analysis.

PubMed

Herkrath, Fernando José; Vettore, Mario Vianna; Werneck, Guilherme Loureiro

2018-01-01

Inequalities in the utilisation of dental services in Brazil are remarkable. The aim of this study was to evaluate the association of contextual and individual factors with the utilisation of dental services by Brazilian adults using the Andersen's behavioural model. Individual-level data from 27,017 adults residents in the State capitals who were interviewed in the 2013 Brazilian National Health Survey were pooled with contextual city-level data. The outcomes were non-utilisation of dental services and last dental visit over 12 months ago. Individual predisposing variables were age, sex, race/skin colour, schooling and social network. Individual enabling variables included income, health insurance and registration in primary health care. Individual need variables were self-perceived dental health and self-reported missing teeth. Multilevel logistic regression models were performed to estimate odds ratio (OR) and 95% confidence intervals (95% CIs) of the association of contextual and individual predisposing, enabling and need-related variables with dental services outcomes. Predisposing (OR = 0.89; 95% CI 0.81-0.97) and enabling (OR = 0.90; 95% CI 0.85-0.96) contextual factors were associated with non-utilisation of dental services. Individual predisposing (sex, race/skin colour, schooling), enabling (income, health insurance) and need (self-perceived oral health, missing teeth) were associated with non-utilisation of dental services and last dental visit over 12 months ago. The latter was also associated with other individual predisposing (age, social network) and need (eating difficulties due to oral problems) characteristics. Individual and contextual determinants influenced dental services utilisation in Brazilian adults. These factors should be on the policy agenda and considered in the organisation of health services aiming to reduce oral health inequalities related to access and utilisation of dental services.

Offensive Cyber Capability: Can it Reduce Cyberterrorism

DTIC Science & Technology

2010-12-02

33 Lech J. Janczewski, and Andrew M. Colarik, eds., Cyber Warfare and Cyber Terrorism (New York: Information Science Reference, 2008...Science and Business Media, 2008. Janczewski, Lech , J. and Andrew M. Colarik, eds., Cyber Warfare and Cyber Terrorism. New York: Information Science

The functionalization of limonite to prepare NZVI and its application in decomposition of p-nitrophenol

NASA Astrophysics Data System (ADS)

Liu, Haibo; Chen, Tianhu; Xie, Qiaoqin; Zou, Xuehua; Chen, Chen; Frost, Ray L.

2015-09-01

Nano zero valent iron (NZVI) was prepared by reducing natural limonite using hydrogen. X-ray fluorescence, thermogravimetry, X-ray diffraction, transmission electron microscope, temperature programmed reduction (TPR), field emission scanning electron microscope/energy disperse spectroscopy (FESEM/EDS) were utilized to characterize the natural limonite and reduced limonite. The ratios of Fe:O before and after reducing was determined using EDS. The reactivity of the NZVI was assessed by decomposition of p-nitrophenol ( p-NP) and was compared with commercial iron powder. In this study, the results of TPR and FESEM/EDS indicated that NZVI can be prepared by reducing natural limonite using hydrogen. Most importantly, this NZVI was proved to have a good performance on decomposition of p-NP and the process of p-NP decomposition agreed well with the pseudo-first-order kinetic model. The reactivity of this NZVI for decomposition of p-NP was greatly superior to that of commercial iron powder.

Low social interactions in eating disorder patients in childhood and adulthood: a multi-centre European case control study.

PubMed

Krug, Isabel; Penelo, Eva; Fernandez-Aranda, Fernando; Anderluh, Marija; Bellodi, Laura; Cellini, Elena; di Bernardo, Milena; Granero, Roser; Karwautz, Andreas; Nacmias, Benedetta; Ricca, Valdo; Sorbi, Sandro; Tchanturia, Kate; Wagner, Gudrun; Collier, David; Treasure, Janet

2013-01-01

The objective of this article was to examine lifestyle behaviours in eating disorder (ED) patients and healthy controls. A total of 801 ED patients and 727 healthy controls from five European countries completed the questions related to lifestyle behaviours of the Cross-Cultural Questionnaire (CCQ). For children, the ED sample exhibited more solitary activities (rigorously doing homework [p<0.001] and watching TV [p<0.05] and less socializing with friends [p<0.05]) than the healthy control group and this continued in adulthood. There were minimal differences across ED sub-diagnoses and various cross-cultural differences emerged. Reduced social activities may be an important risk and maintaining factor for ED symptomatology.

3D analysis of semiconductor devices: A combination of 3D imaging and 3D elemental analysis

NASA Astrophysics Data System (ADS)

Fu, Bianzhu; Gribelyuk, Michael A.

2018-04-01

3D analysis of semiconductor devices using a combination of scanning transmission electron microscopy (STEM) Z-contrast tomography and energy dispersive spectroscopy (EDS) elemental tomography is presented. 3D STEM Z-contrast tomography is useful in revealing the depth information of the sample. However, it suffers from contrast problems between materials with similar atomic numbers. Examples of EDS elemental tomography are presented using an automated EDS tomography system with batch data processing, which greatly reduces the data collection and processing time. 3D EDS elemental tomography reveals more in-depth information about the defect origin in semiconductor failure analysis. The influence of detector shadowing and X-rays absorption on the EDS tomography's result is also discussed.

Ethnic differences in sexual dysfunction among diabetic and nondiabetic males: the Oxford Sexual Dysfunction Study.

PubMed

Malavige, Lasantha S; Wijesekara, Pabasi; Seneviratne Epa, Danesha; Ranasinghe, Priyanga; Levy, Jonathan C

2013-02-01

Erectile dysfunction (ED), premature ejaculation (PE), and reduced libido are common yet poorly investigated complications of diabetes especially among South Asians (SA). To determine possible variations in prevalence and interassociations of ED, PE, and reduced libido among SA and Europids with and without diabetes. Men with diabetes and a randomly selected sample of age-matched nondiabetic men from 25 general practitioners in eight primary care trusts in the United Kingdom were invited to participate in a linguistically validated questionnaire-based study in English, Hindi, Urdu, Panjabi, Tamil, and Sinhala languages. ED, assessed by International Index of Erectile Function (IIEF-5), PE, evaluated using the Premature Ejaculation Diagnostic Tool, and libido, assessed by asking participants to grade their desire for sexual activity. Sample size was 510 (SA: 184, Europid: 326). Mean age was 56.9 ± 9.7 years. There was no difference in erectile function when assessed by IIEF between SA and Europids with diabetes (84.8% and 84.1%, respectively). The overall prevalence of PE was 28.8% (32.6% and 25.8% in those with and without diabetes, respectively, P = NS). Among men with diabetes, the prevalence of PE was 45.8% and 22.4% for SA and Europids, respectively (P < 0.001). In those without diabetes, this figure was 41.9% in SA and 20.2% in Europids (P < 0.001). There was a significant trend of increasing prevalence of PE with increasing severity grade of ED (P < 0.001). Reduced libido was reported by 26.9% men (32.8% and 22.0% in those with and without diabetes, respectively, P < 0.01), with no significant ethnic difference. The association between reduced libido and increasing severity grades of ED was also significant (P < 0.001). No significant difference was observed in the prevalence of ED between SA and Europid men with diabetes. PE was significantly more common in the SA men irrespective of their diabetes status. © 2012 International Society for Sexual Medicine.

Does Increasing Home Care Nursing Reduce Emergency Department Visits at the End of Life? A Population-Based Cohort Study of Cancer Decedents.

PubMed

Seow, Hsien; Barbera, Lisa; Pataky, Reka; Lawson, Beverley; O'Leary, Erin; Fassbender, Konrad; McGrail, Kim; Burge, Fred; Brouwers, Melissa; Sutradhar, Rinku

2016-02-01

Despite being commonplace in health care systems, little research has described home care nursing's effectiveness to reduce acute care use at the end of life. To examine the temporal association between home care nursing rate on emergency department (ED) visit rate in the subsequent week during the last six months of life. We conducted a retrospective cohort study of end-of-life cancer decedents in Ontario, Canada, from 2004 to 2009 by linking administrative databases. We examined the association between home care nursing rate of one week with the ED rate in the subsequent week closer to death, controlling for covariates and repeated measures among decedents. Nursing was dichotomized into standard and end-of-life care intent. Our cohort included 54,576 decedents who used home care nursing services in the last six months before death, where 85% had an ED visit and 68% received end-of-life home care nursing. Patients receiving end-of-life nursing at any week had a significantly reduced ED rate in the subsequent week of 31% (relative rate [RR] 0.69; 95% confidence interval [CI] 0.68, 0.71) compared with standard nursing. In the last month of life, receiving end-of-life nursing and standard nursing rate of more than five hours/week was associated with a decreased ED rate of 41% (RR 0.59, 95% CI 0.58, 0.61) and 32% (RR 0.68, 95% CI 0.66, 0.70), respectively, compared with standard nursing of one hour/week. Our study showed a temporal association between receiving end-of-life nursing in a given week during the last six months of life, and of more standard nursing in the last month of life, with a reduced ED rate in the subsequent week. Copyright © 2016 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Dietary flavonoid intake and incidence of erectile dysfunction.

PubMed

Cassidy, Aedín; Franz, Mary; Rimm, Eric B

2016-02-01

The predominant etiology for erectile dysfunction (ED) is vascular, but limited data are available on the role of diet. A higher intake of several flavonoids reduces diabetes and cardiovascular disease risk, but no studies have examined associations between flavonoids and erectile function. This study examined the relation between habitual flavonoid subclass intakes and incidence of ED. We conducted a prospective study among 25,096 men from the Health Professionals Follow-Up Study. Total flavonoid and subclass intakes were calculated from food-frequency questionnaires collected every 4 y. Participants rated their erectile function in 2000 (with historical reporting from 1986) and again in 2004 and 2008. During 10 y of follow-up, 35.6% reported incident ED. After multivariate adjustment, including classic cardiovascular disease risk factors, several subclasses were associated with reduced ED incidence, specifically flavones (RR = 0.91; 95% CI: 0.85, 0.97; P-trend = 0.006), flavanones (RR = 0.89; 95% CI: 0.83, 0.95; P-trend = 0.0009), and anthocyanins (RR = 0.91; 95% CI: 0.85, 0.98; P-trend = 0.002) comparing extreme intakes. The results remained statistically significant after additional adjustment for a composite dietary intake score. In analyses stratified by age, a higher intake of flavanones, anthocyanins, and flavones was significantly associated with a reduction in risk of ED only in men <70 y old and not older men (11-16% reduction in risk; P-interaction = 0.002, 0.03, and 0.007 for flavones, flavanones, and anthocyanins, respectively). In food-based analysis, higher total intake of fruit, a major source of anthocyanins and flavanones, was associated with a 14% reduction in risk of ED (RR = 0.86; 95% CI: 0.79, 0.92; P = 0.002). These data suggest that a higher habitual intake of specific flavonoid-rich foods is associated with reduced ED incidence. Intervention trials are needed to further examine the impact of increasing intakes of commonly consumed flavonoid-rich foods on men's health.

Development of a clinical prediction rule to improve peripheral intravenous cannulae first attempt success in the emergency department and reduce post insertion failure rates: the Vascular Access Decisions in the Emergency Room (VADER) study protocol

PubMed Central

Carr, Peter J; Rippey, James C R; Cooke, Marie L; Bharat, Chrianna; Murray, Kevin; Higgins, Niall S; Foale, Aileen; Rickard, Claire M

2016-01-01

Introduction Peripheral intravenous cannula (PIVC) insertion is one of the most common clinical interventions performed in emergency care worldwide. However, factors associated with successful PIVC placement and maintenance are not well understood. This study seeks to determine the predictors of first time PIVC insertion success in emergency department (ED) and identify the rationale for removal of the ED inserted PIVC in patients admitted to the hospital ward. Reducing failed insertion attempts and improving peripheral intravenous cannulation practice could lead to better staff and patient experiences, as well as improving hospital efficiency. Methods and analysis We propose an observational cohort study of PIVC insertions in a patient population presenting to ED, with follow-up observation of the PIVC in subsequent admissions to the hospital ward. We will collect specific PIVC observational data such as; clinician factors, patient factors, device information and clinical practice variables. Trained researchers will gather ED PIVC insertion data to identify predictors of insertion success. In those admitted from the ED, we will determine the dwell time of the ED-inserted PIVC. Multivariate regression analyses will be used to identify factors associated with insertions success and PIVC failure and standard statistical validation techniques will be used to create and assess the effectiveness of a clinical predication rule. Ethics and dissemination The findings of our study will provide new evidence to improve insertion success rates in the ED setting and identify strategies to reduce premature device failure for patients admitted to hospital wards. Results will unravel a complexity of factors that contribute to unsuccessful PIVC attempts such as patient and clinician factors along with the products, technologies and infusates used. Trial registration number ACTRN12615000588594; Pre-results. PMID:26868942

Development of a clinical prediction rule to improve peripheral intravenous cannulae first attempt success in the emergency department and reduce post insertion failure rates: the Vascular Access Decisions in the Emergency Room (VADER) study protocol.

PubMed

Carr, Peter J; Rippey, James C R; Cooke, Marie L; Bharat, Chrianna; Murray, Kevin; Higgins, Niall S; Foale, Aileen; Rickard, Claire M

2016-02-11

Peripheral intravenous cannula (PIVC) insertion is one of the most common clinical interventions performed in emergency care worldwide. However, factors associated with successful PIVC placement and maintenance are not well understood. This study seeks to determine the predictors of first time PIVC insertion success in emergency department (ED) and identify the rationale for removal of the ED inserted PIVC in patients admitted to the hospital ward. Reducing failed insertion attempts and improving peripheral intravenous cannulation practice could lead to better staff and patient experiences, as well as improving hospital efficiency. We propose an observational cohort study of PIVC insertions in a patient population presenting to ED, with follow-up observation of the PIVC in subsequent admissions to the hospital ward. We will collect specific PIVC observational data such as; clinician factors, patient factors, device information and clinical practice variables. Trained researchers will gather ED PIVC insertion data to identify predictors of insertion success. In those admitted from the ED, we will determine the dwell time of the ED-inserted PIVC. Multivariate regression analyses will be used to identify factors associated with insertions success and PIVC failure and standard statistical validation techniques will be used to create and assess the effectiveness of a clinical predication rule. The findings of our study will provide new evidence to improve insertion success rates in the ED setting and identify strategies to reduce premature device failure for patients admitted to hospital wards. Results will unravel a complexity of factors that contribute to unsuccessful PIVC attempts such as patient and clinician factors along with the products, technologies and infusates used. ACTRN12615000588594; Pre-results. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Dose-Volume Parameters of the Corpora Cavernosa Do Not Correlate With Erectile Dysfunction After External Beam Radiotherapy for Prostate Cancer: Results From a Dose-Escalation Trial

DOE Office of Scientific and Technical Information (OSTI.GOV)

Wielen, Gerard J. van der; Hoogeman, Mischa S.; Dohle, Gert R.

2008-07-01

Purpose: To analyze the correlation between dose-volume parameters of the corpora cavernosa and erectile dysfunction (ED) after external beam radiotherapy (EBRT) for prostate cancer. Methods and Materials: Between June 1997 and February 2003, a randomized dose-escalation trial comparing 68 Gy and 78 Gy was conducted. Patients at our institute were asked to participate in an additional part of the trial evaluating sexual function. After exclusion of patients with less than 2 years of follow-up, ED at baseline, or treatment with hormonal therapy, 96 patients were eligible. The proximal corpora cavernosa (crura), the superiormost 1-cm segment of the crura, and themore » penile bulb were contoured on the planning computed tomography scan and dose-volume parameters were calculated. Results: Two years after EBRT, 35 of the 96 patients had developed ED. No statistically significant correlations between ED 2 years after EBRT and dose-volume parameters of the crura, the superiormost 1-cm segment of the crura, or the penile bulb were found. The few patients using potency aids typically indicated to have ED. Conclusion: No correlation was found between ED after EBRT for prostate cancer and radiation dose to the crura or penile bulb. The present study is the largest study evaluating the correlation between ED and radiation dose to the corpora cavernosa after EBRT for prostate cancer. Until there is clear evidence that sparing the penile bulb or crura will reduce ED after EBRT, we advise to be careful in sparing these structures, especially when this involves reducing treatment margins.« less

Effect of a redesigned fracture management pathway and 'virtual' fracture clinic on ED performance.

PubMed

Vardy, J; Jenkins, P J; Clark, K; Chekroud, M; Begbie, K; Anthony, I; Rymaszewski, L A; Ireland, A J

2014-06-13

Collaboration between the orthopaedic and emergency medicine (ED) services has resulted in standardised treatment pathways, leaflet supported discharge and a virtual fracture clinic review. Patients with minor, stable fractures are discharged with no further follow-up arranged. We aimed to examine the time taken to assess and treat these patients in the ED along with the rate of unplanned reattendance. A retrospective study was undertaken that covered 1 year before the change and 1 year after. Prospectively collected administrative data from the electronic patient record system were analysed and compared before and after the change. An ED and orthopaedic unit, serving a population of 300 000, in a publicly funded health system. 2840 patients treated with referral to a traditional fracture clinic and 3374 patients managed according to the newly redesigned protocol. Time for assessment and treatment of patients with orthopaedic injuries not requiring immediate operative management, and 7-day unplanned reattendance. Where plaster backslabs were replaced with removable splints, the consultation time was reduced. There was no change in treatment time for other injuries treated by the new discharge protocol. There was no increase in unplanned ED attendance, related to the injury, within 7 days (p=0.149). There was a decrease in patients reattending the ED due to a missed fracture clinic appointment. This process did not require any new time resources from the ED staff. This process brought significant benefits to the ED as treatment pathways were agreed. The pathway reduced unnecessary reattendance of patients at face-to-face fracture clinics for a review of stable, self-limiting injuries. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Erectile Dysfunction after Radical Prostatectomy: Prevalence, Medical Treatments, and Psychosocial Interventions

PubMed Central

Emanu, Jessica C.; Avildsen, Isabelle K.; Nelson, Christian J.

2016-01-01

Purpose of review This review will discuss erectile dysfunction (ED) in prostate cancer patients following radical prostatectomy (RP). It will focus on the prevalence and current treatments for ED as well as the emotional impact of ED and the current psychosocial interventions designed to help patients cope with this side effect. Recent findings While there is a large discrepancy in prevalence rates of ED after RP, several recent studies have cited rates as high as 85%. The concept of “penile rehabilitation” is now the standard of practice to treat ED following RP. However, many men avoid seeking help or utilizing ED treatments. This avoidance is related to the shame, frustration, and distress many men with ED and their partners experience. Recent psychosocial interventions have been developed to facilitate the use of treatments and help men cope with ED. These interventions have shown initial promise, however, continued intervention development is needed to reduce distress and improve long-term erectile function (EF) outcomes. Summary ED is a significant problem following prostate cancer surgery. While there are effective medical treatments, the development of psychosocial interventions should continue to evolve to maximize the assistance we can give to men and their partners. PMID:26808052

Modular operation of membrane bioreactors for higher hydraulic capacity utilisation.

PubMed

Veltmann, K; Palmowski, L M; Pinnekamp, J

2011-01-01

Using data from 6 full-scale municipal membrane bioreactors (MBR) in Germany the hydraulic capacity utilisation and specific energy consumption were studied and their connexion shown. The average hydraulic capacity utilisation lies between 14% and 45%. These low values are justified by the necessity to deal with intense rain events and cater for future flow increases. However, this low hydraulic capacity utilisation leads to high specific energy consumption. The optimisation of MBR operation requires a better utilisation of MBR hydraulic capacity, particularly under consideration of the energy-intensive membrane aeration. A first approach to respond to large influent flow fluctuations consists in adjusting the number of operating modules. This is practised by most MBR operators but so far mostly with variable flux and constant membrane aeration. A second approach is the real-time adjustment of membrane aeration in line with flux variations. This adjustment is not permitted under current manufacturers' warranty conditions. A further opportunity is a discontinuous operation, in which filtration takes place over short periods at high flux and energy for membrane aeration is saved during filtration pauses. The integration of a buffer volume is thereby indispensable. Overall a modular design with small units, which can be activated/ inactivated according to the influent flow and always operate under optimum conditions, enables a better utilisation of MBR hydraulic capacity and forms a solid base to reduce MBR energy demand.

Pitfalls and Rewards for Implementing Ocular Motor Testing in Acute Vestibular Syndrome: A Pilot Project

PubMed Central

Dumitrascu, Oana M.; Torbati, Sam; Tighiouart, Mourad; Newman-Toker, David E.; Song, Shlee S.

2016-01-01

Objectives Isolated Acute Vestibular Syndrome (iAVS) presentations to the Emergency Department (ED) pose management challenges given concerns for posterior circulation strokes. False negative brain imaging may erroneously reassure clinicians, while HINTS-plus examination outperforms imaging to screen for strokes in iAVS. We studied the feasibility of implementing HINTS-plus testing in the ED, aiming to reduce neuroimaging in patients with iAVS. Methods We launched an institutional Quality Improvement initiative, using DMAIC methodology. The outcome measures (proportion of iAVS subjects that had HINTS-plus examinations and underwent neuroimaging by CT/MRI) were compared before and after the established intervention. The intervention consisted of formal training for neurologists and emergency physicians on how to perform, document, and interpret HINTS-plus and implementation of novel iAVS management algorithm. Neuroimaging was not recommended if HINTS-plus suggested peripheral vestibular etiology. If a central process was suspected, brain MRI/MR angiogram was performed. Head CT was reserved only for thrombolytic time-window cases. Results In the first 2 months post-implementation, HINTS-plus testing performance by neurologists increased from 0% to 80% (p = 0.007), and by ED providers from 0% to 9.09% (p = 0.367). Head CT scans were reduced from 18.5% to 6. 25%. Brain MRI use was reduced from 51.8% to 31.2%. 60% of the iAVS subjects were discharged from the ED; none were readmitted or had another ED presentation in the ensuing 30 days. Conclusions Implementation of HINTS-plus evaluation in the ED is valuable and feasible for neurologists, but challenging for emergency physicians. Future studies should determine the ‘dose-response’ curve of educational interventions. PMID:28248913

Pitfalls and Rewards for Implementing Ocular Motor Testing in Acute Vestibular Syndrome: A Pilot Project.

PubMed

Dumitrascu, Oana M; Torbati, Sam; Tighiouart, Mourad; Newman-Toker, David E; Song, Shlee S

2017-03-01

Isolated acute vestibular syndrome (iAVS) presentations to the emergency department (ED) pose management challenges, given the concerns for posterior circulation strokes. False-negative brain imaging may erroneously reassure clinicians, whereas HINTS-plus examination outperforms imaging to screen for strokes in iAVS. We studied the feasibility of implementing HINTS-plus testing in the ED, aiming to reduce neuroimaging in patients with iAVS. We launched an institutional Quality Improvement initiative, using DMAIC methodology. The outcome measures [proportion of iAVS subjects who had HINTS-plus examinations and underwent neuroimaging by computed tomography/magnetic resonance imaging (CT/MRI)] were compared before and after the established intervention. The intervention consisted of formal training for neurologists and emergency physicians on how to perform, document, and interpret HINTS-plus and implementation of novel iAVS management algorithm. Neuroimaging was not recommended if HINTS-plus suggested peripheral vestibular etiology. If a central process was suspected, brain MRI/MR angiogram was performed. Head CT was reserved only for thrombolytic time-window cases. In the first 2 months postimplementation, HINTS-plus testing performance by neurologists increased from 0% to 80% (P=0.007), and by ED providers from 0% to 9.09% (P=0.367). Head CT scans were reduced from 18.5% to 6.25%. Brain MRI use was reduced from 51.8% to 31.2%. About 60% of the iAVS subjects were discharged from the ED; none were readmitted or had another ED presentation in the ensuing 30 days. Implementation of HINTS-plus evaluation in the ED is valuable and feasible for neurologists, but challenging for emergency physicians. Future studies should determine the "dose-response" curve of educational interventions.

Efficacy of emergency department-based interventions designed to reduce repeat visits and other adverse outcomes for older patients after discharge: A systematic review.

PubMed

Karam, Grace; Radden, Zoe; Berall, Laura E; Cheng, Catherine; Gruneir, Andrea

2015-09-01

There is an urgent need for effective geriatric interventions to meet the health service demands of the growing older population. In this paper, we systematically review and update existing literature on interventions within emergency departments (ED) targeted towards reducing ED re-visits, hospitalizations, nursing home admissions and deaths in older patients after initial ED discharge. Databases Medline, CINAHL, Embase and Web of Science were searched to identify all articles published up to June 2012 that focused on older adults in the ED, included a comparison group, and reported quantitative results in four primary outcomes: ED re-visits, hospitalizations, nursing home admissions and death after initial ED discharge. Of the 2826 titles screened, just nine studies met our inclusion criteria. The studies varied in their design and outcome measurements such that results could not be combined. Two trends surfaced: (i) more intensive interventions more frequently resulted in reduced adverse outcomes than did simple referral intervention types; and (ii) among the lowest intensity, referral-based interventions, studies that used a validated prediction tool to identify high-risk patients more frequently reported improved outcomes than those that did not use such a tool. Of the few studies that met the inclusion criteria, there was a lack of consistency and clarity in study designs and evaluative outcomes. Despite this, more intensive interventions that followed patients beyond a referral and the use of a clinical risk prediction tool appeared to be associated with improved outcomes. The dearth of rigorous evaluations with standardized methodologies precludes further recommendations. © 2015 The Authors. Geriatrics & Gerontology International published by Wiley Publishing Asia Pty Ltd on behalf of Japan Geriatrics Society.

Efficacy of emergency department‐based interventions designed to reduce repeat visits and other adverse outcomes for older patients after discharge: A systematic review

PubMed Central

Karam, Grace; Radden, Zoe; Berall, Laura E; Cheng, Catherine

2015-01-01

Aim There is an urgent need for effective geriatric interventions to meet the health service demands of the growing older population. In this paper, we systematically review and update existing literature on interventions within emergency departments (ED) targeted towards reducing ED re‐visits, hospitalizations, nursing home admissions and deaths in older patients after initial ED discharge. Methods Databases Medline, CINAHL, Embase and Web of Science were searched to identify all articles published up to June 2012 that focused on older adults in the ED, included a comparison group, and reported quantitative results in four primary outcomes: ED re‐visits, hospitalizations, nursing home admissions and death after initial ED discharge. Results Of the 2826 titles screened, just nine studies met our inclusion criteria. The studies varied in their design and outcome measurements such that results could not be combined. Two trends surfaced: (i) more intensive interventions more frequently resulted in reduced adverse outcomes than did simple referral intervention types; and (ii) among the lowest intensity, referral‐based interventions, studies that used a validated prediction tool to identify high‐risk patients more frequently reported improved outcomes than those that did not use such a tool. Conclusion Of the few studies that met the inclusion criteria, there was a lack of consistency and clarity in study designs and evaluative outcomes. Despite this, more intensive interventions that followed patients beyond a referral and the use of a clinical risk prediction tool appeared to be associated with improved outcomes. The dearth of rigorous evaluations with standardized methodologies precludes further recommendations. Geriatr Gerontol Int 2015; 15: 1107–1117. PMID:26171554

Chronic Pain in the Emergency Department: A Pilot Mixed-Methods Cross-Sectional Study Examining Patient Characteristics and Reasons for Presentations.

PubMed

Poulin, Patricia A; Nelli, Jennifer; Tremblay, Steven; Small, Rebecca; Caluyong, Myka B; Freeman, Jeffrey; Romanow, Heather; Stokes, Yehudis; Carpino, Tia; Carson, Amanda; Shergill, Yaadwinder; Stiell, Ian G; Taljaard, Monica; Nathan, Howard; Smyth, Catherine E

2016-01-01

Background . Chronic pain (CP) accounts for 10-16% of emergency department (ED) visits, contributing to ED overcrowding and leading to adverse events. Objectives . To describe patients with CP attending the ED and identify factors contributing to their visit. Methods . We used a mixed-method design combining interviews and questionnaires addressing pain, psychological distress, signs of opioid misuse, and disability. Participants were adults who attended the EDs of a large academic tertiary care center for their CP problem. Results . Fifty-eight patients (66% women; mean age 46.5, SD = 16.9) completed the study. The most frequently cited reason (60%) for ED visits was inability to cope with pain. Mental health problems were common, including depression (61%) and anxiety (45%). Participants had questions about the etiology of their pain, concerns about severe pain-related impairment, and problems with medication renewals or efficacy and sometimes felt invalidated in the ED. Although most participants had a primary care physician, the ED was seen as the only or best option when pain became unmanageable. Conclusions . Patients with CP visiting the ED often present with complex difficulties that cannot be addressed in the ED. Better access to interdisciplinary pain treatment is needed to reduce the burden of CP on the ED.

Strategies to reduce nonurgent emergency department use: experience of a Northern Virginia Employer Group.

PubMed

DeVries, Andrea; Li, Chia-Hsuan; Oza, Manish

2013-03-01

This administrative claims analysis evaluated the impact of a health plan-sponsored Emergency Room Utilization Management Initiative (ERUMI), which combined increased patient copays for ED visits with educational outreach to reduce inappropriate ED use and encourage use of retail health clinics (RHCs) and other alternative treatment sites among a commercially insured population. Emergency department (ED) utilization rates for select acute but nonurgent conditions that could be treated appropriately in an RHC were compared for members of an employer group with (intervention group) and without (comparators) ERUMI. Utilization was compared for baseline period (January-June 2009) and ERUMI implementation period (January-June 2010). A total of 56,896 members (14,224 intervention, 42,672 matched comparators) were included. ED utilization for conditions that could be treated appropriately by RHCs decreased by 10.39 visits/1000 members in the intervention group versus 6.29 visits in comparators. RHC visits rose for both the groups, with a greater increase in the intervention group (22.61 visits/1000 members, P<0.001) versus comparison (1.64/1000, P=0.064). After ERUMI implementation, intervention group members were nearly 5 times more likely than comparators to choose RHCs over ED for nonurgent care. The health plan-sponsored ERUMI program, consisting of both financial and educational components, decreased nonurgent ED utilization while increasing the use of alternative treatment sites.

Comparing Emergency Department Use Among Medicaid and Commercial Patients Using All-Payer All-Claims Data.

PubMed

Kim, Hyunjee; McConnell, K John; Sun, Benjamin C

2017-08-01

The high rate of emergency department (ED) use by Medicaid patients is not fully understood. The objective of this paper is (1) to provide context for ED service use by comparing Medicaid and commercial patients' differences across ED and non-ED health service use, and (2) to assess the extent to which Medicaid-commercial differences in ED use can be explained by observable factors in administrative data. Statistical decomposition methods were applied to ED, mental health, and inpatient care using 2011-2013 Medicaid and commercial insurance claims from the Oregon All Payer All Claims database. Demographics, comorbidities, health services use, and neighborhood characteristics accounted for 44% of the Medicaid-commercial difference in ED use, compared to 83% for mental health care and 75% for inpatient care. This suggests that relative to mental health and inpatient care, a large portion of ED use cannot be explained by administrative data. Models that further accounted for patient access to different primary care physicians explained an additional 8% of the Medicaid-commercial difference in ED use, suggesting that the quality of primary care may influence ED use. The remaining unexplained difference suggests that appropriately reducing ED use remains a credible target for policy makers, although success may require knowledge about patients' perceptions and behaviors as well as social determinants of health.

Point-of-care D-dimer testing in emergency departments.

PubMed

Marquardt, Udo; Apau, Daniel

2015-09-01

Overcrowding and prolonged patient stays in emergency departments (EDs) affect patients' experiences and outcomes, and increase healthcare costs. One way of addressing these problems is through using point-of-care blood tests, laboratory testing undertaken near patient locations with rapidly available results. D-dimer tests are used to exclude venous thromboembolism (VTE), a common presentation in EDs, in low-risk patients. However, data on the effects of point-of-care D-dimer testing in EDs and other urgent care settings are scarce. This article reports the results of a literature review that examined the benefits to patients of point-of-care D-dimer testing in terms of reduced turnaround times (time to results), and time to diagnosis, discharge or referral. It also considers the benefits to organisations in relation to reduced ED crowding and increased cost effectiveness. The review concludes that undertaking point-of-care D-dimer tests, combined with pre-test probability scores, can be a quick and safe way of ruling out VTE and improving patients' experience.

Emergency Department Involvement in Accountable Care Organizations in Massachusetts: A Survey Study.

PubMed

Ali, Nissa J; McWilliams, J Michael; Epstein, Stephen K; Smulowitz, Peter B

2017-11-01

We assess Massachusetts emergency department (ED) involvement and internal ED constructs within accountable care organization contracts. An online survey was distributed to 70 Massachusetts ED directors. Questions attempted to assess involvement of EDs in accountable care organizations and the structures in place in EDs-from departmental resources to physician incentives-to help achieve accountable care organization goals of decreasing spending and improving quality. Of responding ED directors, 79% reported alignment between the ED and an accountable care organization. Almost all ED groups (88%) reported bearing no financial risk as a result of the accountable care organization contracts in which their organizations participated. Major obstacles to meeting accountable care organization objectives included care coordination challenges (62%) and lack of familiarity with accountable care organization goals (58%). The most common cost-reduction strategies included ED case management (85%) and information technology (61%). Limitations of this study include that information was self-reported by ED directors, a focus limited to Massachusetts, and a survey response rate of 47%. The ED directors perceived that the majority of physicians were not familiar with accountable care organization goals, many challenges remain in coordinating care for patients in the ED, and most EDs have no financial incentives tied to accountable care organizations. EDs in Massachusetts have begun to implement strategies aimed at reducing admissions, utilization, and overall cost, but these strategies are not widespread apart from case management, even in a state with heavy accountable care organization penetration. Our results suggest that Massachusetts EDs still lack clear directives and direct involvement in meeting accountable care organization goals. Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

mHealth Tool for Alcohol Use Disorders Among Latinos in Emergency Department.

PubMed

Abujarad, Fuad; Vaca, Federico E

2015-06-01

Latino drinkers experience a disparate number of negative health and social consequences. Emergency Department Alcohol Screening Brief Intervention and Referral to Treatment (ED-SBIRT) is viable and effective at reducing harmful and hazardous drinking. However, barriers (e.g. readily available language translators, provider time burden, resources) to broad implementation remain and account for a major lag in adherence to national guidelines. We describe our approach to the design of a patient-centered bilingual Web-based mobile health ED-SBIRT App that could be integrated into a clinically complex ED environment and used regularly to provide ED-SBIRT for Spanish speaking patients.

mHealth Tool for Alcohol Use Disorders Among Latinos in Emergency Department

PubMed Central

Abujarad, Fuad; Vaca, Federico E.

2015-01-01

Latino drinkers experience a disparate number of negative health and social consequences. Emergency Department Alcohol Screening Brief Intervention and Referral to Treatment (ED-SBIRT) is viable and effective at reducing harmful and hazardous drinking. However, barriers (e.g. readily available language translators, provider time burden, resources) to broad implementation remain and account for a major lag in adherence to national guidelines. We describe our approach to the design of a patient-centered bilingual Web-based mobile health ED-SBIRT App that could be integrated into a clinically complex ED environment and used regularly to provide ED-SBIRT for Spanish speaking patients. PMID:26844234

A quasi randomized-controlled trial to evaluate the effectiveness of clowntherapy on children's anxiety and pain levels in emergency department.

PubMed

Felluga, Margherita; Rabach, Ingrid; Minute, Marta; Montico, Marcella; Giorgi, Rita; Lonciari, Isabella; Taddio, Andrea; Barbi, Egidio

2016-05-01

The aim of the study is to investigate if the presence of medical clowns during painful procedures in the emergency department (ED) affects children's anxiety and pain. Forty children (4-11 years) admitted to the ED with the need of painful procedures were prospectively enrolled. They were randomly assigned to the clown group, where children interacted with clowns or to the control group in which they were entertained by parents and ED nurses. The children's anxiety was assessed by the Children's Anxiety and Pain Scales; pain was evaluated with the Numerical Rating Scale and Wong-Backer Scale, according to the children's age. Staff and clown's opinions were evaluated by means of dedicated questionnaires. Children's anxiety levels in the clown group were significantly lower than those compared with the control group, while children's pain levels did not change between the two groups. The presence of clowns in the ED before and during painful procedures was effective in reducing children's anxiety. • Anxiety and fear caused by medical procedures exacerbate children's pain and may interfere with the procedure. • To reduce anxiety, fear, and pain and to facilitate patient's evaluation, different non-pharmacological approaches have been proposed and positive effects of laughter and humor have been reported. What is New: • The presence of clowns in the waiting room and in the ED during medical evaluation and painful procedures helps to reduce children's anxiety.

Prevention of Eating Disorders in At-risk College-Age Women

PubMed Central

Taylor, C. Barr; Bryson, Susan; Luce, Kristine H.; Cunning, Darby; Celio, Angela; Abascal, Liana B.; Rockwell, Roxanne; Dev, Pavarti; Winzelberg, Andrew J.; Wilfley, Denise E.

2013-01-01

Context Eating disorders, an important health problem among college-age women, may be preventable, given that modifiable risk factors for eating disorders have been identified and interventions have been evaluated to reduce these risk factors. Objective To determine if an Internet-based psychosocial intervention can prevent the onset of eating disorders (EDs) in young women at risk for developing EDs. Setting and Participants College-age women in San Diego and the San Francisco Bay Area. Women with high weight and shape concerns were recruited via campus e-mails, posters and mass media. Six hundred thirty-seven eligible participants were identified, of whom 157 were excluded, for a total sample of 480. Recruitment occurred between 11/13/00 and 10/10/03. Design and Intervention A randomized controlled trial of an eight-week Internet-based cognitive-behavioral intervention (Student Bodies; SB) that included a moderated online discussion group. Participants were followed for up to three years. Main Outcome Measures The main outcome measure was time to onset of a subclinical or clinical ED. Secondary measures included change in Weight Concerns Scale (WCS) scores, Global EDE-Q, EDI Drive for Thinness, EDI Bulimia, and depressed mood. Moderators of outcome were examined. Results There was a significant reduction in WCS scores in the SB intervention group compared to the control group at post intervention (p < 0.001), one year (p < 0.001) and two years (p <0.001). The slope for reducing WCS was significantly greater in the treatment compared to the control group (p = 0.023). Over the course of follow-up, 43 participants developed subclinical or clinical EDs. While there was no overall significant difference in onset of EDs between intervention and control groups, the intervention significantly reduced the onset of EDs in two subgroups identified through moderator analyses: 1) participants with an elevated body mass index (BMI ≥ 25) at baseline; and 2) at one site, participants with baseline compensatory behaviors (e.g. self-induced vomiting, laxative use, diuretic use, diet pill use, driven exercise). No intervention participant with an elevated baseline BMI developed an ED, while the rates of onset of ED in the comparable BMI control group (based on survival analysis) were 4.7% at one year and 11.9% at two years (CI = 2.7%–21.1%). In the BMI ≥ 25 subgroup, the cumulative survival incidence was significantly lower at two years for the intervention compared to the control group (CI = 0% for intervention; 2.7% – 21.1% for control). For the San Francisco Bay Area site sample with baseline compensatory behaviors, 4% of participants in the intervention group developed EDs at one year and 14.4% by two years. Rates for the comparable control group were 16% and 30.4%, respectively. Conclusions Among college-age women with high weight and shape concerns, an eight-week Internet-based cognitive-behavioral intervention can significantly reduce weight and shape concerns for up to two years and decrease risk for the onset of EDs, at least in some high-risk groups. This is the first study to show that EDs can be prevented in high risk groups. PMID:16894064

Collaborative effort in Washington state slashes non-essential use of the ED by Medicaid patients, delivering millions in projected savings.

PubMed

2013-04-01

Early data suggest a coordinated, state-wide effort has reduced non-essential use of the ED by 10% among Medicaid recipients in Washington state, and is projected to save the state an estimated $31 million in the first year of the approach. The effort includes the adoption of seven best practices by hospitals across the state.These include the creation of an Emergency Department Information Exchange, so that EDs can immediately access a patient's utilization history, strict narcotic prescribing guidelines, and regular feedback reports to hospitals regarding ED utilization patterns. The effort was prompted by threats by the state legislature to limit Medicaid payments for ED visits deemed not medically necessary in the emergency setting. The legislature backed down when emergency physicians in the state countered with their own proposal to reduce nonessential use of the ED. They worked with other health care groups in the state to develop the plan. Data on the first six months of the effort are included in a report to the state legislature by the Washington State Health Care Authority. Among the findings are a 23% reduction in ED visits among Medicaid recipients with five or more visits, a 250% increase in providers who have registered with the state's Prescription Monitoring Program, aimed at identifying patients with narcotic-seeking behavior, and a doubling in the number of shared care plans, intended to improve care coordination. Emergency providers say big challenges remain, including a need for more resources for patients with mental health and dental care needs.

A Prospective Randomized Controlled Trial of Nonpharmacological Pain Management During Intravenous Cannulation in a Pediatric Emergency Department.

PubMed

Miller, Kate; Tan, Xianghong; Hobson, Andrew Dillon; Khan, Asaduzzaman; Ziviani, Jenny; OʼBrien, Eavan; Barua, Kim; McBride, Craig A; Kimble, Roy M

2016-07-01

Intravenous (IV) cannulation is commonly performed in pediatric emergency departments (EDs). The busy ED environment is often not conducive to conventional nonpharmacological pain management. This study assessed the use of Ditto (Diversionary Therapy Technologies, Brisbane, Australia), a handheld electronic device which provides procedural preparation and distraction, as a means of managing pain and distress during IV cannulation performed in the pediatric ED. A randomized controlled trial with 98 participants, aged 3 to 12 years, was conducted in a pediatric ED. Participants were recruited and randomized into 5 intervention groups as follows: (1) Standard Distraction, (2) PlayStation Portable Distraction, (3) Ditto Distraction, (4) Ditto Procedural Preparation, and (5) Ditto Preparation and Distraction. Children's pain and distress levels were assessed via self-reports and observational reports by caregivers and nursing staff across the following 3 time points: (1) before, (2) during, and (3) after IV cannulation. Caregivers and nursing staff reported significantly reduced pain and distress levels in children accessing the combined preparation and distraction Ditto protocol, as compared to standard distraction (P ≤ 0.01). This intervention also saw the greatest reduction in pain and distress as reported by the child. Caregiver reports indicate that using the combined Ditto protocol was most effective in reducing children's pain experiences while undergoing IV cannulation in the ED. The use of Ditto offers a promising opportunity to negotiate barriers to the provision of nonpharmacological approaches encountered in the busy ED environment, and provide nonpharmacological pain-management interventions in pediatric EDs.

Weapons Retrieved After the Implementation of Emergency Department Metal Detection.

PubMed

Malka, S Terez; Chisholm, Robin; Doehring, Marla; Chisholm, Carey

2015-09-01

Several high-profile violent incidents have occurred within emergency departments (EDs). There are no recent studies reporting the effectiveness of ED metal detection. Our aim was to assess the effect of metal detection on ED weapons retrieval. In September 2011, a metal detector was installed at the entrance of an urban, high-volume teaching hospital ED. The security company recorded retrieved firearms, knives, chemical sprays, and other weapons. We performed qualitative analysis of weapons retrieval data for a 26-month period. A total of 5877 weapons were retrieved, an average of 218 per month: 268 firearms, 4842 knives, 512 chemical sprays, and 275 other weapons, such as brass knuckles, stun guns, and box cutters. The number of retrieved guns decreased from 2012 to 2013 (from 182 to 47), despite an increase in metal detection hours from 8 h per day to 16 h per day. The number of retrieved knives, chemical sprays, and other weapons increased. Recovered knives increased from 2062 in 2012 to 2222 in 2013, chemical sprays increased from 170 to 305, and other weapons increased from 51 to 201. A large number of weapons were retrieved after the initiation of metal detection in the ED entrance. Increasing hours of metal detection increased the number of retrieved knives, chemical sprays, and other weapons. Retrieved firearms decreased after increasing metal detection hours. Metal detection in the ED entrance is effective in reducing entrance of weapons into the ED. Metal detectors may offer additional benefit in reducing attempts to enter with firearms. Copyright © 2015 Elsevier Inc. All rights reserved.

Care plan program reduces the number of visits for challenging psychiatric patients in the ED.

PubMed

Abello, Arthur; Brieger, Ben; Dear, Kim; King, Ben; Ziebell, Chris; Ahmed, Atheer; Milling, Truman J

2012-09-01

A small number of patients representing a significant demand on emergency department (ED) services present regularly for a variety of reasons, including psychiatric or behavioral complaints and lack of access to other services. A care plan program was created as a database of ED high users and patients of concern, as identified by ED staff and approved by program administrators to improve care and mitigate ED strain. A list of medical record numbers was assembled by searching the care plan program database for adult patients initially enrolled between the dates of November 1, 2006, and October 21, 2007. Inclusion criteria were the occurrence of a psychiatric International Classification Diseases, Ninth Revision, code in their medical record and a care plan level implying a serious psychiatric disorder causing harmful behavior. Additional data about these patients were acquired using an indigent care tracking database and electronic medical records. Variables collected from these sources were analyzed for changes before and after program enrollment. Of 501 patients in the database in the period studied, 48 patients fulfilled the criteria for the cohort. There was a significant reduction in the number of visits to the ED from the year before program enrollment to the year after enrollment (8.9, before; 5.9, after; P < .05). There was also an increase in psychiatric hospital visits (2%, before; 25%, after; P < .05). An alert program that identifies challenging ED patients with psychiatric conditions and creates a care plan appears to reduce visits and lead to more appropriate use of other resources. Copyright © 2012 Elsevier Inc. All rights reserved.

Unexpected metabolic disorders induced by endocrine disruptors in Xenopus tropicalis provide new lead for understanding amphibian decline.

PubMed

Regnault, Christophe; Usal, Marie; Veyrenc, Sylvie; Couturier, Karine; Batandier, Cécile; Bulteau, Anne-Laure; Lejon, David; Sapin, Alexandre; Combourieu, Bruno; Chetiveaux, Maud; Le May, Cédric; Lafond, Thomas; Raveton, Muriel; Reynaud, Stéphane

2018-05-08

Despite numerous studies suggesting that amphibians are highly sensitive to endocrine disruptors (EDs), both their role in the decline of populations and the underlying mechanisms remain unclear. This study showed that frogs exposed throughout their life cycle to ED concentrations low enough to be considered safe for drinking water, developed a prediabetes phenotype and, more commonly, a metabolic syndrome. Female Xenopus tropicalis exposed from tadpole stage to benzo( a )pyrene or triclosan at concentrations of 50 ng⋅L -1 displayed glucose intolerance syndrome, liver steatosis, liver mitochondrial dysfunction, liver transcriptomic signature, and pancreatic insulin hypersecretion, all typical of a prediabetes state. This metabolic syndrome led to progeny whose metamorphosis was delayed and occurred while the individuals were both smaller and lighter, all factors that have been linked to reduced adult recruitment and likelihood of reproduction. We found that F 1 animals did indeed have reduced reproductive success, demonstrating a lower fitness in ED-exposed Xenopus Moreover, after 1 year of depuration, Xenopus that had been exposed to benzo( a )pyrene still displayed hepatic disorders and a marked insulin secretory defect resulting in glucose intolerance. Our results demonstrate that amphibians are highly sensitive to EDs at concentrations well below the thresholds reported to induce stress in other vertebrates. This study introduces EDs as a possible key contributing factor to amphibian population decline through metabolism disruption. Overall, our results show that EDs cause metabolic disorders, which is in agreement with epidemiological studies suggesting that environmental EDs might be one of the principal causes of metabolic disease in humans.

Paid sick leave is associated with fewer ED visits among US private sector working adults.

PubMed

Bhuyan, Soumitra S; Wang, Yang; Bhatt, Jay; Dismuke, S Edward; Carlton, Erik L; Gentry, Dan; LaGrange, Chad; Chang, Cyril F

2016-05-01

The United States (US) is the only developed country that does not guarantee short-term or longer-term paid sick leave. This study used a multiyear nationally representative database to examine the association between availability of paid sick leave and frequency of emergency department (ED) use among US private sector employees. We used the National Health Interview Survey data (2012-2014). The final study sample consists of 42,460 US adults between 18 and 64years of age and working in nongovernmental private sector. Our results suggest that availability of paid sick leave is significantly associated with lower likelihood of ED use, for both moderate (1-3 times/year) and repeated users (4 or more times/year). After controlling for confounding factors, respondents with paid sick leave are 14% less likely to be moderate ED users (adjusted odds ratio, 0.86; 95% CI, 0.79-0.93) and 32% less likely to be repeated ED users (adjusted odds ratio, 0.68; 95% CI, 0.50-0.91). Although expansion of health insurance coverage under the Affordable Care Act has not been shown to reduce utilization of high cost health care services such as the ED, our study suggests other factors such as the availability of paid sick leave may do so, by allowing patients to seek care through other more cost-effective mechanisms (eg, primary care providers). To reduce ED utilization, health policymakers should consider alternative reforms including paid sick leave. Copyright © 2016 Elsevier Inc. All rights reserved.

Identifying causes of laboratory turnaround time delay in the emergency department.

PubMed

Jalili, Mohammad; Shalileh, Keivan; Mojtahed, Ali; Mojtahed, Mohammad; Moradi-Lakeh, Maziar

2012-12-01

Laboratory turnaround time (TAT) is an important determinant of patient stay and quality of care. Our objective is to evaluate laboratory TAT in our emergency department (ED) and to generate a simple model for identifying the primary causes for delay. We measured TATs of hemoglobin, potassium, and prothrombin time tests requested in the ED of a tertiary-care, metropolitan hospital during a consecutive one-week period. The time of different steps (physician order, nurse registration, blood-draw, specimen dispatch from the ED, specimen arrival at the laboratory, and result availability) in the test turnaround process were recorded and the intervals between these steps (order processing, specimen collection, ED waiting, transit, and within-laboratory time) and total TAT were calculated. Median TATs for hemoglobin and potassium were compared with those of the 1990 Q-Probes Study (25 min for hemoglobin and 36 min for potassium) and its recommended goals (45 min for 90% of tests). Intervals were compared according to the proportion of TAT they comprised. Median TATs (170 min for 132 hemoglobin tests, 225 min for 172 potassium tests, and 195.5 min for 128 prothrombin tests) were drastically longer than Q-Probes reported and recommended TATs. The longest intervals were ED waiting time and order processing.  Laboratory TAT varies among institutions, and data are sparse in developing countries. In our ED, actions to reduce ED waiting time and order processing are top priorities. We recommend utilization of this model by other institutions in settings with limited resources to identify their own priorities for reducing laboratory TAT.

Chronic substance use and self-harm in a primary health care setting.

PubMed

Breet, Elsie; Bantjes, Jason; Lewis, Ian

2018-06-19

Chronic substance use (CSU) is associated with health problems, including selfharm, placing a significant burden on health care resources and emergency departments (EDs). This is problematic in low- and middle-income countries like South Africa (SA), where primary care facilitates and emergency departments (EDs) are often poorly resourced. To investigate the epidemiology of CSU and self-harm and to consider the implications for primary health care service delivery and suicide prevention in SA. Data were collected from 238 consecutive self-harm patients treated at the emergency department (ED) of an urban hospital in SA. The data were analysed using bivariate and multivariate analyses. Approximately 37% of self-harm patients reported CSU. The patients in the CSU subgroup, compared to other self-harm patients, were more likely to be men (odds ratio[OR] = 8.33, 95% confidence interval [CI] = 3.19-20.9, p < 0.001), to have self-harmed by inflicting damage to their body tissue OR = 4.45, 95% CI = 1.77-11.2, p < 0.01) and to have a history of self-harm (OR = 3.71, 95% CI = 1.44-9.54, p = 0.007). A significantly smaller proportion of CSU patients, compared to other self-harm patients, were referred for psychiatric assessment (OR = 8.05, 95% CI = 4.16-15.7, p < 0.001). The findings of this study confirm that CSU is associated with greater service utilisation and repetition of self-harm among patients in primary health care settings. Treating self-harm as the presenting problem within primary care settings does not necessarily ensure that patients receive the care that they need. It might be helpful to include psychiatric assessments and screening for CSU as an integral component of care for self-harm patientswho present in primary health care settings.

Dose versus diagnosis: iatrogenic radiation exposure by multidetector computerised tomography in an academic emergency department with measurement of clinically actionable results and emergently treatable findings.

PubMed

Baskerville, J R; Chang, J H; Viator, M; Rutledge, W; Miryala, R; Duval, K E; Nishino, T K

2009-01-01

To determine the iatrogenic absorbed dosage of radiation of the patient in milligray (mGy) computerised tomography dose index volume (CTDIvol) when tested with multidetector computerised tomography (MDCT) in the emergency department (ED) setting and calculate the absorbed dosage of radiation per clinically actionable result and emergently treatable finding (ETF). The University of Texas Medical Branch (UTMB) ED located in Galveston, Texas, USA, is a level 1 trauma and tertiary referral centre treating 70,000 patients per annum. A retrospective cross-sectional data analysis of 770 emergency patients investigated by MDCT in July 2007. The presence of actionable results and ETF were determined by chart review. A total of 5320 emergency patients was treated in the UTMB ED in July 2007. This included 4508 medical and 812 trauma patients. A total of 1094 MDCT studies was performed, of which complete data were available on 1046. A total of 770 patients was investigated by MDCT, representing 14.47% of all emergency patients. This included 33.99% of trauma patients and 10.96% of medical patients. Actionable results were found in 341 studies and ETF in 105 studies. The mean radiation was 163.27 and 530.23 mGy CTDIvol for actionable results and ETF, respectively, for all studies. The mean radiation was 53.27 and 106.36 mGy CTDIvol for medical and trauma patients, respectively. The absorbed dosage of radiation of patients investigated by MDCT is clinically significant. The actionable results and ETF in our study demonstrate considerable opportunity for improvement in the utilisation of this technology by physicians.

Recommended next care following hospital-treated self-harm: Patterns and trends over time.

PubMed

Arensman, Ella; Griffin, Eve; Daly, Caroline; Corcoran, Paul; Cassidy, Eugene; Perry, Ivan J

2018-01-01

The specific objectives of this study were to examine variation in the care of self-harm patients in hospital settings and to identify the factors that predict recommended next care following self-harm. Data on consecutive presentations to Irish emergency departments (EDs) involving self-harm from the National Self-Harm Registry Ireland from 2004 to 2012 were utilised. Univariate and multivariate regression analyses were performed to assess the associations between patients' clinical and demographic characteristics, and recommended next care received. Across the study period a total 101,904 self-harm presentations were made to hospital EDs, involving 63,457 individuals. Over the course of the study there was a declining number of presentations resulting in patient admission following attendance with self-harm. Recommended next care varied according to hospital location, with general admission rates ranging from 11% to 61% across administrative health regions. Multinomial logistic regression identified that the factor which most strongly affected next care was the presenting hospital. Being male, older age, method, repeat self-harm, time of attendance and residence of the patient were all identified as influencing care received. Psychiatric admission was most common when highly lethal methods of self-harm were used (OR = 4.00, 95% CI, 3.63-4.41). A relatively large proportion of patients left the ED without being seen (15%) and the risk of doing so was highest for self-harm repeaters (1.64, 1.55-1.74 for those with 5+ presentations). The extensive hospital variation in recommended next care indicates that management of self-harm patients may be determined more by where they present than by the needs of the patient. The study outcomes underline the need to standardise the clinical management of self-harm patients in general hospital settings.

Pharmaceutical advertising in emergency departments.

PubMed

Marco, Catherine A

2004-04-01

Promotion of prescription drugs represents a growing source of pharmaceutical marketing expenditures. This study was undertaken to identify the frequency of items containing pharmaceutical advertising in clinical emergency departments (EDs). In this observational study, emergency physician on-site investigators quantified a variety of items containing pharmaceutical advertising present at specified representative times and days, in clinical EDs. Measurements were obtained by 65 on-site investigators, representing 22 states. Most EDs in this study were community EDs (87% community and 14% university or university affiliate), and most were in urban settings (50% urban, 38% suburban, and 13% rural). Investigators measured 42 items per ED (mean = 42; median = 31; interquartile range of 14-55) containing pharmaceutical advertising in the clinical area. The most commonly observed items included pens (mean 15 per ED; median 10), product brochures (mean 5; median 3), stethoscope labels (mean 4; median 2), drug samples (mean 3; median 0), books (mean 3.4), mugs (mean 2.4), and published literature (mean 3.1). EDs with a policy restricting pharmaceutical representatives in the ED had significantly fewer items containing pharmaceutical advertising (median 7.5; 95% CI = 0 to 27) than EDs without such a policy (median 35; 95% CI = 27 to 47, p = 0.005, nonparametric Wilcoxon two-sample test). There were no differences in quantities of pharmaceutical advertising for EDs in community compared with university settings (p = 0.5), rural compared with urban settings (p = 0.3), or annual ED volumes (p = 0.9). Numerous items containing pharmaceutical advertising are frequently observed in EDs. Policies restricting pharmaceutical representatives in the ED are associated with reduced pharmaceutical advertising.

Electrodynamic Dust Shield for Space Applications

NASA Technical Reports Server (NTRS)

Mackey, Paul J.; Johansen, Michael R.; Olsen, Robert C.; Raines, Matthew G.; Phillips, James R., III; Cox, Rachel E.; Hogue, Michael D.; Calle, Carlos I.; Pollard, Jacob R. S.

2016-01-01

The International Space Exploration Coordination Group (ISECG) has chosen dust mitigation technology as a Global Exploration Roadmap (GER) critical technology need in order to reduce life cycle cost and risk, and increase the probability of mission success. NASA has also included Particulate Contamination Prevention and Mitigation as a cross-cutting technology to be developed for contamination prevention, cleaning and protection. This technology has been highlighted due to the detrimental effect of dust on both human and robotic missions. During manned Apollo missions, dust caused issues with both equipment and crew. Contamination of equipment caused many issues including incorrect instrument readings and increased temperatures due to masking of thermal radiators. The astronauts were directly affected by dust that covered space suits, obscured face shields and later propagated to the cabin and into the crew's eyes and lungs. Robotic missions on Mars were affected when solar panels were obscured by dust thereby reducing the effectiveness of the solar panels. The Electrostatics and Surface Physics Lab in Swamp Works at the Kennedy Space Center has been developing an Electrodynamic Dust Shield (EDS) to remove dust from multiple surfaces, including glass shields and thermal radiators. This technology has been tested in lab environments and has evolved over several years. Tests of the technology include reduced gravity flights (6g) in which Apollo Lunar dust samples were successfully removed from glass shields while under vacuum (1 millipascal). Further development of the technology is underway to reduce the size of the EDS as well as to perform material and component testing outside of the International Space Station (ISS) on the Materials on International Space Station Experiment X (MISSE-X). This experiment is designed to verify that the EDS can withstand the harsh environment of space and will look to closely replicate the solar environment experienced on the moon. A second flight opportunity exists to provide an EDS to several companies as part of NASA's Lunar CATALYST program. The current mission concept would fly the EDS on the footpad of one of the Lunar CATALYST vehicles. To determine the effectiveness of the EDS system, image analysis will be performed on the footpad before, during and after EDS activation. If successful in these test flights, the Technology Readiness Level (TRL) of the EDS will be raised to a sufficient level to be used in the protection of mission equipment for future NASA and commercial missions to the moon, asteroids, and Mars.

Effectiveness of Interventions to Decrease Image Ordering for Low Back Pain Presentations in the Emergency Department: A Systematic Review.

PubMed

Liu, Chaocheng; Desai, Shashwat; Krebs, Lynette D; Kirkland, Scott W; Keto-Lambert, Diana; Rowe, Brian H

2018-01-08

Low back pain (LBP) is an extremely frequent reason for patients to present to an emergency department (ED). Despite evidence against the utility of imaging, simple and advanced imaging (i.e., computed tomography [CT], magnetic resonance imaging) for patients with LBP has become increasingly frequent in the ED. The objective of this review was to identify and examine the effectiveness of interventions aimed at reducing image ordering in the ED for LBP patients. A protocol was developed a priori, following the PRISMA guidelines, and registered with PROSPERO. Six bibliographic databases (including MEDLINE, EMBASE, EBM Reviews, SCOPUS, CINAHL, and Dissertation Abstracts) and the gray literature were searched. Comparative studies assessing interventions that targeted image ordering in the ED for adult patients with LBP were eligible for inclusion. Two reviewers independently screened study eligibility and completed data extraction. Study quality was completed independently by two reviewers using the before-after quality assessment checklist, with a third-party mediator resolving any differences. Due to a limited number of studies and significant heterogeneity, only a descriptive analysis was performed. The search yielded 603 unique citations of which a total of five before-after studies were included. Quality assessment identified potential biases relating to comparability between the pre- and postintervention groups, reliable assessment of outcomes, and an overall lack of information on the intervention (i.e., time point, description, intervention data collection). The type of interventions utilized included clinical decision support tools, clinical practice guidelines, a knowledge translation initiative, and multidisciplinary protocols. Overall, four studies reported a decrease in the relative percentage change in imaging in a specific image modality (22.7%-47.4%) following implementation of the interventions; however, one study reported a 35% increase in patient referrals to radiography, while another study reported a subsequent 15.4% increase in referrals to CT and myelography after implementing an intervention which reduced referrals for simple radiography. While imaging of LBP has been identified as a key area of imaging overuse (e.g., Choosing Wisely recommendation), evidence on interventions to reduce image ordering for ED patients with LBP is sparse. There is some evidence to suggest that interventions can reduce the use of simple imaging in LBP in the ED; however, a shift in imaging modality has also been demonstrated. Additional studies employing higher-quality methods and measuring intervention fidelity are strongly recommended to further explore the potential of ED-based interventions to reduce image ordering for this patient population. © 2018 by the Society for Academic Emergency Medicine.

Enhanced Disease Susceptibility1 Mediates Pathogen Resistance and Virulence Function of a Bacterial Effector in Soybean1[C][W][OPEN

PubMed Central

Wang, Jialin; Shine, M.B.; Gao, Qing-Ming; Navarre, Duroy; Jiang, Wei; Liu, Chunyan; Chen, Qingshan; Hu, Guohua; Kachroo, Aardra

2014-01-01

Enhanced disease susceptibility1 (EDS1) and phytoalexin deficient4 (PAD4) are well-known regulators of both basal and resistance (R) protein-mediated plant defense. We identified two EDS1-like (GmEDS1a/GmEDS1b) proteins and one PAD4-like (GmPAD4) protein that are required for resistance signaling in soybean (Glycine max). Consistent with their significant structural conservation to Arabidopsis (Arabidopsis thaliana) counterparts, constitutive expression of GmEDS1 or GmPAD4 complemented the pathogen resistance defects of Arabidopsis eds1 and pad4 mutants, respectively. Interestingly, however, the GmEDS1 and GmPAD4 did not complement pathogen-inducible salicylic acid accumulation in the eds1/pad4 mutants. Furthermore, the GmEDS1a/GmEDS1b proteins were unable to complement the turnip crinkle virus coat protein-mediated activation of the Arabidopsis R protein Hypersensitive reaction to Turnip crinkle virus (HRT), even though both interacted with HRT. Silencing GmEDS1a/GmEDS1b or GmPAD4 reduced basal and pathogen-inducible salicylic acid accumulation and enhanced soybean susceptibility to virulent pathogens. The GmEDS1a/GmEDS1b and GmPAD4 genes were also required for Resistance to Pseudomonas syringae pv glycinea2 (Rpg2)-mediated resistance to Pseudomonas syringae. Notably, the GmEDS1a/GmEDS1b proteins interacted with the cognate bacterial effector AvrA1 and were required for its virulence function in rpg2 plants. Together, these results show that despite significant structural similarities, conserved defense signaling components from diverse plants can differ in their functionalities. In addition, we demonstrate a role for GmEDS1 in regulating the virulence function of a bacterial effector. PMID:24872380

Treatment of Nausea and Vomiting in Pregnancy: Factors Associated with ED Revisits

PubMed Central

Sharp, Brian R.; Sharp, Kristen M.; Patterson, Brian; Dooley-Hash, Suzanne

2016-01-01

Introduction Nausea and vomiting in pregnancy (NVP) is a condition that commonly affects women in the first trimester of pregnancy. Despite frequently leading to emergency department (ED) visits, little evidence exists to characterize the nature of ED visits or to guide its treatment in the ED. Our objectives were to evaluate the treatment of NVP in the ED and to identify factors that predict return visits to the ED for NVP. Methods We conducted a retrospective database analysis using the electronic medical record from a single, large academic hospital. Demographic and treatment variables were collected using a chart review of 113 ED patient visits with a billing diagnosis of “nausea and vomiting in pregnancy” or “hyperemesis gravidarum.” Logistic regression analysis was used with a primary outcome of return visit to the ED for the same diagnoses. Results There was wide treatment variability of nausea and vomiting in pregnancy patients in the ED. Of the 113 patient visits, 38 (33.6%) had a return ED visit for NVP. High gravidity (OR 1.31, 95% CI [1.06–1.61]), high parity (OR 1.50 95% CI [1.12–2.00]), and early gestational age (OR 0.74 95% CI [0.60–0.90]) were associated with an increase in return ED visits in univariate logistic regression models, while only early gestational age (OR 0.74 95% CI [0.59–0.91]) was associated with increased return ED visits in a multiple regression model. Admission to the hospital was found to decrease the likelihood of return ED visits (p=0.002). Conclusion NVP can be difficult to manage and has a high ED return visit rate. Optimizing care with aggressive, standardized treatment in the ED and upon discharge, particularly if factors predictive of return ED visits are present, may improve quality of care and reduce ED utilization for this condition. PMID:27625723

Feasibility of an ED-to-Home Intervention to Engage Patients: A Mixed-Methods Investigation.

PubMed

Schumacher, Jessica R; Lutz, Barbara J; Hall, Allyson G; Pines, Jesse M; Jones, Andrea L; Hendry, Phyllis; Kalynych, Colleen; Carden, Donna L

2017-06-01

Older, chronically ill patients with limited health literacy are often under-engaged in managing their health and turn to the emergency department (ED) for healthcare needs. We tested the impact of an ED-initiated coaching intervention on patient engagement and follow-up doctor visits in this high-risk population. We also explored patients' care-seeking decisions. We conducted a mixed-methods study including a randomized controlled trial and in-depth interviews in two EDs in northern Florida. Participants were chronically ill older ED patients with limited health literacy and Medicare as a payer source. Patients were assigned to an evidence-based coaching intervention (n= 35) or usual post-ED care (n= 34). Qualitative interviews (n=9) explored patients' reasons for ED use. We assessed average between-group differences in patient engagement over time with the Patient Activation Measure (PAM) tool, using logistic regression and a difference-in-difference approach. Between-group differences in follow-up doctor visits were determined. We analyzed qualitative data using open coding and thematic analysis. PAM scores fell in both groups after the ED visit but fell significantly more in "usual care" (average decline -4.64) than "intervention" participants (average decline -2.77) (β=1.87, p=0.043). There were no between-group differences in doctor visits. Patients described well-informed reasons for ED visits including onset and severity of symptoms, lack of timely provider access, and immediate and comprehensive ED care. The coaching intervention significantly reduced declines in patient engagement observed after usual post-ED care. Patients reported well-informed reasons for ED use and will likely continue to make ED visits unless strategies, such as ED-initiated coaching, are implemented to help vulnerable patients better manage their health and healthcare.

Feasibility of an ED-to-Home Intervention to Engage Patients: A Mixed-Methods Investigation

PubMed Central

Schumacher, Jessica R.; Lutz, Barbara J.; Hall, Allyson G.; Pines, Jesse M.; Jones, Andrea L.; Hendry, Phyllis; Kalynych, Colleen; Carden, Donna L.

2017-01-01

Introduction Older, chronically ill patients with limited health literacy are often under-engaged in managing their health and turn to the emergency department (ED) for healthcare needs. We tested the impact of an ED-initiated coaching intervention on patient engagement and follow-up doctor visits in this high-risk population. We also explored patients’ care-seeking decisions. Methods We conducted a mixed-methods study including a randomized controlled trial and in-depth interviews in two EDs in northern Florida. Participants were chronically ill older ED patients with limited health literacy and Medicare as a payer source. Patients were assigned to an evidence-based coaching intervention (n= 35) or usual post-ED care (n= 34). Qualitative interviews (n=9) explored patients’ reasons for ED use. We assessed average between-group differences in patient engagement over time with the Patient Activation Measure (PAM) tool, using logistic regression and a difference-in-difference approach. Between-group differences in follow-up doctor visits were determined. We analyzed qualitative data using open coding and thematic analysis. Results PAM scores fell in both groups after the ED visit but fell significantly more in “usual care” (average decline −4.64) than “intervention” participants (average decline −2.77) (β=1.87, p=0.043). There were no between-group differences in doctor visits. Patients described well-informed reasons for ED visits including onset and severity of symptoms, lack of timely provider access, and immediate and comprehensive ED care. Conclusion The coaching intervention significantly reduced declines in patient engagement observed after usual post-ED care. Patients reported well-informed reasons for ED use and will likely continue to make ED visits unless strategies, such as ED-initiated coaching, are implemented to help vulnerable patients better manage their health and healthcare. PMID:28611897

Effects of emergency department expansion on emergency department patient flow.

PubMed

Mumma, Bryn E; McCue, James Y; Li, Chin-Shang; Holmes, James F

2014-05-01

Emergency department (ED) crowding is an increasing problem associated with adverse patient outcomes. ED expansion is one method advocated to reduce ED crowding. The objective of this analysis was to determine the effect of ED expansion on measures of ED crowding. This was a retrospective study using administrative data from two 11-month periods before and after the expansion of an ED from 33 to 53 adult beds in an academic medical center. ED volume, staffing, and hospital admission and occupancy data were obtained either from the electronic health record (EHR) or from administrative records. The primary outcome was the rate of patients who left without being treated (LWBT), and the secondary outcome was total ED boarding time for admitted patients. A multivariable robust linear regression model was used to determine whether ED expansion was associated with the outcome measures. The mean (±SD) daily adult volume was 128 (±14) patients before expansion and 145 (±17) patients after. The percentage of patients who LWBT was unchanged: 9.0% before expansion versus 8.3% after expansion (difference = 0.6%, 95% confidence interval [CI] = -0.16% to 1.4%). Total ED boarding time increased from 160 to 180 hours/day (difference = 20 hours, 95% CI = 8 to 32 hours). After daily ED volume, low-acuity area volume, daily wait time, daily boarding hours, and nurse staffing were adjusted for, the percentage of patients who LWBT was not independently associated with ED expansion (p = 0.053). After ED admissions, ED intensive care unit (ICU) admissions, elective surgical admissions, hospital occupancy rate, ICU occupancy rate, and number of operational ICU beds were adjusted for, the increase in ED boarding hours was independently associated with the ED expansion (p = 0.005). An increase in ED bed capacity was associated with no significant change in the percentage of patients who LWBT, but had an unintended consequence of an increase in ED boarding hours. ED expansion alone does not appear to be an adequate solution to ED crowding. © 2014 by the Society for Academic Emergency Medicine.

76 FR 39343 - Reducing Regulatory Burden; Retrospective Review Under E.O. 13563

Federal Register 2010, 2011, 2012, 2013, 2014

2011-07-06

... on ED regulations. c. How, if at all, will the agency incorporate experimental designs into retrospective analyses? Although ED will not be incorporating experimental designs into its analyses, its... evaluations, including those that use experimental designs, reveal about the efficacy of the regulations and...

Medicaid dental coverage alone may not lower rates of dental emergency department visits.

PubMed

Fingar, Kathryn R; Smith, Mark W; Davies, Sheryl; McDonald, Kathryn M; Stocks, Carol; Raven, Maria C

2015-08-01

Medicaid was expanded to millions of individuals under the Affordable Care Act, but many states do not provide dental coverage for adults under their Medicaid programs. In the absence of dental coverage, patients may resort to costly emergency department (ED) visits for dental conditions. Medicaid coverage of dental benefits could help ease the burden on the ED, but ED use for dental conditions might remain a problem in areas with a scarcity of dentists. We examined county-level rates of ED visits for nontraumatic dental conditions in twenty-nine states in 2010 in relation to dental provider density and Medicaid coverage of nonemergency dental services. Higher density of dental providers was associated with lower rates of dental ED visits by patients with Medicaid in rural counties but not in urban counties, where most dental ED visits occurred. County-level Medicaid-funded dental ED visit rates were lower in states where Medicaid covered nonemergency dental services than in other states, although this difference was not significant after other factors were adjusted for. Providing dental coverage alone might not reduce Medicaid-funded dental ED visits if patients do not have access to dental providers. Project HOPE—The People-to-People Health Foundation, Inc.

Body-Related Social Comparison and Disordered Eating among Adolescent Females with an Eating Disorder, Depressive Disorder, and Healthy Controls

PubMed Central

Hamel, Andrea E.; Zaitsoff, Shannon L.; Taylor, Andrew; Menna, Rosanne; Le Grange, Daniel

2012-01-01

The purpose of this study was to investigate the association between body-related social comparison (BRSC) and eating disorders (EDs) by: (a) comparing the degree of BRSC in adolescents with an ED, depressive disorder (DD), and no psychiatric history; and (b) investigating whether BRSC is associated with ED symptoms after controlling for symptoms of depression and self-esteem. Participants were 75 girls, aged 12–18 (25 per diagnostic group). To assess BRSC, participants reported on a 5-point Likert scale how often they compare their body to others’. Participants also completed a diagnostic interview, Eating Disorders Inventory-2 (EDI-2), Beck Depression Inventory-II (BDI-II), and Rosenberg Self-Esteem Scale (RSE). Compared to adolescents with a DD and healthy adolescents, adolescents with an ED engaged in significantly more BRSC (p ≤ 0.001). Collapsing across groups, BRSC was significantly positively correlated with ED symptoms (p ≤ 0.01), and these associations remained even after controlling for two robust predictors of both ED symptoms and social comparison, namely BDI-II and RSE. In conclusion, BRSC seems to be strongly related to EDs. Treatment for adolescents with an ED may focus on reducing BRSC. PMID:23112914

Body-related social comparison and disordered eating among adolescent females with an eating disorder, depressive disorder, and healthy controls.

PubMed

Hamel, Andrea E; Zaitsoff, Shannon L; Taylor, Andrew; Menna, Rosanne; Le Grange, Daniel

2012-09-01

The purpose of this study was to investigate the association between body-related social comparison (BRSC) and eating disorders (EDs) by: (a) comparing the degree of BRSC in adolescents with an ED, depressive disorder (DD), and no psychiatric history; and (b) investigating whether BRSC is associated with ED symptoms after controlling for symptoms of depression and self-esteem. Participants were 75 girls, aged 12-18 (25 per diagnostic group). To assess BRSC, participants reported on a 5-point Likert scale how often they compare their body to others'. Participants also completed a diagnostic interview, Eating Disorders Inventory-2 (EDI-2), Beck Depression Inventory-II (BDI-II), and Rosenberg Self-Esteem Scale (RSE). Compared to adolescents with a DD and healthy adolescents, adolescents with an ED engaged in significantly more BRSC (p ≤ 0.001). Collapsing across groups, BRSC was significantly positively correlated with ED symptoms (p ≤ 0.01), and these associations remained even after controlling for two robust predictors of both ED symptoms and social comparison, namely BDI-II and RSE. In conclusion, BRSC seems to be strongly related to EDs. Treatment for adolescents with an ED may focus on reducing BRSC.

Health Information Technology Adoption in the Emergency Department.

PubMed

Selck, Frederic W; Decker, Sandra L

2016-02-01

To describe the trend in health information technology (IT) systems adoption in hospital emergency departments (EDs) and its effect on ED efficiency and resource use. 2007-2010 National Hospital Ambulatory Medical Care Survey - ED Component. We assessed changes in the percent of visits to EDs with health IT capability and the estimated effect on waiting time to see a provider, visit length, and resource use. The percent of ED visits that took place in an ED with at least a basic health IT or an advanced IT system increased from 25.2 and 3.1 percent in 2007 to 69.1 and 30.6 percent in 2010, respectively (p < .05). Controlling for ED fixed effects, waiting times were reduced by 6.0 minutes in advanced IT-equipped EDs (p < .05), and the number of tests ordered increased by 9 percent (p < .01). In models using a 1-year lag, advanced systems also showed an increase in the number of medications and images ordered per visit. Almost a third of visits now occur in EDs with advanced IT capability. While advanced IT adoption may decrease wait times, resource use during ED visits may also increase depending on how long the system has been in place. We were not able to determine if these changes indicated more appropriate care. © Health Research and Educational Trust.

Emergency department utilization and subsequent prescription drug overdose death

PubMed Central

Brady, Joanne E.; DiMaggio, Charles J.; Keyes, Katherine M.; Doyle, John J.; Richardson, Lynne D.; Li, Guohua

2015-01-01

Purpose Prescription drug overdose (PDO) deaths are a critical public health problem in the United States. This study aims to assess the association between emergency department (ED) utilization patterns in a cohort of ED patients and the risk of subsequent unintentional PDO mortality. Methods Using data from the New York Statewide Planning and Research Cooperative System for 2006–2010, a nested case-control design was used to examine the relationship between ED utilization patterns in New York State residents of age 18–64 years and subsequent PDO death. Results The study sample consisted of 2732 case patients who died of PDO and 2732 control ED patients who were selected through incidence density sampling. With adjustment for demographic characteristics, and diagnoses of pain, substance abuse, and psychiatric disorders, the estimated odds ratios of PDO death relative to one ED visit or less in the previous year were 4.90 (95% confidence interval [CI]: 4.50–5.34) for those with two ED visits, 16.61 (95% CI: 14.72–18.75) for those with three ED visits, and 48.24 (95% CI: 43.23–53.83) for those with four ED visits or more. Conclusions Frequency of ED visits is strongly associated with the risk of subsequent PDO death. Intervention programs targeting frequent ED users are warranted to reduce PDO mortality. PMID:25935710

TaEDS1 genes positively regulate resistance to powdery mildew in wheat.

PubMed

Chen, Guiping; Wei, Bo; Li, Guoliang; Gong, Caiyan; Fan, Renchun; Zhang, Xiangqi

2018-04-01

Three EDS1 genes were cloned from common wheat and were demonstrated to positively regulate resistance to powdery mildew in wheat. The EDS1 proteins play important roles in plant basal resistance and TIR-NB-LRR protein-triggered resistance in dicots. Until now, there have been very few studies on EDS1 in monocots, and none in wheat. Here, we report on three common wheat orthologous genes of EDS1 family (TaEDS1-5A, 5B and 5D) and their function in powdery mildew resistance. Comparisons of these genes with their orthologs in diploid ancestors revealed that EDS1 is a conserved gene family in Triticeae. The cDNA sequence similarity among the three TaEDS1 genes was greater than 96.5%, and they shared sequence similarities of more than 99.6% with the respective orthologs from diploid ancestors. The phylogenetic analysis revealed that the EDS1 family originated prior to the differentiation of monocots and dicots, and EDS1 members have since undergone clear structural differentiation. The transcriptional levels of TaEDS1 genes in the leaves were obviously higher than those of the other organs, and they were induced by Blumeria graminis f. sp. tritici (Bgt) infection and salicylic acid (SA) treatment. The BSMV-VIGS experiments indicated that knock-down the transcriptional levels of the TaEDS1 genes in a powdery mildew-resistant variety of common wheat compromised resistance. Contrarily, transient overexpression of TaEDS1 genes in a susceptible common wheat variety significantly reduced the haustorium index and attenuated the growth of Bgt. Furthermore, the expression of TaEDS1 genes in the Arabidopsis mutant eds1-1 complemented its susceptible phenotype to powdery mildew. The above evidences strongly suggest that TaEDS1 acts as a positive regulator and confers resistance against powdery mildew in common wheat.

Scientific principles for the identification of endocrine-disrupting chemicals: a consensus statement.

PubMed

Solecki, Roland; Kortenkamp, Andreas; Bergman, Åke; Chahoud, Ibrahim; Degen, Gisela H; Dietrich, Daniel; Greim, Helmut; Håkansson, Helen; Hass, Ulla; Husoy, Trine; Jacobs, Miriam; Jobling, Susan; Mantovani, Alberto; Marx-Stoelting, Philip; Piersma, Aldert; Ritz, Vera; Slama, Remy; Stahlmann, Ralf; van den Berg, Martin; Zoeller, R Thomas; Boobis, Alan R

2017-02-01

Endocrine disruption is a specific form of toxicity, where natural and/or anthropogenic chemicals, known as "endocrine disruptors" (EDs), trigger adverse health effects by disrupting the endogenous hormone system. There is need to harmonize guidance on the regulation of EDs, but this has been hampered by what appeared as a lack of consensus among scientists. This publication provides summary information about a consensus reached by a group of world-leading scientists that can serve as the basis for the development of ED criteria in relevant EU legislation. Twenty-three international scientists from different disciplines discussed principles and open questions on ED identification as outlined in a draft consensus paper at an expert meeting hosted by the German Federal Institute for Risk Assessment (BfR) in Berlin, Germany on 11-12 April 2016. Participants reached a consensus regarding scientific principles for the identification of EDs. The paper discusses the consensus reached on background, definition of an ED and related concepts, sources of uncertainty, scientific principles important for ED identification, and research needs. It highlights the difficulty in retrospectively reconstructing ED exposure, insufficient range of validated test systems for EDs, and some issues impacting on the evaluation of the risk from EDs, such as non-monotonic dose-response and thresholds, modes of action, and exposure assessment. This report provides the consensus statement on EDs agreed among all participating scientists. The meeting facilitated a productive debate and reduced a number of differences in views. It is expected that the consensus reached will serve as an important basis for the development of regulatory ED criteria.

Emergency medicine versus primary care: a case study of three prevalent, costly, and non-emergent diagnoses at a community teaching hospital.

PubMed

Martin, B C

2000-01-01

The high cost of emergency department (ED) care is often viewed as an area for achieving cost savings through reduced utilization for inappropriate conditions. The implementation of outpatient prospective payment for Medicare ED patients heightens scrutiny of costs and utilization in the ED versus primary care settings. Data from hospital clinical records, financial records, and a provider survey was used to develop a costing methodology and complete a comparative analysis of the cost of care for three diagnoses by setting. Total costs were significantly higher in the ED due primarily to differences in ancillary tests and prescription drugs ordered.

Effect of an independent-capacity protocol on overcrowding in an urban emergency department.

PubMed

Cha, Won Chul; Shin, Sang Do; Song, Kyoung Jun; Jung, Sung Koo; Suh, Gil Joon

2009-12-01

The authors hypothesized that a new strategy, termed the independent-capacity protocol (ICP), which was defined as primary stabilization at the emergency department (ED) and utilization of community resources via transfer to local hospitals, would reduce ED overcrowding without requiring additional hospital resources. This is a before-and-after trial that included all patients who visited an urban, tertiary care ED in Korea from July 2006 to June 2008. To improve ED throughput, introduction of the ICP gave emergency physicians (EPs) more responsibility and authority over patient disposition, even when the patients belonged to another specific clinical department. The ICP utilizes the ED as a temporary, nonspecific place that cares for any patient for a limited time period. Within 48 hours, EPs, associated specialists, and transfer coordinators perform secondary assessment and determine patient disposition. If the hospital is full and cannot admit these patients after 48 hours, the EP and transfer coordinators move the patients to other appropriate community facilities. We collected clinical data such as sex, age, diagnosis, and treatment. The main outcomes included ED length of stay (LOS), the numbers of admissions to inpatient wards, and the mortality rate. A total of 87,309 patients were included. The median number of daily patients was 114 (interquartile range [IQR] = 104 to 124) in the control phase and 124 (IQR = 112 to 135) in the ICP phase. The mean ED LOS decreased from 15.1 hours (95% confidence interval [CI] = 14.8 to 15.3) to 13.4 hours (95% CI = 13.2 to 13.6; p < 0.001). The mean LOS in the emergency ward decreased from 4.5 days (95% CI = 4.4 to 4.6 days) to 3.1 days (95% CI = 3.0 to 3.2 days; p < 0.001). The percentage of transfers from the ED to other hospitals decreased from 3.5% to 2.5% (p < 0.001). However, transfers from the emergency ward to other hospitals increased from 2.9% to 8.2% (p < 0.001). Admissions to inpatient wards from the ED were significantly reduced, and admission from the emergency ward did not change. The ED mortality and hospital mortality rates did not change (p = 0.15 and p = 0.10, respectively). After introduction of the ICP, ED LOS decreased without an increase in hospital capacity.

The characteristics of hospital emergency department visits made by people with mental health conditions who had dental problems.

PubMed

Nalliah, Romesh P; Da Silva, John D; Allareddy, Veerasathpurush

2013-06-01

There is a paucity of knowledge regarding nationally representative estimates of hospital-based emergency department (ED) visits for dental problems made by people with mental health conditions. The authors conducted a study to provide nationwide estimates of hospital-based ED visits attributed to dental caries, pulpal and periapical lesions, gingival and periodontal lesions and mouth cellulitis/abscess made by people with mental health conditions. The authors used the Nationwide Emergency Department Sample, which is a component of the Healthcare Cost and Utilization Project sponsored by the Agency for Healthcare Research and Quality. ED visits attributable to dental caries, pulpal and periapical lesions, gingival and periodontal lesions and mouth cellulitis/abscess were identified by the emergency care provider by using diagnostic codes in International Classification of Diseases, Ninth Revision, Clinical Modification. The authors examined outcomes, including hospital charges. They used simple descriptive statistics to summarize the data. In 2008, people with mental health conditions made 15,635,253 visits to hospital-based ED in the United States. A diagnosis of dental caries, pulpal and periapical lesions, gingival and periodontal lesions and mouth cellulitis/abscess represented 63,164 of these ED visits. The breakdown of the ED visits was 34,574 with dental caries, 25,352 with pulpal and periapical lesions, 9,657 with gingival and periodontal lesions, and 2,776 with mouth cellulitis/abscess. The total charge for ED visits in the United States was $55.46 million in 2008. In 2008, people with mental health conditions made 63,164 visits to hospital-based EDs and received a diagnosis of dental caries, pulpal and periapical lesions, gingival and periodontal lesions or mouth cellulitis/abscess. These ED visits incurred substantial hospital charges. Programs designed to reduce the number of ED visits made by this population for common dental problems could have a substantial impact in reducing the use of hospital resources. Practical Implications. Clinicians should implement preventive practices for patients with mental health conditions. The authors identified combinations of mental health conditions and dental problems that led to patients with mental health conditions making visits to hospital-based EDs for dental problems more frequently than did patients in the general population.

The association between the availability of ambulatory care and non-emergency treatment in emergency medicine departments: a comprehensive and nationwide validation.

PubMed

Chan, Chien-Lung; Lin, Wender; Yang, Nan-Ping; Huang, Hsin-Tsung

2013-05-01

To quantify dynamic availability of ambulatory care, and to examine possible associations with non-emergency treatments in emergency departments (EDs). Longitudinal data from the Taiwan National health Insurance Research Database were used to evaluate 749,584 emergency-medicine cases occurring between 2005 and 2010 according to a modified New York University algorithm. Multivariable-cumulative-logistic-regression analysis with generalized estimating-equation methods was used to determine associations between availability of ambulatory care and the urgency of patients' medical needs during ED visits. More than half (53.04%) of the ED visits that were evaluated in our study were classified as non-emergencies, and over half of these occurred despite a high availability of ambulatory care facilities (median > 96%). Compared with patients in areas with a low availability of ambulatory care, patients in areas of medium to high availability showed approximately 0.8 times lower odds ratios for associations with non-emergency ED visits. Non-emergency ED visits may be reduced by increasing the availability of ambulatory care facilities in areas with deficits in the availability of such facilities. However, increasing the availability of ambulatory care by raising the number of available ambulatory care physicians or the number of ambulatory care facilities may not reduce non-emergency ED visits in areas with medium to high availability of ambulatory care facilities. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Low volume tubes are not effective to reduce the rate of hemolyzed specimens from the emergency department.

PubMed

Lippi, Giuseppe; Bonelli, Patrizia; Graiani, Virna; Caleffi, Catia; Cervellin, Gianfranco

2014-02-01

Spurious hemolysis is the leading source of nonconformities that can be recorded in diagnostic samples, especially those collected in the emergency department (ED). The aim of this study was to assess whether the shift from regular to low volume blood collection tubes may reduce the rate of hemolysis in a large urban ED, where approximately 80% of blood collections are performed through catheters. In a former 5-month period, blood collection in the ED was performed using 5.0mL (13×100mm) plastic serum tubes, which were then completely replaced with 3.5mL (13×75mm) plastic serum tubes for another period of 5months. The rate of hemolyzed specimens (i.e., those containing a cell-free hemoglobin ≥0.5gL) collected in the two periods was compared by Fisher exact test. The rate of hemolyzed specimens received from the ED increased from 3.5% using 5.0mL plastic serum tubes to 5.2% after introduction of 3.5mL plastic serum tubes (p<0.001). The use of low volume tubes was not effective to decrease the hemolysis rate in a large urban ED. Copyright © 2013 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.

Time-trends, Predictors and Outcome of Emergency Department Utilization for Gout: A Nationwide U.S. Study

PubMed Central

Singh, Jasvinder A.; Yu, Shaohua

2016-01-01

Objective To assess gout-related emergency department (ED) utilization/charges and discharge disposition. Methods We used the U.S. National ED Sample (NEDS) data to examine the time-trends in total ED visits and charges and ED-related hospitalizations with gout as the primary diagnosis. We assessed multivariable-adjusted predictors of ED charges and hospitalization for gout-related visits using the 2012 NEDS data. Results There were 180,789, 201,044 and 205,152 ED visits in years 2009, 2010 and 2012 with gout as the primary diagnosis, with total ED charges of $195, $239 and $287 million, respectively; these accounted for 0.14-0.16% of all ED visits. Mean/median 2012 ED charges/visit were $1,398/$956. Of all gout-related ED visits, 7.7% were admitted to the hospital in 2012. Mean/median length of hospital stay was 3.9/2.6 days and mean/median inpatient charge/admission was $22,066/$15,912 in 2012. In multivariable-adjusted analyses, older age, female gender, highest income quartile, being uninsured, metropolitan residence, Western U.S. hospital location, heart disease, renal failure, congestive heart failure (CHF), hypertension, diabetes, osteoarthritis and chronic obstructive pulmonary disease (COPD) were associated with higher ED charges. Older age, Northeast location, Metropolitan teaching hospital, higher income quartile, heart disease, renal failure, CHF, hyperlipidemia, hypertension, diabetes, COPD, and osteoarthritis were associated with higher odds where as self-pay insurance status was associated with lower odds of hospitalization following an ED visit for gout. Conclusions Absolute ED utilization and charges for gout increased over time, but relative utilization remained stable. Modifiable comorbidity factors associated with higher gout-related utilization should be targeted to reduce morbidity and healthcare utilization. PMID:27134260

Elimination of Emergency Department Medication Errors Due To Estimated Weights.

PubMed

Greenwalt, Mary; Griffen, David; Wilkerson, Jim

2017-01-01

From 7/2014 through 6/2015, 10 emergency department (ED) medication dosing errors were reported through the electronic incident reporting system of an urban academic medical center. Analysis of these medication errors identified inaccurate estimated weight on patients as the root cause. The goal of this project was to reduce weight-based dosing medication errors due to inaccurate estimated weights on patients presenting to the ED. Chart review revealed that 13.8% of estimated weights documented on admitted ED patients varied more than 10% from subsequent actual admission weights recorded. A random sample of 100 charts containing estimated weights revealed 2 previously unreported significant medication dosage errors (.02 significant error rate). Key improvements included removing barriers to weighing ED patients, storytelling to engage staff and change culture, and removal of the estimated weight documentation field from the ED electronic health record (EHR) forms. With these improvements estimated weights on ED patients, and the resulting medication errors, were eliminated.

The effects of viewing pro-eating disorder websites: a systematic review.

PubMed

Talbot, T Sloper

2010-12-01

To determine health-related effects of viewing pro-eating disorder (Pro-ED) websites. A systematic review was carried out addressing: 1. The effect of viewing pro-ED websites on eating disorder behaviour 2. The effect of viewing pro-ED websites on viewers' negative and positive affect. Seven studies were included. Pro-ED viewers compared with controls showed higher levels of dieting and exercise (3 studies, 2 suggesting causation); higher levels of drive for thinness, body dissatisfaction and perfectionism (2 studies, both associative); a reduced likelihood of binging/purging (one study); increased negative affect (two studies); and a positive correlation between viewing pro-ED websites, disease duration and hospitalisations (one study). Viewing pro-ED websites may increase eating disorder behaviour but might not cause it. It may cause increased negative affect after a single short website exposure. For those with eating disorders, viewing is positively correlated with disease duration and hospitalisations. Professionals should be aware of these sites and their potential damage for health.

A Successful ED Fall Risk Program Using the KINDER 1 Fall RiskAssessment Tool.

PubMed

Townsend, Ann B; Valle-Ortiz, Marisol; Sansweet, Tracy

2016-11-01

Emergency nurses did not perform falls risk assessments routinely on our ED patients; the instrument used was aimed at inpatients. We identified a need to revise fall assessment practices specific to our emergency department. The purpose of the performance improvement project was to reduce ED falls and evaluate the use of an ED-specific fall risk tool, the KINDER 1 Fall Risk Assessment. The plan was to establish fall risk assessment practices at point of ED entry and to decrease total falls. We retrospectively reviewed ED fall data for each quarter of 2013, which included risk assessments scores, the total number of falls, and the circumstances of each fall. Using Kotter's framework to guide a successful change process, we implemented the KINDER 1 to assess fall risk. During the first 4 weeks of the project, 937 patients (27%) were identified as high risk for falls using the KINDER 1. During the subsequent 3 quarters, the total number of falls decreased; reported falls without injuries dropped from 0.21 to 0.07 per 1000 patients, and falls with injuries were reduced from 0.21 to 0.0 per 1000 patients. The results of this project represented a valuable step toward achieving our goal to keep ED patients safe from injuries as a result of falls. The findings add to the body of nursing knowledge on the application of clinical-based performance improvement projects to improve patient outcomes and to provide data on the use of the KINDER 1 tool, which has not been extensively tested. Copyright © 2016 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved.

Lifestyle and metabolic approaches to maximizing erectile and vascular health.

PubMed

Meldrum, D R; Gambone, J C; Morris, M A; Esposito, K; Giugliano, D; Ignarro, L J

2012-01-01

Oxidative stress and inflammation, which disrupt nitric oxide (NO) production directly or by causing resistance to insulin, are central determinants of vascular diseases including ED. Decreased vascular NO has been linked to abdominal obesity, smoking and high intakes of fat and sugar, which all cause oxidative stress. Men with ED have decreased vascular NO and circulating and cellular antioxidants. Oxidative stress and inflammatory markers are increased in men with ED, and all increase with age. Exercise increases vascular NO, and more frequent erections are correlated with decreased ED, both in part due to stimulation of endothelial NO production by shear stress. Exercise and weight loss increase insulin sensitivity and endothelial NO production. Potent antioxidants or high doses of weaker antioxidants increase vascular NO and improve vascular and erectile function. Antioxidants may be particularly important in men with ED who smoke, are obese or have diabetes. Omega-3 fatty acids reduce inflammatory markers, decrease cardiac death and increase endothelial NO production, and are therefore critical for men with ED who are under age 60 years, and/or have diabetes, hypertension or coronary artery disease, who are at increased risk of serious or even fatal cardiac events. Phosphodiesterase inhibitors have recently been shown to improve antioxidant status and NO production and allow more frequent and sustained penile exercise. Some angiotensin II receptor blockers decrease oxidative stress and improve vascular and erectile function and are therefore preferred choices for lowering blood pressure in men with ED. Lifestyle modifications, including physical and penile-specific exercise, weight loss, omega-3 and folic acid supplements, reduced intakes of fat and sugar, and improved antioxidant status through diet and/or supplements should be integrated into any comprehensive approach to maximizing erectile function, resulting in greater overall success and patient satisfaction, as well as improved vascular health and longevity.

Ways to reduce patient turnaround time and improve service quality in emergency departments.

PubMed

Sinreich, David; Marmor, Yariv

2005-01-01

Recent years have witnessed a fundamental change in the function of emergency departments (EDs). The emphasis of the ED shifts from triage to saving the lives of shock-trauma rooms equipped with state-of-the-art equipment. At the same time walk-in clinics are being set up to treat ambulatory type patients. Simultaneously ED overcrowding has become a common sight in many large urban hospitals. This paper recognises that in order to provide quality treatment to all these patient types, ED process operations have to be flexible and efficient. The paper aims to examine one major benchmark for measuring service quality--patient turnaround time, claiming that in order to provide the quality treatment to which EDs aspire, this time needs to be reduced. This study starts by separating the process each patient type goes through when treated at the ED into unique components. Next, using a simple model, the impact each of these components has on the total patient turnaround time is determined. This in turn, identifies the components that need to be addressed if patient turnaround time is to be streamlined. The model was tested using data that were gathered through a comprehensive time study in six major hospitals. The analysis reveals that waiting time comprises 51-63 per cent of total patient turnaround time in the ED. Its major components are: time away for an x-ray examination; waiting time for the first physician's examination; and waiting time for blood work. The study covers several hospitals and analyses over 20,000 process components; as such the common findings may serve as guidelines to other hospitals when addressing this issue.

Bone involvement in adult patients affected with Ehlers-Danlos syndrome.

PubMed

Eller-Vainicher, C; Bassotti, A; Imeraj, A; Cairoli, E; Ulivieri, F M; Cortini, F; Dubini, M; Marinelli, B; Spada, A; Chiodini, I

2016-08-01

The Ehlers-Danlos syndrome is characterized by abnormal connective tissue but bone involvement is debated. We found a reduced BMD and bone quality and increased prevalence of asymptomatic vertebral fractures in eugonadal patients with Ehlers-Danlos syndrome. These findings suggest the need of a bone health evaluation in these patients. The Ehlers-Danlos (EDS) syndrome is characterized by abnormalities of the connective tissue leading to ligamentous laxity and skin and tissue fragility. We evaluated the bone metabolism, bone mineral density (BMD) and bone quality (measured by trabecular bone score, TBS), and the prevalence of vertebral fractures (VFx) in a group of eugonadal adult EDS patients. Fifty consecutive Caucasian patients, aged 30-50 years (36 females, 14 males) with classical or hypermobility EDS and 50 age-, gender-, and body mass index (BMI)-matched control subjects were enrolled. In all subjects' calcium-phosphorous metabolism, bone turnover, BMD at the lumbar spine (LS) and femur (femoral neck, FN and total femur, FT) and TBS by dual-energy X-ray absorptiometry, and the VFx presence by spine radiograph were assessed. Patients showed reduced BMD (Z-scores LS -0.45 ± 1.00, FN -0.56 ± 1.01, FT -0.58 ± 0.92) and TBS (1.299 ± 0.111) and increased prevalence of morphometric VFx (32 %) than controls (Z-scores LS 0.09 ± 1.22, FN 0.01 ± 0.97, FT 0.08 ± 0.89; TBS 1.382 ± 0.176; VFx 8 %, p <0.05 for all comparisons), while vitamin D levels, calcium-phosphorous metabolism, and bone turnover were comparable. Fractured EDS patients showed lower TBS values than non-fractured ones (1.245 ± 0.138 vs 1.325 ± 0.086, p < 0.05), despite comparable BMD. In EDS patients, the VFx presence was significantly associated with TBS even after adjusting for sex, age, BMD, EDS type, and falls frequency. EDS patients have reduced BMD and bone quality (as measured by TBS) and increased prevalence of VFx.

Exploring the relationship between general practice characteristics, and attendance at walk-in centres, minor injuries units and EDs in England 2012/2013: a cross-sectional study.

PubMed

Tammes, Peter; Morris, Richard W; Brangan, Emer; Checkland, Kath; England, Helen; Huntley, Alyson; Lasserson, Daniel; MacKichan, Fiona; Salisbury, Chris; Wye, Lesley; Purdy, Sarah

2016-10-01

For several years, EDs in the UK NHS have faced considerable increases in attendance rates. Walk-in centres (WiCs) and minor injuries units (MIUs) have been suggested as solutions. We aimed to investigate the associations between practice and practice population characteristics with ED attendance rates or combined ED/WiC/MIU attendance, and the associations between WiC/MIU and ED attendance. We used general practice-level data including 7462 English practices in 2012/2013 and present adjusted regression coefficients from linear multivariable analysis for relationships between patients' emergency attendance rates and practice characteristics. Every percentage-point increase in patients reporting inability to make an appointment was associated with an increase in emergency attendance by 0.36 (95% CI 0.06 to 0.66) per 1000 population. Percentage-point increases in patients unable to speak to a general practitioner (GP)/nurse within two workdays and patients able to speak often to their preferred GP were associated with increased emergency attendance/1000 population by 0.23 (95% CI 0.05 to 0.42) and 0.10 (95% CI 0.00 to 0.19), respectively. Practices in areas encompassing several towns (conurbations) had higher attendance than rural practices, as did practices with more non-UK-qualified GPs. Practice population characteristics associated with increased emergency attendance included higher unemployment rates, higher percentage of UK whites and lower male life expectancy, which showed stronger associations than practice characteristics. Furthermore, higher MIU or WiC attendance rates were associated with lower ED attendance rates. Improving availability of appointments and opportunities to speak a GP/nurse at short notice might reduce ED attendance. Establishing MIUs and WiCs might also reduce ED attendance. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Methodology of AA CRASH: a prospective observational study evaluating the incidence and pathogenesis of adverse post-traumatic sequelae in African-Americans experiencing motor vehicle collision.

PubMed

Linnstaedt, Sarah D; Hu, JunMei; Liu, Andrea Y; Soward, April C; Bollen, Kenneth A; Wang, Henry E; Hendry, Phyllis L; Zimny, Erin; Lewandowski, Christopher; Velilla, Marc-Anthony; Damiron, Kathia; Pearson, Claire; Domeier, Robert; Kaushik, Sangeeta; Feldman, James; Rosenberg, Mark; Jones, Jeffrey; Swor, Robert; Rathlev, Niels; McLean, Samuel A

2016-09-06

A motor vehicle collision (MVC) is one of the most common life-threatening events experienced by individuals living in the USA. While most individuals recover following MVC, a significant proportion of individuals develop adverse post-traumatic sequelae such as post-traumatic stress disorder or persistent musculoskeletal pain. Adverse post-traumatic sequelae are common, morbid and costly public health problems in the USA and other industrialised countries. The pathogenesis of these disorders following MVC remains poorly understood. In the USA, available data suggest that African-Americans experience an increased burden of adverse post-traumatic sequelae after MVC compared to European Americans, but to date no studies examining the pathogenesis of these disorders among African-Americans experiencing MVC have been performed. The African-American CRASH (AA CRASH) study is an NIH-funded, multicentre, prospective study that enrols African-Americans (n=900) who present to the emergency department (ED) within 24 hours of MVC. Participants are enrolled at 13 ED sites in the USA. Individuals who are admitted to the hospital or who report a fracture or tissue injury are excluded. Participants complete a detailed ED interview that includes an assessment of crash history, current post-traumatic symptoms and health status prior to the MVC. Blood samples are also collected in the ED using PAXgene DNA and PAXgene RNA tubes. Serial mixed-mode assessments 6 weeks, 6 months and 1 year after MVC include an assessment of adverse sequelae, general health status and health service utilisation. The results from this study will provide insights into the incidence and pathogenesis of persistent pain and other post-traumatic sequelae in African-Americans experiencing MVC. AA CRASH has ethics approval in the USA, and the results will be published in a peer-reviewed journal. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Current European data collection on emergency department presentations with acute recreational drug toxicity: gaps and national variations.

PubMed

Heyerdahl, Fridtjof; Hovda, Knut Erik; Giraudon, Isabelle; Yates, Christopher; Dines, Alison M; Sedefov, Roumen; Wood, David M; Dargan, Paul I

2014-12-01

The number of new (novel) psychoactive substances (NPS) available in the illegal market is increasing; however, current monitoring of the drug situation in Europe focuses mainly on classical drugs of abuse, with limited emphasis on clinical presentation in the emergency department (ED). The European Drug Emergencies Network (Euro-DEN) is a European Commission-funded project that aims to improve the knowledge of acute drug toxicity of both classical recreational drugs and NPS. As a baseline for this project, we performed a study to establish which data are currently being collected and reported in Europe on ED presentations with acute toxicity related to NPS and classical drugs of abuse. We used a three-pronged approach to identify any systematic collection of data on NPS toxicity in Europe by i) performing a literature search, ii) utilising an online survey of the European Monitoring Centre for Drugs and Drug Addiction Re seau Europe en d'Information sur les Drogues et les Toxicomanies national focal points and iii) exploiting the knowledge and resources of the Euro-DEN network members. The literature search revealed 21 papers appropriate for assessment, but only one described a systematic collection of clinical data on NPS. Twenty-seven of thirty countries responded to the online survey. More than half of all the countries (52%) did not perform any registration at all of such data, 37% collected systematic clinical data on NPS at a national level, while 44% collected data on classical drugs. A few examples for good practice of systematic collection of clinical data on ED presentations due to acute toxicity were identified. The systematic collection of data on ED presentation of toxicity related to NPS and classical drugs in Europe is scarce; the existing collection is limited to single centres, single countries, groups of patients or not focused on novel drugs; the collection of data is highly variable between the different countries. Euro-DEN, a European Commission funded project, aims at closing some of these gaps.

Reducing Blood Culture Contamination in the Emergency Department: An Interrupted Time Series Quality Improvement Study

PubMed Central

Self, Wesley H.; Speroff, Theodore; Grijalva, Carlos G.; McNaughton, Candace D.; Ashburn, Jacki; Liu, Dandan; Arbogast, Patrick G.; Russ, Stephan; Storrow, Alan B.; Talbot, Thomas R.

2012-01-01

Objectives Blood culture contamination is a common problem in the emergency department (ED) that leads to unnecessary patient morbidity and health care costs. The study objective was to develop and evaluate the effectiveness of a quality improvement (QI) intervention for reducing blood culture contamination in an ED. Methods The authors developed a QI intervention to reduce blood culture contamination in the ED and then evaluated its effectiveness in a prospective interrupted times series study. The QI intervention involved changing the technique of blood culture specimen collection from the traditional clean procedure, to a new sterile procedure, with standardized use of sterile gloves and a new materials kit containing a 2% chlorhexidine skin antisepsis device, a sterile fenestrated drape, a sterile needle, and a procedural checklist. The intervention was implemented in a university-affiliated ED and its effect on blood culture contamination evaluated by comparing the biweekly percentages of blood cultures contaminated during a 48-week baseline period (clean technique), and 48-week intervention period (sterile technique), using segmented regression analysis with adjustment for secular trends and first-order autocorrelation. The goal was to achieve and maintain a contamination rate below 3%. Results During the baseline period, 321 out of 7,389 (4.3%) cultures were contaminated, compared to 111 of 6,590 (1.7%) during the intervention period (p < 0.001). In the segmented regression model, the intervention was associated with an immediate 2.9% (95% CI = 2.2% to 3.2%) absolute reduction in contamination. The contamination rate was maintained below 3% during each biweekly interval throughout the intervention period. Conclusions A QI assessment of ED blood culture contamination led to development of a targeted intervention to convert the process of blood culture collection from a clean to a fully sterile procedure. Implementation of this intervention led to an immediate and sustained reduction of contamination in an ED with a high baseline contamination rate. PMID:23570482

Opportunities for improvement on current nuclear cardiology practices and radiation exposure in Latin America: Findings from the 65-country IAEA Nuclear Cardiology Protocols cross-sectional Study (INCAPS).

PubMed

Vitola, João V; Mut, Fernando; Alexánderson, Erick; Pascual, Thomas N B; Mercuri, Mathew; Karthikeyan, Ganesan; Better, Nathan; Rehani, Madan M; Kashyap, Ravi; Dondi, Maurizio; Paez, Diana; Einstein, Andrew J

2017-06-01

Comparison of Latin American (LA) nuclear cardiology (NC) practice with that in the rest of the world (RoW) will identify areas for improvement and lead to educational activities to reduce radiation exposure from NC. INCAPS collected data on all SPECT and PET procedures performed during a single week in March-April 2013 in 36 laboratories in 10 LA countries (n = 1139), and 272 laboratories in 55 countries in RoW (n = 6772). Eight "best practices" were identified a priori and a radiation-related Quality Index (QI) was devised indicating the number used. Mean radiation effective dose (ED) in LA was higher than in RoW (11.8 vs 9.1 mSv, p < 0.001). Within a populous country like Brazil, a wide variation in laboratory mean ED was found, ranging from 8.4 to 17.8 mSv. Only 11% of LA laboratories achieved median ED <9 mSv, compared to 32% in RoW (p < 0.001). QIs ranged from 2 in a laboratory in Mexico to 7 in a laboratory in Cuba. Three major opportunities to reduce ED for LA patients were identified: (1) more laboratories could implement stress-only imaging, (2) camera-based methods of ED reduction, including prone imaging, could be more frequently used, and (3) injected activity of 99m Tc could be adjusted reflecting patient weight/habitus. On average, radiation dose from NC is higher in LA compared to RoW, with median laboratory ED <9 mSv achieved only one third as frequently as in RoW. Opportunities to reduce radiation exposure in LA have been identified and guideline-based recommendations made to optimize protocols and adhere to the "as low as reasonably achievable" (ALARA) principle.

Assessment of bone in Ehlers Danlos syndrome by ultrasound and densitometry.

PubMed

Dolan, A L; Arden, N K; Grahame, R; Spector, T D

1998-10-01

Ehlers Danlos syndrome (EDS) is an inherited disorder of connective tissue characterised by hyperextensible skin, joint laxity, and easy bruising. There are phenotypic similarities with osteogenesis imperfecta, but in EDS a tendency to fracture or altered bone mass has not previously been considered to be a cardinal feature. This case-control design study investigates whether 23 patients with EDS had differences in fracture rates, bone mass, and calcaneal ultrasound parameters compared with age and sex matched controls. 23 cases of EDS (mean (SD) age 38.5 (15.5)) were compared with 23 controls (mean age 37.8 (14.5)). A significant reduction in bone density measured by dual energy x ray absorptiometry was found at the neck of femur by 0.9 SD, p = 0.05, and lumbar spine by 0.74 SD, p = 0.02. At the calcaneum, broad band ultrasound attenuation and speed of sound were significantly reduced compared with controls by 0.95 SD (p = 0.004) and 0.49 SD (p = 0.004) for broad band ultrasound attenuation and speed of sound respectively. Broad band ultrasound attenuation and speed of sound remained significantly reduced after adjusting for bone mineral density (BMD). After adjusting for functional status (HAQ), age and sex, hypermobility was inversely correlated with broad band ultrasound attenuation and SOS, but not BMD at hip or spine. Previous fracture was 10 times more common in EDS (p < 0.001), with 86.9% of patients reporting a total of 47 low impact fractures, compared with 8.7% of controls. This study has identified a tendency of EDS patients to fracture, have low bone mass and abnormal bone structure. The aetiology is likely to be multifactorial, with an inherited structural element, accentuated by immobility or reduced exercise. This is one of the first clinical studies to suggest ultrasound can detect structural differences in bone, independent of dual energy x ray absorptiometry.

Erectile dysfunction and central obesity: an Italian perspective

PubMed Central

Corona, Giovanni; Rastrelli, Giulia; Filippi, Sandra; Vignozzi, Linda; Mannucci, Edoardo; Maggi, Mario

2014-01-01

Erectile dysfunction (ED) is a frequent complication of obesity. The aim of this review is to critically analyze the framework of obesity and ED, dissecting the connections between the two pathological entities. Current clinical evidence shows that obesity, and in particular central obesity, is associated with both arteriogenic ED and reduced testosterone (T) levels. It is conceivable that obesity-associated hypogonadism and increased cardiovascular risk might partially justify the higher prevalence of ED in overweight and obese individuals. Conversely, the psychological disturbances related to obesity do not seem to play a major role in the pathogenesis of obesity-related ED. However, both clinical and preclinical data show that the association between ED and visceral fat accumulation is independent from known obesity-associated comorbidities. Therefore, how visceral fat could impair penile microcirculation still remains unknown. This point is particularly relevant since central obesity in ED subjects categorizes individuals at high cardiovascular risk, especially in the youngest ones. The presence of ED in obese subjects might help healthcare professionals in convincing them to initiate a virtuous cycle, where the correction of sexual dysfunction will be the reward for improved lifestyle behavior. Unsatisfying sexual activity represents a meaningful, straightforward motivation for consulting healthcare professionals, who, in turn, should take advantage of the opportunity to encourage obese patients to treat, besides ED, the underlying unfavorable conditions, thus not only restoring erectile function, but also overall health. PMID:24713832

Erectile dysfunction and central obesity: an Italian perspective.

PubMed

Corona, Giovanni; Rastrelli, Giulia; Filippi, Sandra; Vignozzi, Linda; Mannucci, Edoardo; Maggi, Mario

2014-01-01

Erectile dysfunction (ED) is a frequent complication of obesity. The aim of this review is to critically analyze the framework of obesity and ED, dissecting the connections between the two pathological entities. Current clinical evidence shows that obesity, and in particular central obesity, is associated with both arteriogenic ED and reduced testosterone (T) levels. It is conceivable that obesity-associated hypogonadism and increased cardiovascular risk might partially justify the higher prevalence of ED in overweight and obese individuals. Conversely, the psychological disturbances related to obesity do not seem to play a major role in the pathogenesis of obesity-related ED. However, both clinical and preclinical data show that the association between ED and visceral fat accumulation is independent from known obesity-associated comorbidities. Therefore, how visceral fat could impair penile microcirculation still remains unknown. This point is particularly relevant since central obesity in ED subjects categorizes individuals at high cardiovascular risk, especially in the youngest ones. The presence of ED in obese subjects might help healthcare professionals in convincing them to initiate a virtuous cycle, where the correction of sexual dysfunction will be the reward for improved lifestyle behavior. Unsatisfying sexual activity represents a meaningful, straightforward motivation for consulting healthcare professionals, who, in turn, should take advantage of the opportunity to encourage obese patients to treat, besides ED, the underlying unfavorable conditions, thus not only restoring erectile function, but also overall health.

A missed primary care appointment correlates with a subsequent emergency department visit among children with asthma.

PubMed

McGovern, Colleen Marie; Redmond, Margaret; Arcoleo, Kimberly; Stukus, David R

2017-11-01

Since the Affordable Care Act's implementation, emergency department (ED) visits have increased. Poor asthma control increases the risk of acute exacerbations and preventable ED visits. The Centers for Medicare and Medicaid Services support the reduction of preventable ED visits to reduce healthcare spending. Implementation of interventions to avoid preventable ED visits has become a priority for many healthcare systems yet little data exist examining children's missed asthma management primary care (PC) appointments and subsequent ED visits. Longitudinal, retrospective review at a children's hospital was conducted for children with diagnosed asthma (ICD-9 493.xx), ages 2-18 years, scheduled for a PC visit between January 1, 2010, and June 30, 2012 (N = 3895). Records were cross-referenced with all asthma-related ED visits from January 1, 2010 to December 31, 2012. Logistic regression with maximum likelihood estimation was conducted. None of the children who completed a PC appointment experienced an ED visit in the subsequent 6 months whereas 2.7% of those with missed PC appointments had an ED visit (χ 2 = 64.28, p <.0001). Males were significantly more likely to have an ED visit following a missed PC appointment than females (χ 2 = 34.37, p <.0001). There was a statistically significant interaction of sex × age. Younger children (<12 years) made more visits than older children. The importance of adherence to PC appointments for children with asthma as one mechanism for preventing ED visits was demonstrated. Interventions targeting missed visits could decrease asthma-related morbidity, preventable ED visits, and healthcare costs.

Overcrowding in emergency departments: A review of strategies to decrease future challenges.

PubMed

Yarmohammadian, Mohammad H; Rezaei, Fatemeh; Haghshenas, Abbas; Tavakoli, Nahid

2017-01-01

Emergency departments (EDs) are the most challenging ward with respect to patient delay. The goal of this study is to present strategies that have proven to reduce delay and overcrowding in EDs. In this review article, initial electronic database search resulted in a total of 1006 articles. Thirty articles were included after reviewing full texts. Inclusion criteria were assessments of real patient flows and implementing strategies inside the hospitals. In this study, we discussed strategies of team triage, point-of-care testing, ideal ED patient journey models, streaming, and fast track. Patients might be directed to different streaming channels depending on clinical status and required practitioners. The most comprehensive strategy is ideal ED patient journey models, in which ten interrelated substrategies are provided. ED leaders should apply strategies that provide a continuous care process without deeply depending on external services.

SYNTHESIS AND STUDY OF HALOGENATED BENZYLAMIDES OF SOME ISOCYCLIC AND HETEROCYCLIC ACIDS AS POTENTIAL ANTICONVULSANTS.

PubMed

Strupińska, Marzanna; Rostafińska-Suchar, Grażyna; Pirianowicz-Chaber, Elżbieta; Grabczuk, Mateusz; Józwenko, Magdalena; Kowalczyk, Hubert; Szuba, Joanna; Wójcicka, Monika; Chen, Tracy; Mazurek, Aleksander P

2015-01-01

A series of potential anticonvulsants have been synthesized. There are eight fluorobenzylamides and three chlorobenzylamides of isocyclic or heterocyclic acids. Two not halogenated benzylamides were also synthesized to compare the effect of halogenation. The aim of the research performed was to evaluate whether halogenation of the mother structure is able to improve its anticonvulsant activity. The compounds were tested in Anticonvulsant Screening Project (ASP) of Antiepileptic Drug Development Program (ADDP) of NIH. Compound 1 showed MES ED50 = 80.32 mg/kg, PI = 3.16. Compound 7 showed CKM ED50 = 56.72 mg/kg. Compound 8 showed MES ED50 = 34.23 mg/kg and scPTZ ED50 > 300 mg/kg, PI = 8.53.Compound 13 showed 6Hz ED50 = 78.96, PI = 3.37. The results indicate that fluorination does not improve activity, whereas chlorination in our experiment even reduces it.

Stigmatizing Attitudes and Beliefs About Anorexia and Bulimia Nervosa Among Italian Undergraduates.

PubMed

Caslini, Manuela; Crocamo, Cristina; Dakanalis, Antonios; Tremolada, Martina; Clerici, Massimo; Carrà, Giuseppe

2016-12-01

Stigmatizing attitudes toward eating disorders (EDs) may lead to reduced treatment seeking. We aimed to estimate the prevalence of stigmatizing trends and beliefs related to anorexia nervosa (AN) and bulimia nervosa (BN), and the associations with the experiential knowledge of the problem, in a large sample of Italian undergraduates. A total of 2109 participants completed an online survey including questionnaires related to stigmatizing beliefs toward AN and BN, and personal contacts with people with EDs. Undergraduates reported almost overlapping low levels of stigmatizing trends for AN and BN, apart from personal responsibility and social distance. Those aged 18 to 25 and living with family held higher stigmatizing attitudes. Stigma was lower in underweight participants and in those (12%) reporting a previous ED diagnosis. Although not improving stigmatizing attitudes, 83% of the sample was familiar with people with an ED. Antistigma actions to increase awareness on EDs and to improve treatment-seeking behaviors are needed.

Work-related knee injuries treated in US emergency departments.

PubMed

Chen, Zhiqiang; Chakrabarty, Sangita; Levine, Robert S; Aliyu, Muktar H; Ding, Tan; Jackson, Larry L

2013-09-01

To characterize work-related knee injuries treated in US emergency departments (EDs). We characterized work-related knee injuries treated in EDs in 2007 and examined trends from 1998 to 2007 by using the National Electronic Injury Surveillance System-occupational supplement. In 2007, 184,300 (± 54,000; 95% confidence interval) occupational knee injuries were treated in US EDs, accounting for 5% of the 3.4 (± 0.9) million ED-treated occupational injuries. The ED-treated knee injury rate was 13 (± 4) injuries per 10,000 full-time equivalent workers. Younger workers and older female workers had high rates. Strains/sprains and contusions/abrasions were common-frequently resulting from falls and bodily reaction/overexertion events. Knee injury rates declined from 1998 through 2007. Knee injury prevention should emphasize reducing falls and bodily reaction/overexertion events, particularly among all youth and older women.

Telescopic overdenture for oral rehabilitation of ectodermal dysplasia patient.

PubMed

Gupta, Charu; Verma, Mahesh; Gupta, Rekha; Gill, Shubhra

2015-09-01

Reduced number of teeth with underdeveloped alveolar ridges poses a greatest prosthetic challenge in rehabilitation of ectodermal dysplasia patients (ED). Furthermore, surgical risks and financial constraints may preclude the implant supported prosthesis, the most desirable treatment option in an adult ED patient. Long edentulous span does not permit fixed dental prosthesis (FDP) as well. Telescopic denture by incorporating the best of both fixed and removable prosthesis can be a viable treatment alternative for ED patients with compromised dentition and limited finances. A 21-year-old young girl presented with chief complaint of esthetics and mastication due to missing upper and lower teeth. A provisional diagnosis of ED was made based on familial history, physical, and oral examination. This clinical report describes management of an adult ED patient by means of telescopic overdenture prosthesis in mandibular arch and FDP in maxillary arch which restored esthetics, function, and social confidence of the patient in a cost effective manner.

Telescopic overdenture for oral rehabilitation of ectodermal dysplasia patient

PubMed Central

Gupta, Charu; Verma, Mahesh; Gupta, Rekha; Gill, Shubhra

2015-01-01

Reduced number of teeth with underdeveloped alveolar ridges poses a greatest prosthetic challenge in rehabilitation of ectodermal dysplasia patients (ED). Furthermore, surgical risks and financial constraints may preclude the implant supported prosthesis, the most desirable treatment option in an adult ED patient. Long edentulous span does not permit fixed dental prosthesis (FDP) as well. Telescopic denture by incorporating the best of both fixed and removable prosthesis can be a viable treatment alternative for ED patients with compromised dentition and limited finances. A 21-year-old young girl presented with chief complaint of esthetics and mastication due to missing upper and lower teeth. A provisional diagnosis of ED was made based on familial history, physical, and oral examination. This clinical report describes management of an adult ED patient by means of telescopic overdenture prosthesis in mandibular arch and FDP in maxillary arch which restored esthetics, function, and social confidence of the patient in a cost effective manner. PMID:26604583

New ways of working in theatres. Three session working days.

PubMed

Collins, Gill

2006-01-01

Innovative ideas will be required to meet government targets for the health service in the future. Increasing the number of hours available to surgical teams from two to three sessions could be one solution. Efficient and effective utilisation of a huge capital resource would appear to be further justification for increased hours, although the Audit Commission suggests that improving existing utilisation rather than extending hours should be the priority. However if operating sessions could be increased from two to three there is a potential to reduce waiting lists.

Biomarkers from distinct biological pathways improve early risk stratification in medical emergency patients: the multinational, prospective, observational TRIAGE study.

PubMed

Schuetz, Philipp; Hausfater, Pierre; Amin, Devendra; Amin, Adina; Haubitz, Sebastian; Faessler, Lukas; Kutz, Alexander; Conca, Antoinette; Reutlinger, Barbara; Canavaggio, Pauline; Sauvin, Gabrielle; Bernard, Maguy; Huber, Andreas; Mueller, Beat

2015-10-29

Early risk stratification in the emergency department (ED) is vital to reduce time to effective treatment in high-risk patients and to improve patient flow. Yet, there is a lack of investigations evaluating the incremental usefulness of multiple biomarkers measured upon admission from distinct biological pathways for predicting fatal outcome and high initial treatment urgency in unselected ED patients in a multicenter and multinational setting. We included consecutive, adult, medical patients seeking ED care into this observational, cohort study in Switzerland, France and the USA. We recorded initial clinical parameters and batch-measured prognostic biomarkers of inflammation (pro-adrenomedullin [ProADM]), stress (copeptin) and infection (procalcitonin). During a 30-day follow-up, 331 of 7132 (4.6 %) participants reached the primary endpoint of death within 30 days. In logistic regression models adjusted for conventional risk factors available at ED admission, all three biomarkers strongly predicted the risk of death (AUC 0.83, 0.78 and 0.75), ICU admission (AUC 0.67, 0.69 and 0.62) and high initial triage priority (0.67, 0.66 and 0.58). For the prediction of death, ProADM significantly improved regression models including (a) clinical information available at ED admission (AUC increase from 0.79 to 0.84), (b) full clinical information at ED discharge (AUC increase from 0.85 to 0.88), and (c) triage information (AUC increase from 0.67 to 0.83) (p <0.01 for each comparison). Similarly, ProADM also improved clinical models for prediction of ICU admission and high initial treatment urgency. Results were robust in regard to predefined patient subgroups by center, main diagnosis, presenting symptoms, age and gender. Combination of clinical information with results of blood biomarkers measured upon ED admission allows early and more adequate risk stratification in individual unselected medical ED patients. A randomized trial is needed to answer the question whether biomarker-guided initial patient triage reduces time to initial treatment of high-risk patients in the ED and thereby improves patient flow and clinical outcomes. ClinicalTrials.gov NCT01768494 . Registered January 9, 2013.

Aging and pathogenesis of erectile dysfunction.

PubMed

Corona, G; Mannucci, E; Mansani, R; Petrone, L; Bartolini, M; Giommi, R; Mancini, M; Forti, G; Maggi, M

2004-10-01

The prevalence and the severity of erectile dysfunction (ED) increase with advancing age; different pathogenetic factors could contribute to age-related ED. We studied organic, relational and intrapsychic components of ED as a function of patients' age in a consecutive series of 977 patients with ED, using the specifically designed structured interview SIEDY. A complete physical examination and a series of biochemical, hormonal, psychometric and penile vascular tests were also performed. Relational factors seems to be more relevant in patients aged over 60 y, while intrapsychic disturbances play a major role in younger subjects. Organic factors are the most important determinant of ED in all age groups, but their contribution is more important in older patients. In fact, basal and dynamic peak cavernosal velocity at Doppler ultrasound penile examination was reduced in older patients. Among hormonal factors, the body mass index-dependent reduction of testosterone in older patients does not seem to play a crucial role in the pathogenesis of ED. No significant correlation was observed between testosterone level and the severity of ED, although patients reporting hypoactive sexual desire showed significantly lower testosterone levels when compared with the rest of the sample. A better understanding of the relative contribution of age-related pathogenetic factors of ED could be of help in the design of appropriate therapeutic approaches.

Predicting Appropriate Admission of Bronchiolitis Patients in the Emergency Department: Rationale and Methods.

PubMed

Luo, Gang; Stone, Bryan L; Johnson, Michael D; Nkoy, Flory L

2016-03-07

In young children, bronchiolitis is the most common illness resulting in hospitalization. For children less than age 2, bronchiolitis incurs an annual total inpatient cost of $1.73 billion. Each year in the United States, 287,000 emergency department (ED) visits occur because of bronchiolitis, with a hospital admission rate of 32%-40%. Due to a lack of evidence and objective criteria for managing bronchiolitis, ED disposition decisions (hospital admission or discharge to home) are often made subjectively, resulting in significant practice variation. Studies reviewing admission need suggest that up to 29% of admissions from the ED are unnecessary. About 6% of ED discharges for bronchiolitis result in ED returns with admission. These inappropriate dispositions waste limited health care resources, increase patient and parental distress, expose patients to iatrogenic risks, and worsen outcomes. Existing clinical guidelines for bronchiolitis offer limited improvement in patient outcomes. Methodological shortcomings include that the guidelines provide no specific thresholds for ED decisions to admit or to discharge, have an insufficient level of detail, and do not account for differences in patient and illness characteristics including co-morbidities. Predictive models are frequently used to complement clinical guidelines, reduce practice variation, and improve clinicians' decision making. Used in real time, predictive models can present objective criteria supported by historical data for an individualized disease management plan and guide admission decisions. However, existing predictive models for ED patients with bronchiolitis have limitations, including low accuracy and the assumption that the actual ED disposition decision was appropriate. To date, no operational definition of appropriate admission exists. No model has been built based on appropriate admissions, which include both actual admissions that were necessary and actual ED discharges that were unsafe. The goal of this study is to develop a predictive model to guide appropriate hospital admission for ED patients with bronchiolitis. This study will: (1) develop an operational definition of appropriate hospital admission for ED patients with bronchiolitis, (2) develop and test the accuracy of a new model to predict appropriate hospital admission for an ED patient with bronchiolitis, and (3) conduct simulations to estimate the impact of using the model on bronchiolitis outcomes. We are currently extracting administrative and clinical data from the enterprise data warehouse of an integrated health care system. Our goal is to finish this study by the end of 2019. This study will produce a new predictive model that can be operationalized to guide and improve disposition decisions for ED patients with bronchiolitis. Broad use of the model would reduce iatrogenic risk, patient and parental distress, health care use, and costs and improve outcomes for bronchiolitis patients.

Double trouble: Portion size and energy density combine to increase preschool children’s lunch intake

PubMed Central

Kling, Samantha M.R.; Roe, Liane S.; Keller, Kathleen L.; Rolls, Barbara J.

2016-01-01

Background Both portion size and energy density (ED) have substantial effects on intake; however, their combined effects on preschool children’s intake have not been examined when multiple foods are varied at a meal. Objective We tested the effects on intake of varying the portion size and ED of lunches served to children in their usual eating environment. Design In a crossover design, lunch was served in 3 childcare centers once a week for 6 weeks to 120 children aged 3 to 5 y. Across the 6 meals, all items were served at 3 levels of portion size (100%, 150%, or 200%) and 2 levels of ED (100% or 142%). The lunch menu had either lowerED or higher-ED versions of chicken, macaroni and cheese, vegetables, applesauce, ketchup, and milk. Children’s ratings of the foods indicated that the lower-ED and higher-ED meals were similarly well liked. Results The weight of food and milk consumed at meals was increased by serving larger portions (P<0.0001) but was unaffected by varying the ED (P=0.22). Meal energy intake, however, was independently affected by portion size and ED (both P<0.0001). Doubling the portions increased energy intake by 24% and increasing meal ED by 42% increased energy intake by 40%. These effects combined to increase intake by 175±12 kcal or 79% at the higherED meal with the largest portions compared to the lower-ED meal with the smallest portions. The foods contributing the most to this increase were chicken, macaroni and cheese, and applesauce. The effects of meal portion size and ED on intake were not influenced by child age or body size, but were significantly affected by parental ratings of child eating behavior. Conclusion Strategically moderating the portion size and ED of foods typically consumed by children could substantially reduce their energy intake without affecting acceptability. PMID:26879105

Three-dimensional electron diffraction as a complementary technique to powder X-ray diffraction for phase identification and structure solution of powders.

PubMed

Yun, Yifeng; Zou, Xiaodong; Hovmöller, Sven; Wan, Wei

2015-03-01

Phase identification and structure determination are important and widely used techniques in chemistry, physics and materials science. Recently, two methods for automated three-dimensional electron diffraction (ED) data collection, namely automated diffraction tomography (ADT) and rotation electron diffraction (RED), have been developed. Compared with X-ray diffraction (XRD) and two-dimensional zonal ED, three-dimensional ED methods have many advantages in identifying phases and determining unknown structures. Almost complete three-dimensional ED data can be collected using the ADT and RED methods. Since each ED pattern is usually measured off the zone axes by three-dimensional ED methods, dynamic effects are much reduced compared with zonal ED patterns. Data collection is easy and fast, and can start at any arbitrary orientation of the crystal, which facilitates automation. Three-dimensional ED is a powerful technique for structure identification and structure solution from individual nano- or micron-sized particles, while powder X-ray diffraction (PXRD) provides information from all phases present in a sample. ED suffers from dynamic scattering, while PXRD data are kinematic. Three-dimensional ED methods and PXRD are complementary and their combinations are promising for studying multiphase samples and complicated crystal structures. Here, two three-dimensional ED methods, ADT and RED, are described. Examples are given of combinations of three-dimensional ED methods and PXRD for phase identification and structure determination over a large number of different materials, from Ni-Se-O-Cl crystals, zeolites, germanates, metal-organic frameworks and organic compounds to intermetallics with modulated structures. It is shown that three-dimensional ED is now as feasible as X-ray diffraction for phase identification and structure solution, but still needs further development in order to be as accurate as X-ray diffraction. It is expected that three-dimensional ED methods will become crucially important in the near future.

Double trouble: Portion size and energy density combine to increase preschool children's lunch intake.

PubMed

Kling, Samantha M R; Roe, Liane S; Keller, Kathleen L; Rolls, Barbara J

2016-08-01

Both portion size and energy density (ED) have substantial effects on intake; however, their combined effects on preschool children's intake have not been examined when multiple foods are varied at a meal. We tested the effects on intake of varying the portion size and ED of lunches served to children in their usual eating environment. In a crossover design, lunch was served in 3 childcare centers once a week for 6weeks to 120 children aged 3-5y. Across the 6 meals, all items were served at 3 levels of portion size (100%, 150%, or 200%) and 2 levels of ED (100% or 142%). The lunch menu had either lower-ED or higher-ED versions of chicken, macaroni and cheese, vegetables, applesauce, ketchup, and milk. Children's ratings of the foods indicated that the lower-ED and higher-ED meals were similarly well liked. The total weight of food and milk consumed at meals was increased by serving larger portions (P<0.0001) but was unaffected by varying the ED (P=0.22). Meal energy intake, however, was independently affected by portion size and ED (both P<0.0001). Doubling the portions increased energy intake by 24% and increasing meal ED by 42% increased energy intake by 40%. These effects combined to increase intake by 175±12kcal or 79% at the higher-ED meal with the largest portions compared to the lower-ED meal with the smallest portions. The foods contributing the most to this increase were chicken, macaroni and cheese, and applesauce. The effects of meal portion size and ED on intake were not influenced by child age or body size, but were significantly affected by parental ratings of child eating behavior. Strategically moderating the portion size and ED of foods typically consumed by children could substantially reduce their energy intake without affecting acceptability. Copyright © 2016 Elsevier Inc. All rights reserved.

Drug-related stigma and access to care among people who inject drugs in Vietnam.

PubMed

Lan, Chiao-Wen; Lin, Chunqing; Thanh, Duong Cong; Li, Li

2018-03-01

There are considerable challenges faced by people with a history of injecting drug use (PWID) in Vietnam, including drug-related stigma and lack of access to healthcare. Seeking and utilising healthcare, as well as harm reduction programs for PWID, are often hampered by drug-related stigma. This study aimed to examine the impacts of drug-related stigma on access to care and utilisation of harm reduction programs among PWID in Vietnam. A cross-sectional study was conducted in two provinces in Vietnam, Phú Thọ and Vinh Phúc. The study participants completed the survey by using Audio Computer-Assisted Self-Interview between late 2014 and early 2015. Linear multiple regression models and logistic regression models were used to assess the relationship among drug-related stigma, access to care and utilisation of harm reduction programs, including methadone maintenance treatment (MMT) and needle exchange programs (NEP). A total of 900 PWID participated in this study. Drug-related stigma was significantly associated with lower level of access to care, but not with utilisation of MMT or NEP. Older age was positively associated with higher levels of access to care. Levels of education were positively correlated with access to care, as well as utilisation of MMT and NEP. This study underscores the need for future interventions to reduce drug-related stigma in society and in health-care settings to improve PWID's utilisation of care services. Special attention should be paid to younger PWID and those with lower levels of education. © 2017 Australasian Professional Society on Alcohol and other Drugs.

Insight into effects of electro-dewatering pretreatment on nitrous oxide emission involved in related functional genes in sewage sludge composting.

PubMed

Wang, Ke; Wu, Yiqi; Wang, Zhe; Wang, Wei; Ren, Nanqi

2018-05-26

Electro-dewatering (ED) pretreatment could improve sludge dewatering performance and remove heavy metal, but the effect of ED pretreatment on nitrous oxide (N 2 O) emission and related functional genes in sludge composting process is still unknown, which was firstly investigated in this study. The results revealed that ED pretreatment changed the physicochemical characteristics of sludge and impacted N 2 O related functional genes, resulting in the reduction of cumulative N 2 O emission by 77.04% during 60 days composting. The higher pH and NH 4 + -N, but lower moisture, ORP and NO 2 - -N emerged in the composting of ED sludge compared to mechanical dewatering (MD) sludge. Furthermore, ED pretreatment reduced amoA, hao, narG, nirK and nosZ in ED sludge on Day-10 and Day-60 of composting. It was found that nirK reduction was the major factor impacting N 2 O generation in the initial composting of ED sludge, and the decline of amoA restricted N 2 O production in the curing period. Copyright © 2018 Elsevier Ltd. All rights reserved.

Suicide Prevention in an Emergency Department Population: The ED-SAFE Study.

PubMed

Miller, Ivan W; Camargo, Carlos A; Arias, Sarah A; Sullivan, Ashley F; Allen, Michael H; Goldstein, Amy B; Manton, Anne P; Espinola, Janice A; Jones, Richard; Hasegawa, Kohei; Boudreaux, Edwin D

2017-06-01

Suicide is a leading cause of deaths in the United States. Although the emergency department (ED) is an opportune setting for initiating suicide prevention efforts, ED-initiated suicide prevention interventions remain underdeveloped. To determine whether an ED-initiated intervention reduces subsequent suicidal behavior. This multicenter study of 8 EDs in the United States enrolled adults with a recent suicide attempt or ideation and was composed of 3 sequential phases: (1) a treatment as usual (TAU) phase from August 2010 to December 2011, (2) a universal screening (screening) phase from September 2011 to December 2012, and (3) a universal screening plus intervention (intervention) phase from July 2012 to November 2013. Screening consisted of universal suicide risk screening. The intervention phase consisted of universal screening plus an intervention, which included secondary suicide risk screening by the ED physician, discharge resources, and post-ED telephone calls focused on reducing suicide risk. The primary outcome was suicide attempts (nonfatal and fatal) over the 52-week follow-up period. The proportion and total number of attempts were analyzed. A total of 1376 participants were recruited, including 769 females (55.9%) with a median (interquartile range) age of 37 (26-47) years. A total of 288 participants (20.9%) made at least 1 suicide attempt, and there were 548 total suicide attempts among participants. There were no significant differences in risk reduction between the TAU and screening phases (23% vs 22%, respectively). However, compared with the TAU phase, patients in the intervention phase showed a 5% absolute reduction in suicide attempt risk (23% vs 18%), with a relative risk reduction of 20%. Participants in the intervention phase had 30% fewer total suicide attempts than participants in the TAU phase. Negative binomial regression analysis indicated that the participants in the intervention phase had significantly fewer total suicide attempts than participants in the TAU phase (incidence rate ratio, 0.72; 95% CI, 0.52-1.00; P = .05) but no differences between the TAU and screening phases (incidence rate ratio, 1.00; 95% CI, 0.71-1.41; P = .99). Among at-risk patients in the ED, a combination of brief interventions administered both during and after the ED visit decreased post-ED suicidal behavior.

Determinants of skilled birth attendants for delivery in Nepal.

PubMed

Baral, Y R; Lyons, K; Skinner, J; van Teijlingen, E R

2010-01-01

This review is to explore the factors affecting the uptake of skilled birth attendants for delivery and the issues associated with women's role and choices of maternal health care service for delivery in Nepal. Literature was reviewed across the globe and discussed in a Nepalese context. Delivery by Skilled Birth Attendance serves as an indicator of progress towards reducing maternal mortality worldwide, the fifth Millennium Development Goal. Nepal has committed to reducing its maternal mortality by 75% by 2015 through ensuring accessibility to the availability and utilisation of skilled care at every birth. The literature suggests that several socio-economic, cultural and religious factors play a significant role in the use of Skilled Birth Attendance for delivery in Nepal. Availability of transportation and distance to the health facility; poor infrastructure and lack of services; availability and accessibility of the services; cost and convenience; staff shortages and attitudes; gender inequality; status of women in society; women's involvement in decision making; and women's autonomy and place of residence are significant contributing factors for uptake of Skilled Birth Attendance for delivery in Nepal. The review found more quantitative research studies exploring the determinants of utilisation of the maternal health services during pregnancy in Nepal than qualitative studies. Findings of quantitative research show that different social demographic, economic, socio-cultural and religious factors are responsible for the utilisation of maternal health services but very few studies discussed how and why these factors are responsible for utilisation of skilled birth attendants in pregnancy. It is suggested that there is need for more qualitative research to explore the women's role and choice regarding use of skilled birth attendants services and to find out how and why these factors are responsible for utilisation of skilled birth attendants for delivery. Qualitative research will help further exploration of the issues and contribute to improvement of maternal health services.

Association between use of a health information exchange system and hospital admissions.

PubMed

Vest, J R; Kern, L M; Campion, T R; Silver, M D; Kaushal, R

2014-01-01

Relevant patient information is frequently difficult to obtain in emergency department (ED) visits. Improved provider access to previously inaccessible patient information may improve the quality of care and reduce hospital admissions. Health information exchange (HIE) systems enable access to longitudinal, community-wide patient information at the point of care. However, the ability of HIE to avert admissions is not well demonstrated. We sought to determine if HIE system usage is correlated with a reduction in admissions via the ED. We identified 15,645 adults from New York State with an ED visit during a 6-month period, all of whom consented to have their information accessible in the HIE system, and were continuously enrolled in two area health plans. Using claims we determined if the ED encounter resulted in an admission. We used the HIE's system log files to determine usage during the encounter. We determined the association between HIE system use and the likelihood of admission to the hospital from the ED and potential cost savings. The HIE system was accessed during 2.4% of encounters. The odds of an admission were 30% lower when the system was accessed after controlling for confounding (odds ratio = 0.70; 95%C I= 0.52, 0.95). The annual savings in the sample was $357,000. These findings suggest that the use of an HIE system may reduce hospitalizations from the ED with resultant cost savings. This is an important outcome given the substantial financial investment in interventions designed to improve provider access to patient information in the US.

Association Between Use of a Health Information Exchange System and Hospital Admissions

PubMed Central

Vest, J.R.; Kern, L.M.; Campion, T.R.; Silver, M.D.; Kaushal, R.

2014-01-01

Summary Objective Relevant patient information is frequently difficult to obtain in emergency department (ED) visits. Improved provider access to previously inaccessible patient information may improve the quality of care and reduce hospital admissions. Health information exchange (HIE) systems enable access to longitudinal, community-wide patient information at the point of care. However, the ability of HIE to avert admissions is not well demonstrated. We sought to determine if HIE system usage is correlated with a reduction in admissions via the ED. Methods We identified 15,645 adults from New York State with an ED visit during a 6-month period, all of whom consented to have their information accessible in the HIE system, and were continuously enrolled in two area health plans. Using claims we determined if the ED encounter resulted in an admission. We used the HIE’s system log files to determine usage during the encounter. We determined the association between HIE system use and the likelihood of admission to the hospital from the ED and potential cost savings. Results The HIE system was accessed during 2.4% of encounters. The odds of an admission were 30% lower when the system was accessed after controlling for confounding (odds ratio = 0.70; 95%C I= 0.52, 0.95). The annual savings in the sample was $357,000. Conclusion These findings suggest that the use of an HIE system may reduce hospitalizations from the ED with resultant cost savings. This is an important outcome given the substantial financial investment in interventions designed to improve provider access to patient information in the US. PMID:24734135

Safety Planning Intervention: A Brief Intervention to Mitigate Suicide Risk

ERIC Educational Resources Information Center

Stanley, Barbara; Brown, Gregory K.

2012-01-01

The usual care for suicidal patients who are seen in the emergency department (ED) and other emergency settings is to assess level of risk and refer to the appropriate level of care. Brief psychosocial interventions such as those administered to promote lower alcohol intake or to reduce domestic violence in the ED are not typically employed for…

Migrant female head porters' enrolment in and utilisation and renewal of the National Health Insurance Scheme in Kumasi, Ghana.

PubMed

Boateng, Simon; Amoako, Prince; Poku, Adjoa Afriyie; Baabereyir, Anthony; Gyasi, Razak Mohammed

2017-01-01

As a social protection policy, Ghana's National Health Insurance Scheme (NHIS) aims to improve access to healthcare, especially for the vulnerable. Migrant female head porters ( kayayoo ), who are part of the informal economic workforce, are underscored as an ethnic minority and vulnerable group in Ghana. This study aimed to analyse the factors associated with enrolment in and renewal and utilisation of the NHIS among migrant female head porters in the Kumasi Metropolis. We purposively sampled 392 migrant female head porters in the Kejetia, Asafo and Bantama markets. We used a binary logit regression model to estimate associations among baseline characteristics, convenience and benefit factors and enrolment in and renewal and utilisation of the NHIS. Age and income significantly increased the probability of NHIS enrolment, renewal and utilisation. Long waiting times at NHIS offices significantly reduced the likelihood of renewal, while provision of drugs highly significantly increased the tendency for migrant female head porters to enrol in, renew and use the NHIS. Consulting and surgery also significantly increased renewal and utilisation of the NHIS. Political commitment is imperative for effective implementation of the decentralisation policy of the NHIS through the National Health Insurance Authority in Kumasi. We argue that retail offices should be well equipped with logistic facilities to ensure convenience in NHIS initial enrolment and renewal processes by citizenry, and by vulnerable groups in particular.

New to care: demands on a health system when homeless veterans are enrolled in a medical home model.

PubMed

O'Toole, Thomas P; Bourgault, Claire; Johnson, Erin E; Redihan, Stephen G; Borgia, Matthew; Aiello, Riccardo; Kane, Vincent

2013-12-01

We compared service use among homeless and nonhomeless veterans newly enrolled in a medical home model and identified patterns of use among homeless veterans associated with reductions in emergency department (ED) use. We used case-control matching with a nested cohort analysis to measure 6-month health services use, new diagnoses, and care use patterns in veterans at the Providence, Rhode Island, Veterans Affairs Medical Center from 2008 to 2011. We followed 127 homeless and 106 nonhomeless veterans. Both groups had similar rates of chronic medical and mental health diagnoses; 25.4% of the homeless and 18.1% of the nonhomeless group reported active substance abuse. Homeless veterans used significantly more primary, mental health, substance abuse, and ED care during the first 6 months. Homeless veterans who accessed primary care at higher rates (relative risk ratio [RRR] = 1.46; 95% confidence interval [CI] = 1.11, 1.92) or who used specialty and primary care (RRR = 10.95; 95% CI = 1.58, 75.78) had reduced ED usage. Homeless veterans in transitional housing or doubled-up at baseline (RRR = 3.41; 95% CI = 1.24, 9.42) had similar reductions in ED usage. Homeless adults had substantial health needs when presenting for care. High-intensity primary care and access to specialty care services could reduce ED use.

Effect of a children's at-home nursing team on reducing emergency admissions.

PubMed

Farnham, Laura; Harwood, Hannah; Robertson, Meredith

2017-12-05

This article explores the effect of a children's at-home nursing team, Hospital at Home (H@H), which aimed to reduce demand on acute hospital beds, support families to improve patient experience, and empower parents to care safely for their unwell children and help prevent emergency department (ED) reattendance. Data on demographics and clinical presentation of H@H and ED attendances were collected and compared. A survey measuring parents' confidence in managing their unwell children was also conducted. Of 72 patients treated by the H@H service between May and July 2016, 32 (44%) would have been admitted to hospital from the ED if the H@H service had not existed. This is equivalent to a saving of 64 bed days. Patients treated by the H@H service had similar demographics to those discharged from the ED to usual care. The H@H service took on patients with higher Bedside Paediatric Early Warning System scores before discharge. Parents reported that they would be more confident caring for their children after discharge from the H@H service. The H@H service decreased the number of unnecessary ED admissions. The service promotes a positive patient experience and increases parents' confidence when caring for unwell children at home. ©2017 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.

Could inter-agency working reduce emergency department attendances due to alcohol consumption?

PubMed

Benger, J; Carter, R

2008-06-01

Excess alcohol consumption and associated harms in terms of health, crime and disorder have been highlighted by the government and media, causing considerable public concern. This study quantified the number of patient attendances at an urban adult and children's emergency department (ED) directly attributable to alcohol intoxication, and investigated ways in which the inter-agency sharing of anonymised information could be used to design, implement and monitor interventions to reduce these harms. Intoxicated patients attending either the adult or children's ED were prospectively identified by qualified nursing staff and anonymised data collected by a dedicated researcher. Collaboration and data sharing between health, police, social services, university experts and local authorities was achieved through the establishment of steering and operational groups with agreed objectives and the formation of a shared anonymised database. The proportion of patients attending the ED as a result of alcohol intoxication was 4% in adults and <1% in children. 70% of patients were male, with a mean age of 30 years, and 72% attended between 20.00 and 08.00 h. The most common reason for ED attendance was accident (34%), followed closely by assault (30%). 27% of patients had done most of their drinking at home, 36% in a pub and 16% in a nightclub. Inter-agency collaboration proved highly successful: pooling of anonymised data created a much clearer picture of the extent of the problem and immediately suggested strategies for intervention. The initiative to achieve inter-agency collaboration and data sharing was highly successful, with clear potential for the development and implementation of interventions that will reduce ED attendance due to excess alcohol consumption.

Is alcohol more dangerous than heroin? The physical, social and financial costs of alcohol.

PubMed

Lee, Geraldine A; Forsythe, Marcus

2011-07-01

A recent paper claimed in its classification of harmful substances, that alcohol is more dangerous than heroin. This paper aims to weigh up some of the evidence in the literature on the physical, social and financial effects of alcohol and the associated disease burden. We will also explore alcohol within the context of emergency department (ED) presentations. Reasons for ED attendance can be overtly and directly alcohol related such as alcohol intoxication, assaults, injuries and falls and indirectly such as child neglect, psychological problems and chronic diseases. Alcohol is often viewed as an isolated incident or factor for ED presentations but there are data that refute this perception. In ED, the priority is to treat the patient and their primary complaint, however it may be appropriate to screen for alcohol use, give advice and potentially offer an intervention to the patient. With the recent UK and Australian guidelines on reducing health risks from drinking alcohol, the ED has the ability to play an active role in reducing the harmful effects of alcohol through screening, advising and undertaking intervention as appropriate. However this cannot be achieved in isolation but within the broader political and health policy framework. There is now a growing body of literature supporting the need to make alcohol less affordable, less easy to buy and reducing alcohol advertising. Although alcohol is a legal substance, this paper concludes that examining the wider effects in physical, social and financial terms, alcohol is more dangerous than heroin. It has become an endemic problem in society affecting the individual and the whole community. Copyright © 2011 Elsevier Ltd. All rights reserved.

Using music to reduce anxiety among older adults in the emergency department: a randomized pilot study.

PubMed

Belland, Laura; Rivera-Reyes, Laura; Hwang, Ula

2017-11-01

An emergency department (ED) visit may be distressing and anxiety-provoking for older adults (age > 65 years). No studies have specifically evaluated the effect of music listening on anxiety in older adults in the ED. The objective of this pilot study was to evaluate the effect of music listening on anxiety levels in older ED patients. This was a randomized pilot study in the geriatric ED of an urban academic tertiary medical center. This was a sample of English-speaking adults (age > 65 years) who were not deaf (n = 35). Subjects consented to participate and were randomized to receive up to 60 min of music listening with routine care, while the control group received routine care with no music. Subjects in the music treatment group received headphones and an electronic tablet with pre-downloaded music, and were allowed to choose from 5 selections. The primary outcome was change in anxiety levels, measured by the state-trait anxiety inventory (STAI), at enrollment and 1 h later. A total of 35 participants were enrolled: 74% were female, 40% were white, and 40% were black; of these, 32 subjects completed the study protocol. When comparing control (n = 18) against intervention subjects (n = 17), there were no significant differences in enrollment STAI scores (43.00 ± 15.00 vs. 40.30 ± 12.80, P = 0.57). STAI scores 1 hour after enrollment (after the music intervention) were significantly reduced in the intervention subjects compared to the control subjects (with reduction of 10.00 ± 12.29 vs. 1.88 ± 7.97, P = 0.03). These pilot results suggest that music listening may be an effective tool for reducing anxiety among older adults in the ED.

Reduction of admit wait times: the effect of a leadership-based program.

PubMed

Patel, Pankaj B; Combs, Mary A; Vinson, David R

2014-03-01

Prolonged admit wait times in the emergency department (ED) for patients who require hospitalization lead to increased boarding time in the ED, a significant cause of ED congestion. This is associated with decreased quality of care, higher morbidity and mortality, decreased patient satisfaction, increased costs for care, ambulance diversion, higher numbers of patients who leave without being seen (LWBS), and delayed care with longer lengths of stay (LOS) for other ED patients. The objective was to assess the effect of a leadership-based program to expedite hospital admissions from the ED. This before-and-after observational study was undertaken from 2006 through 2011 at one community hospital ED. A team of ED and hospital leaders implemented a program to reduce admit wait times, using a computerized hospital-wide tracking system to monitor inpatient and ED bed status. The team collaboratively and consistently moved ED patients to their inpatient beds within an established goal of 60 minutes after an admission decision was reached. Top leadership actively intervened in real time by contacting staff whenever delays occurred to expedite immediate solutions to achieve the 60-minute goal. The primary outcome measures were the percentage of ED patients who were admitted to inpatient beds within 60 minutes from the time the beds were requested and ED boarding time. LOS, patient satisfaction, LWBS rate, and ambulance diversion hours were also measured. After ED census, hospital admission rates, and ED bed capacity were controlled for using a multivariable linear regression analysis, the admit wait time reduction program contributed to an increase in patients being admitted to the hospital within 60 minutes by 16 percentage points (95% confidence intervals [CI] = 10 to 22 points; p < 0.0001) and a decrease in boarding time per admission of 46 minutes (95% CI = 63 to 82 minutes; p < 0.0001). LOS decreased for admitted patients by 79 minutes (95% CI = 55 to 104 minutes; p < 0.0001), for discharged patients by 17 minutes (95% CI = 12 to 23 minutes; p < 0.0001), and for all patients by 34 minutes (95% CI = 25 to 43 minutes; p < 0.0001). Patient satisfaction increased 4.9 percentage points (95% CI = 3.8 to 6.0 points; p < 0.0001). LWBS patients decreased 0.9 percentage points (95% CI = 0.6 to 1.2 points; p < 0.0001) and monthly ambulance diversion decreased 8.2 hours (95% CI = 4.6 to 11.8 hours; p < 0.0001). A leadership-based program to reduce admit wait times and boarding times was associated with a significant increase in the percentage of patients admitted to the hospital within 60 minutes and a significant decrease in boarding time. Also associated with the program were decreased ED LOS, LWBS rate, and ambulance diversion, as well as increased patient satisfaction. © 2014 by the Society for Academic Emergency Medicine.

Comorbid psychiatric diagnosis and psychological correlates of eating disorders in dance students.

PubMed

Liu, Chao-Yu; Tseng, Mei-Chih Meg; Chang, Chin-Hao; Fang, David; Lee, Ming-Been

2016-02-01

Although dancers are at risk for eating disorders (EDs), little is known about the features of EDs among the dance population. This study explores the prevalence of EDs, and their psychiatric comorbidities and correlates in dance students. In total, 442 female high-school dance students participated in a two-phase survey. All participants completed screening questionnaires as well as measures assessing teasing, self-esteem, perfectionism, body dissatisfaction, and personality. Of the participating students, 311 underwent the Structured Clinical Interview for DSM-IV-TR Axis I Disorders. Sixty-eight individuals (15.4%) had an ED by DSM-IV diagnosis. The prevalence of any co-occurring mood (47.1%) and anxiety disorders (30.9%) was high. Although low self-esteem, high neuroticism, and high psychological distress were associated with EDs in univariate analysis, only teasing for overweight and body image dissatisfaction were significantly associated with EDs by multivariate analysis. Prevention and intervention programs for dance students should include recognition and management of emotional disorders and strategies promoting positive body image and reducing the incidence of negative weight-related comments. Copyright © 2015. Published by Elsevier B.V.

Back so soon: rapid re-presentations to the emergency department following intentional self-harm.

PubMed

Kuehl, Silke; Nelson, Katherine; Collings, Sunny

2012-12-14

To describe the number, characteristics and management of patients who presented to an emergency department (ED) with intentional self-harm and then re-presented for any reason within 1 week, over a 1-year period. A retrospective records review from one New Zealand ED over 12 months. Of the 120 patients who attended the ED more than once with intentional self-harm, 48 re-presented on 73 occasions within 7 days of the index presentation. Of the re-presentations, 55% occurred within 1 day. Mental health assessments by emergency department staff were minimal; challenging incidents occurred in 40% of presentations; and there was an increase in the inpatient admission rate for second presentations. We identified a small group of patients who rapidly re-present to the ED following intentional self-harm. The reasons behind those re-presentations could include limited mental health assessments in ED and inadequate follow-up on discharge. System improvements in the ED including better collaboration with mental health services could improve how services address the needs of patients who present with intentional self-harm and reduce costs.

Allele-specific siRNA knockdown as a personalized treatment strategy for vascular Ehlers-Danlos syndrome in human fibroblasts.

PubMed

Müller, Gerd A; Hansen, Uwe; Xu, Zhi; Griswold, Benjamin; Talan, Mark I; McDonnell, Nazli B; Briest, Wilfried

2012-02-01

The vascular type of the Ehlers-Danlos syndrome (vEDS) is caused by dominant-negative mutations in the procollagen type III (COL3A1) gene. Patients with this autosomal dominant disorder have a shortened life expectancy due to complications from ruptured vessels or hollow organs. We tested the effectiveness of allele-specific RNA interference (RNAi) to reduce the mutated phenotype in fibroblasts. Small-interfering RNAs (siRNAs) discriminating between wild-type and mutant COL3A1 allele were identified by a luciferase reporter gene assay and in primary fibroblasts from a normal donor and a patient with vEDS. The best discriminative siRNA with the mutation at position 10 resulted in >90% silencing of the mutant allele without affecting the wild-type allele. Transmission and immunogold electron microscopy of extracted extracellular matrices from untreated fibroblasts of the patient with vEDS revealed structurally abnormal fibrils. After siRNA treatment, collagen fibrils became similar to fibrils from fibroblasts of normal and COL3A1 haploinsufficient donors. In addition, it was shown that expression of mutated COL3A1 activates the unfolded protein response and that reduction of the amount of mutated protein by siRNA reduces cellular stress. Taken together, the results provide evidence that allele-specific siRNAs are able to reduce negative effects of mutated COL3A1 proteins. Thus, the application of allele-specific RNAi may be a promising direction for future personalized therapies to reduce the severity of vEDS.

Amelioration of erectile dysfunction following a switch from carbamazepine to oxcarbazepine: recent clinical experience.

PubMed

Sachdeo, Rajesh; Sathyan, Revathi R

2005-07-01

Oxcarbazepine is an antiepileptic drug (AED) indicated for use as monotherapy and add-on therapy in adults and children 4 years of age and older. Despite being structurally related to carbamazepine, oxcarbazepine differs substantially in its pharmacokinetic and safety profile; oxcarbazepine has a much lower risk of pharmacokinetic drug-drug interactions than carbamazepine. Carbamazepine has also been shown to induce the hepatic synthesis of sex hormone-binding globulin, thus reducing free serum testosterone levels and possibly causing erectile dysfunction (ED) in some men; these effects have not been observed with oxcarbazepine. This paper provides a discussion of recent clinical experience with men who presented in private clinical practice with complaints of ED while being treated with carbamazepine for seizure disorders. The four illustrative case studies presented in this report suggest that switching AED treatment from carbamazepine to oxcarbazepine in men with epilepsy can reduce the ED side effects observed with carbamazepine.

Understanding patient acceptance and refusal of HIV testing in the emergency department

PubMed Central

2012-01-01

Background Despite high rates of patient satisfaction with emergency department (ED) HIV testing, acceptance varies widely. It is thought that patients who decline may be at higher risk for HIV infection, thus we sought to better understand patient acceptance and refusal of ED HIV testing. Methods In-depth interviews with fifty ED patients (28 accepters and 22 decliners of HIV testing) in three ED HIV testing programs that serve vulnerable urban populations in northern California. Results Many factors influenced the decision to accept ED HIV testing, including curiosity, reassurance of negative status, convenience, and opportunity. Similarly, a number of factors influenced the decision to decline HIV testing, including having been tested recently, the perception of being at low risk for HIV infection due to monogamy, abstinence or condom use, and wanting to focus on the medical reason for the ED visit. Both accepters and decliners viewed ED HIV testing favorably and nearly all participants felt comfortable with the testing experience, including the absence of counseling. While many participants who declined an ED HIV test had logical reasons, some participants also made clear that they would prefer not to know their HIV status rather than face psychosocial consequences such as loss of trust in a relationship or disclosure of status in hospital or public health records. Conclusions Testing for HIV in the ED as for any other health problem reduces barriers to testing for some but not all patients. Patients who decline ED HIV testing may have rational reasons, but there are some patients who avoid HIV testing because of psychosocial ramifications. While ED HIV testing is generally acceptable, more targeted approaches to testing are necessary for this subgroup. PMID:22214543

Understanding patient acceptance and refusal of HIV testing in the emergency department.

PubMed

Christopoulos, Katerina A; Weiser, Sheri D; Koester, Kimberly A; Myers, Janet J; White, Douglas A E; Kaplan, Beth; Morin, Stephen F

2012-01-03

Despite high rates of patient satisfaction with emergency department (ED) HIV testing, acceptance varies widely. It is thought that patients who decline may be at higher risk for HIV infection, thus we sought to better understand patient acceptance and refusal of ED HIV testing. In-depth interviews with fifty ED patients (28 accepters and 22 decliners of HIV testing) in three ED HIV testing programs that serve vulnerable urban populations in northern California. Many factors influenced the decision to accept ED HIV testing, including curiosity, reassurance of negative status, convenience, and opportunity. Similarly, a number of factors influenced the decision to decline HIV testing, including having been tested recently, the perception of being at low risk for HIV infection due to monogamy, abstinence or condom use, and wanting to focus on the medical reason for the ED visit. Both accepters and decliners viewed ED HIV testing favorably and nearly all participants felt comfortable with the testing experience, including the absence of counseling. While many participants who declined an ED HIV test had logical reasons, some participants also made clear that they would prefer not to know their HIV status rather than face psychosocial consequences such as loss of trust in a relationship or disclosure of status in hospital or public health records. Testing for HIV in the ED as for any other health problem reduces barriers to testing for some but not all patients. Patients who decline ED HIV testing may have rational reasons, but there are some patients who avoid HIV testing because of psychosocial ramifications. While ED HIV testing is generally acceptable, more targeted approaches to testing are necessary for this subgroup. © 2012 Christopoulos et al; licensee BioMed Central Ltd.

Clinical and Economic Burden of Emergency Department Presentations for Neutropenia Following Outpatient Chemotherapy for Cancer in Victoria, Australia

PubMed Central

Craike, Melinda; Slavin, Monica

2012-01-01

Objective. To examine the clinical characteristics and financial charges associated with treating adult cancer patients receiving chemotherapy in outpatient clinics who presented to the emergency department (ED) with neutropenia. Design and Setting. A retrospective audit was conducted across two health services involving ED episodes and subsequent hospital admissions of patients who received chemotherapy through day oncology from January 1 to December 31, 2007 and presented to the ED with neutropenia. ED data were collected from the Victorian Emergency Minimum Dataset and charges were collected from Health Information Services. Descriptive and bivariate statistics were used to describe the patient and clinical characteristics and financial outcomes, and to explore associations between these factors. Results. In total, 200 neutropenic episodes in 159 outpatients were seen in the ED over the survey period. The mean patient age was 56.6 years (standard deviation, 13.2 years) and 47.2% were male. Overall, 70.0% of ED episodes were triaged as Australasian Triage Scale 2 (emergency). The median ED wait time was 10 minutes and the median ED length of stay was 6.8 hours. The median charge for each ED episode was $764.08 Australian dollars. The total combined ED and inpatient charge per episode was in the range of $144.27–$174,732.68, with a median charge of $5,640.87. Conclusions. This study provides important insights into the clinical and economic burden of neutropenia from both the ED and inpatient perspectives. Alternative treatment models, such as outpatient treatment, early discharge programs or prophylactic interventions to reduce the clinical and economic burden of neutropenia on our health system, must be explored. PMID:22707511

Identifying Patients With Problematic Drug Use in the Emergency Department: Results of a Multisite Study

PubMed Central

Konstantopoulos, Wendy L. Macias; Dreifuss, Jessica A.; McDermott, Katherine A.; Parry, Blair Alden; Howell, Melissa L.; Mandler, Raul N.; Fitzmaurice, Garrett M.; Bogenschutz, Michael P.; Weiss, Roger D.

2014-01-01

Study objective Drug-related emergency department (ED) visits have steadily increased, with substance users relying heavily on the ED for medical care. The present study aims to identify clinical correlates of problematic drug use that would facilitate identification of ED patients in need of substance use treatment. Methods Using previously validated tests, 15,224 adult ED patients across 6 academic institutions were prescreened for drug use as part of a large randomized prospective trial. Data for 3,240 participants who reported drug use in the past 30 days were included. Self-reported variables related to demographics, substance use, and ED visit were examined to determine their correlative value for problematic drug use. Results Of the 3,240 patients, 2,084 (64.3%) met criteria for problematic drug use (Drug Abuse Screening Test score ≥3). Age greater than or equal to 30 years, tobacco smoking, daily or binge alcohol drinking, daily drug use, primary noncannabis drug use, resource-intense ED triage level, and perceived drug-relatedness of ED visit were highly correlated with problematic drug use. Among primary cannabis users, correlates of problematic drug use were age younger than 30 years, tobacco smoking, binge drinking, daily drug use, and perceived relatedness of the ED visit to drug use. Conclusion Clinical correlates of drug use problems may assist the identification of ED patients who would benefit from comprehensive screening, intervention, and referral to treatment. A clinical decision rule is proposed. The correlation between problematic drug use and resource-intense ED triage levels suggests that ED-based efforts to reduce the unmet need for substance use treatment may help decrease overall health care costs. PMID:24999283

Implementation of an emergency department atrial fibrillation and flutter pathway improves rates of appropriate anticoagulation, reduces length of stay and thirty-day revisit rates for congestive heart failure.

PubMed

Barbic, David; DeWitt, Chris; Harris, Devin; Stenstrom, Robert; Grafstein, Eric; Wu, Crane; Vadeanu, Cristian; Heilbron, Brett; Haaf, Jenelle; Tung, Stanley; Kalla, Dan; Marsden, Julian; Christenson, Jim; Scheuermeyer, Frank

2018-05-01

An evidence-based emergency department (ED) atrial fibrillation and flutter (AFF) pathway was developed to improve care. The primary objective was to measure rates of new anticoagulation (AC) on ED discharge for AFF patients who were not AC correctly upon presentation. This is a pre-post evaluation from April to December 2013 measuring the impact of our pathway on rates of new AC and other performance measures in patients with uncomplicated AFF solely managed by emergency physicians. A standardized chart review identified demographics, comorbidities, and ED treatments. The primary outcome was the rate of new AC. Secondary outcomes were ED length of stay (LOS), referrals to AFF clinic, ED revisit rates, and 30-day rates of return visits for congestive heart failure (CHF), stroke, major bleeding, and death. ED AFF patients totalling 301 (129 pre-pathway [PRE]; 172 post-pathway [POST]) were included; baseline demographics were similar between groups. The rates of AC at ED presentation were 18.6% (PRE) and 19.7% (POST). The rates of new AC on ED discharge were 48.6 % PRE (95% confidence interval [CI] 42.1%-55.1%) and 70.2% POST (62.1%-78.3%) (20.6% [p<0.01; 15.1-26.3]). Median ED LOS decreased from 262 to 218 minutes (44 minutes [p<0.03; 36.2-51.8]). Thirty-day rates of ED revisits for CHF decreased from 13.2% to 2.3% (10.9%; p<0.01; 8.1%-13.7%), and rates of other measures were similar. The evidence-based pathway led to an improvement in the rate of patients with new AC upon discharge, a reduction in ED LOS, and decreased revisit rates for CHF.

Community characteristics affecting emergency department use by Medicaid enrollees.

PubMed

Lowe, Robert A; Fu, Rongwei; Ong, Emerson T; McGinnis, Paul B; Fagnan, Lyle J; Vuckovic, Nancy; Gallia, Charles

2009-01-01

In seeking to identify modifiable, system-level factors affecting emergency department (ED) use, we used a statewide Medicaid database to study community variation in ED use and ascertain community characteristics associated with higher use. This historical cohort study used administrative data from July 1, 2003 to December 31, 2004. Residence ZIP codes were used to assign all 555,219 Medicaid enrollees to 130 primary care service areas (PCSAs). PCSA characteristics studied included rural/urban status, presence of hospital(s), driving time to hospital, and several measures of primary care capacity. Statistical analyses used a 2-stage model. In the first stage (enrollee level), ED utilization rates adjusted for enrollee demographics and medical conditions were calculated for each PCSA. In the second stage (community level), a mixed effects linear model was used to determine the association between PCSA characteristics and ED use. ED utilization rates varied more than 20-fold among the PCSAs. Compared with PCSAs with primary care capacity less than need, PCSAs with capacity 1 to 2 times the need had 0.12 (95% CI: -0.044, -0.20) fewer ED visits/person/yr. Compared with PCSAs with the nearest hospital accessible within 10 minutes, PCSAs with the nearest hospital >30 minutes' drive had 0.26 (95% CI: -0.38, -0.13) fewer ED visits/person/yr. Within this Medicaid population, ED utilization was determined not only by patient characteristics but by community characteristics. Better understanding of system-level factors affecting ED use can enable communities to improve their health care delivery systems-augmenting access to care and reducing reliance on EDs.

Genital image, sexual anxiety, and erectile dysfunction among young male military personnel.

PubMed

Wilcox, Sherrie L; Redmond, Sarah; Davis, Teaniese L

2015-06-01

More than a third of young military personnel report experiencing some level of erectile dysfunction (ED). Preoccupation with body image, particularly genitals, is a distraction that can influence sexual anxiety (SA) and sexual functioning problems (SFPs), particularly ED. This study assessed the relationships between male genital self-image (MGSI), SA, and ED in a sample of male military personnel age 40 or younger. Data were from a larger study on SFPs in military populations. This sample consisted of 367 male military personnel age 40 or younger. Hierarchical regression analyses and process modeling using mediation analysis were performed to examine the effects of MGSI on ED with SA as an intermediate variable. We predicted that SA would mediate the relationship between MGSI and ED. ED severity was assessed with the International Index of Erectile Function. MGSI was assessed using the MGSI Scale. SA was assessed with the SA subscale of the Sexual Needs Scale. As hypothesized, greater satisfaction with MGSI was predictive of significantly lower SA (F[8, 352] = 4.07, P = 0.001) and lower ED (F[8, 352] = 13.20, P = 0.001). Lower levels of SA were predictive of lower levels of ED (F[8, 354] = 21.35, P < 0.001). Additionally, results also revealed a significant indirect effect of MGSI on ED through SA (b = -0.07, standard error = 0.03, confidence interval = [-0.14,-0.02], P < 0.05), indicating mediation of MGSI on ED via SA. This study underscores the complex etiologic basis of SFPs, particularly ED, and highlights the importance of considering psychologic contributors to ED, such as SA and MGSI. Strategies aimed at reducing SA may be useful in improving ED in young military populations and are worth considering as complements to strategies that improve SFPs. © 2015 International Society for Sexual Medicine.

A pilot study of implantable cardiac device interrogation by emergency department personnel.

PubMed

Neuenschwander, James F; Hiestand, Brian C; Peacock, W Frank; Billings, John M; Sondrup, Cole; Hummel, John D; Abraham, William T

2014-03-01

Implanted devices (eg, pacemakers and defibrillators) provide valuable information and may be interrogated to obtain diagnostic information and to direct management. During admission to an emergency department (ED), significant time and cost are spent waiting for device manufacturer representatives or cardiologists to access the data. If ED personnel could safely interrogate implanted devices, more rapid disposition could occur, thus leading to potentially better outcomes at a reduced cost. This was a pilot study examining the feasibility of ED device interrogation. This was a prospective convenience sample study of patients presenting to the ED with any chief complaint and who had an implantable device capable of being interrogated by a Medtronic reader. After obtaining informed consent, study patients underwent device interrogation by ED research personnel. After reviewing the device data, the physician documented their opinions of the value of data in aiding care. Patients were followed up at intervals ranging from 30 days out to 1 year to determine adverse events relating to interrogation. Forty-four patients underwent device interrogation. Their mean age was 56 ± 14.7 years (range, 28-83), 75% (33/44) were male and 75% (33/44) were hospitalized from the ED. The interrogations took less than 10 minutes 89% of the time. In 60% of the cases, ED physicians reported the data-assisted patient care. No adverse events were reported relating to the ED interrogations. In this pilot study, we found that ED personnel can safely and quickly interrogate implantable devices to obtain potentially useful clinical data.

Anterior Cruciate Ligament Reconstruction in Ehlers-Danlos Syndrome

PubMed Central

Williams, John; Hutt, Jonathan; Rickman, Mark

2015-01-01

This report details the reconstruction of the anterior cruciate ligament in an 18-year-old man with Ehlers-Danlos syndrome (EDS). The reduced mechanical properties of the tissue in EDS can pose a challenge to the orthopaedic surgeon. In this case, we describe the use of a hamstring autograft combined with a Ligament Advanced Reinforcement System (LARS). There was a good radiographical, clinical, and functional outcome after two years. This technique gave a successful outcome in the reconstruction of the ACL in a patient with EDS and therefore may help surgeons faced with the same clinical scenario. PMID:26221555

Web-Based Fully Automated Self-Help With Different Levels of Therapist Support for Individuals With Eating Disorder Symptoms: A Randomized Controlled Trial.

PubMed

Aardoom, Jiska J; Dingemans, Alexandra E; Spinhoven, Philip; van Ginkel, Joost R; de Rooij, Mark; van Furth, Eric F

2016-06-17

Despite the disabling nature of eating disorders (EDs), many individuals with ED symptoms do not receive appropriate mental health care. Internet-based interventions have potential to reduce the unmet needs by providing easily accessible health care services. This study aimed to investigate the effectiveness of an Internet-based intervention for individuals with ED symptoms, called "Featback." In addition, the added value of different intensities of therapist support was investigated. Participants (N=354) were aged 16 years or older with self-reported ED symptoms, including symptoms of anorexia nervosa, bulimia nervosa, and binge eating disorder. Participants were recruited via the website of Featback and the website of a Dutch pro-recovery-focused e-community for young women with ED problems. Participants were randomized to: (1) Featback, consisting of psychoeducation and a fully automated self-monitoring and feedback system, (2) Featback supplemented with low-intensity (weekly) digital therapist support, (3) Featback supplemented with high-intensity (3 times a week) digital therapist support, and (4) a waiting list control condition. Internet-administered self-report questionnaires were completed at baseline, post-intervention (ie, 8 weeks after baseline), and at 3- and 6-month follow-up. The primary outcome measure was ED psychopathology. Secondary outcome measures were symptoms of depression and anxiety, perseverative thinking, and ED-related quality of life. Statistical analyses were conducted according to an intent-to-treat approach using linear mixed models. The 3 Featback conditions were superior to a waiting list in reducing bulimic psychopathology (d=-0.16, 95% confidence interval (CI)=-0.31 to -0.01), symptoms of depression and anxiety (d=-0.28, 95% CI=-0.45 to -0.11), and perseverative thinking (d=-0.28, 95% CI=-0.45 to -0.11). No added value of therapist support was found in terms of symptom reduction although participants who received therapist support were significantly more satisfied with the intervention than those who did not receive supplemental therapist support. No significant differences between the Featback conditions supplemented with low- and high-intensity therapist support were found regarding the effectiveness and satisfaction with the intervention. The fully automated Internet-based self-monitoring and feedback intervention Featback was effective in reducing ED and comorbid psychopathology. Supplemental therapist support enhanced satisfaction with the intervention but did not increase its effectiveness. Automated interventions such as Featback can provide widely disseminable and easily accessible care. Such interventions could be incorporated within a stepped-care approach in the treatment of EDs and help to bridge the gap between mental disorders and mental health care services. Netherlands Trial Registry: NTR3646; http://www.trialregister.nl/trialreg/admin/ rctview.asp?TC=3646 (Archived by WebCite at http://www.webcitation.org/6fgHTGKHE).

Prevalence and correlates of erectile dysfunction (ED) and treatment seeking for ED in Asian Men: the Asian Men's Attitudes to Life Events and Sexuality (MALES) study.

PubMed

Tan, Hui-Meng; Low, Wah Yun; Ng, Chirk Jenn; Chen, Kuang-Kuo; Sugita, Minoru; Ishii, Nobuhisa; Marumo, Ken; Lee, Sung Won; Fisher, William; Sand, Michael

2007-11-01

There have been limited multiregional studies in Asia examining the parameters of men's general and sexual health and quality of life in the general population vs. those in clinical cohorts of patients with erectile dysfunction (ED). The aims of the Asian Men's Attitudes to Life Events and Sexuality (Asian MALES) study were to investigate the prevalence of ED, associated health conditions, and ED treatment-seeking patterns in the general male population in five regions of Asia (China, Japan, Korea, Malaysia, and Taiwan). Standardized questionnaire previously used in a similar multiregional study and modified to ensure culturally appropriate content for Asia. Phase I of the study involved 10,934 adult men, aged 20-75 years, who were interviewed using the standardized questionnaire. Phase II of the study involved men with self-reported ED recruited from Phase I and via physician referral, invitations in general practitioner offices, and street interception (total Phase II sample, N = 1,209). The overall prevalence of self-reported ED in the Phase I study population was 6.4%. ED prevalence varied by region and significantly increased with age (P < 0.01). Men with ED reported significantly greater rates of comorbid illness (P < 0.0001) and a reduced quality of life (P = 0.0001), compared with men without ED. Phase II of the study revealed that fewer than half of men with self-reported ED had sought treatment for their problem. Men were more likely to seek help for erection difficulties from Western doctors than from traditional medicine practitioners (P = 0.0001). A man's partner/spouse was the most common influencer of treatment seeking in all regions except Malaysia. The findings confirm those of existing research on ED in both Asian and non-Asian males: ED is a prevalent condition; the prevalence of ED increases with age and is strongly associated with comorbid conditions; and the majority of men have never sought treatment for their condition. This study highlights a substantial need for the evaluation and treatment of ED in Asian men.

The Effect of Utilization Review on Emergency Department Operations.

PubMed

Desai, Shoma; Gruber, Phillip F; Eiting, Erick; Seabury, Seth A; Mack, Wendy J; Voyageur, Christian; Vasquez, Veronica; Kim, Hyung T; Terp, Sophie

2017-11-01

Increasingly, hospitals are using utilization review software to reduce hospital admissions in an effort to contain costs. Such practices have the potential to increase the number of unsafe discharges, particularly in public safety-net hospitals. Utilization review software tools are not well studied with regard to their effect on emergency department (ED) operations. We study the effect of prospectively used admission decision support on ED operations. In 2012, Los Angeles County + University of Southern California Medical Center implemented prospective use of computerized admission criteria. After implementation, only ED patients meeting primary review (diagnosis-based criteria) or secondary review (medical necessity as determined by an on-site emergency physician) were assigned inpatient beds. Data were extracted from electronic medical records from September 2011 through December 2013. Outcomes included operational metrics, 30-day ED revisits, and 30-day admission rates. Excluding a 6-month implementation period, monthly summary metrics were compared pre- and postimplementation with nonparametric and negative binomial regression methods. All adult ED visits, excluding incarcerated and purely behavioral health visits, were analyzed. The primary outcomes were disposition rates. Secondary outcomes were 30-day ED revisits, 30-day admission rate among return visitors to the ED, and estimated cost. Analysis of 245,662 ED encounters was performed. The inpatient admission rate decreased from 14.2% to 12.8%. Increases in discharge rate (82.4% to 83.4%) and ED observation unit utilization (2.5% to 3.4%) were found. Thirty-day revisits increased (20.4% to 24.4%), although the 30-day admission rate decreased (3.2% to 2.8%). Estimated cost savings totaled $193.17 per ED visit. The prospective application of utilization review software in the ED led to a decrease in the admission rate. This was tempered by a concomitant increase in ED observation unit utilization and 30-day ED revisits. Cost savings suggest that resources should be redirected to the more highly affected ED and ED observation unit, although more work is needed to confirm the generalizability of these findings. Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

"It's not healthy and it's decidedly not masculine": a media analysis of UK newspaper representations of eating disorders in males.

PubMed

MacLean, Alice; Sweeting, Helen; Walker, Laura; Patterson, Chris; Räisänen, Ulla; Hunt, Kate

2015-05-29

Recent qualitative research found young men reporting that an expectation that eating disorders (EDs) mainly affect young women led them, and others, to only recognise their symptoms when their ED had become entrenched. This raises questions about how these stereotypes persist. We therefore explored how EDs in males were represented in articles published in UK newspapers over a 10-year period (7.12.2002-7.12.2012), specifically attending to whether newsprint media represent EDs in males as 'gender appropriate', 'gender anomalous' or 'gender neutral'. A qualitative thematic analysis of UK newspaper articles. We searched two databases, Newsbank and LexisNexis, for newspaper articles including ED and male terms in the lead/first paragraph. Following de-duplication, 420 articles were scrutinised; 138 met inclusion criteria for detailed textual analysis and were imported into NVivo10. The number of articles peaked in 2008 when a UK politician announced that he had experienced bulimia nervosa. Analysis of how the articles portrayed male ED-related characterisations and experiences revealed that they conveyed ambiguous messages about EDs in males. Despite apparently aiming to dispel stereotypes that only young women experience EDs and to address stigma surrounding EDs in males, many aspects of the articles, including repetition of phrases such as 'a young woman's illness', serve to reinforce messages that EDs are inherently 'female' and so 'anomalous' for men. Newspaper articles represent men with EDs as atypical of men, as a result of having an ED (and any feminising or demasculinising characteristics associated with this), and as atypical of people with EDs, who are still usually portrayed as teenage girls. Such media representations frame a cultural paradigm in which there is an expectation that men may feel shame about or strive to conceal EDs, potentially contributing to men with EDs delaying help-seeking, gaining late access to treatments and reducing chances of successful outcomes. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

“It's not healthy and it's decidedly not masculine”: a media analysis of UK newspaper representations of eating disorders in males

PubMed Central

MacLean, Alice; Sweeting, Helen; Walker, Laura; Patterson, Chris; Räisänen, Ulla; Hunt, Kate

2015-01-01

Objectives Recent qualitative research found young men reporting that an expectation that eating disorders (EDs) mainly affect young women led them, and others, to only recognise their symptoms when their ED had become entrenched. This raises questions about how these stereotypes persist. We therefore explored how EDs in males were represented in articles published in UK newspapers over a 10-year period (7.12.2002–7.12.2012), specifically attending to whether newsprint media represent EDs in males as ‘gender appropriate’, ‘gender anomalous’ or ‘gender neutral’. Design A qualitative thematic analysis of UK newspaper articles. Methods We searched two databases, Newsbank and LexisNexis, for newspaper articles including ED and male terms in the lead/first paragraph. Following de-duplication, 420 articles were scrutinised; 138 met inclusion criteria for detailed textual analysis and were imported into NVivo10. Findings The number of articles peaked in 2008 when a UK politician announced that he had experienced bulimia nervosa. Analysis of how the articles portrayed male ED-related characterisations and experiences revealed that they conveyed ambiguous messages about EDs in males. Despite apparently aiming to dispel stereotypes that only young women experience EDs and to address stigma surrounding EDs in males, many aspects of the articles, including repetition of phrases such as ‘a young woman's illness’, serve to reinforce messages that EDs are inherently ‘female’ and so ‘anomalous’ for men. Conclusions Newspaper articles represent men with EDs as atypical of men, as a result of having an ED (and any feminising or demasculinising characteristics associated with this), and as atypical of people with EDs, who are still usually portrayed as teenage girls. Such media representations frame a cultural paradigm in which there is an expectation that men may feel shame about or strive to conceal EDs, potentially contributing to men with EDs delaying help-seeking, gaining late access to treatments and reducing chances of successful outcomes. PMID:26024997

Tadalafil once daily in the treatment of lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH) in men without erectile dysfunction.

PubMed

Brock, Gerald; Broderick, Gregory; Roehrborn, Claus G; Xu, Lei; Wong, David; Viktrup, Lars

2013-11-01

To assess the safety and efficacy of tadalafil once daily on lower urinary tract symptoms suggestive of clinical benign prostatic hyperplasia (BPH-LUTS) in men without erectile dysfunction (ED). To compare these with effects in men with ED. After a 4-week washout period and 4-week placebo run-in period, 1089 men without ED (n = 338) and with ED (n = 751) were randomly assigned to placebo or tadalafil 5 mg once daily for 12 weeks in three global clinical studies with similar designs. In the pooled dataset, post hoc analyses of covariance assessed the impact and severity of BPH-LUTS using the International Prostate Symptom Score (IPSS) and the BPH Impact Index (BII) and IPSS quality-of-life (IPSS-QoL) subscores. Safety was assessed using treatment-emergent adverse events. The treatment-by-ED-status interaction was used to assess efficacy differences between the with/without ED subgroups. Men without ED were similar in BPH-LUTS severity/previous therapy to men with ED. Tadalafil significantly reduced BPH-LUTS from baseline when compared with placebo in men without ED (IPSS -5.4 vs -3.3, P < 0.01; IPSS voiding subscore -3.5 vs -2.0, P < 0.01; IPSS storage subscore -1.9 vs -1.3, P < 0.05). Tadalafil also significantly improved quality of life from baseline when compared with placebo in men without ED (IPSS-QoL -1.0 vs -0.7, BII -1.4 vs -1.0; both P < 0.05). Between-ED-subgroup interactions were not significant (all P > 0.68). Tadalafil was safe and well tolerated. Tadalafil 5 mg once daily improved BPH-LUTS in men without ED by a magnitude similar to that observed in men with ED. The adverse event profile in men without ED was consistent with that observed in men with ED. © 2013 The Authors. BJU International © 2013 BJU International.

A randomized controlled trial of brief interventions to reduce drug use among adults in a low-income urban emergency department: the HealthiER You study.

PubMed

Blow, Frederic C; Walton, Maureen A; Bohnert, Amy S B; Ignacio, Rosalinda V; Chermack, Stephen; Cunningham, Rebecca M; Booth, Brenda M; Ilgen, Mark; Barry, Kristen L

2017-08-01

To examine efficacy of drug brief interventions (BIs) among adults presenting to a low-income urban emergency department (ED). Randomized controlled trial on drug use outcomes at 3, 6 and 12 months. Participants were assigned to (1) computer-delivered BI (Computer BI), (2) therapist-delivered, computer-guided BI (Therapist BI) or (3) enhanced usual care (EUC-ED) for drug-using adults. Participants were re-randomized after the 3-month assessment to either adapted motivational enhancement therapy (AMET) booster or enhanced usual care booster (EUC-B). Patients recruited from low-income urban emergency departments (ED) in Flint, Michigan, USA. A total of 780 ED patients reporting recent drug use, 44% males, mean age = 31 years. Computer BI consisted of an interactive program guided by a virtual health counselor. Therapist BI included computer guidance. The EUC-ED conditions included review of community health and HIV prevention resources. The BIs and boosters were based on motivational interviewing, focusing on reduction of drug use and HIV risk behaviors. Primary outcome was past 90 days using drugs at 6 and 12 months and secondary outcomes were weighted drug-days and days of marijuana use. Percentage changes in mean days used any drug from baseline to 12 months were: Computer BI + EUC-B: -10.9%, P = 0.0844; Therapist BI + EUC-B: -26.7%, P = 0.0041, for EUC-ED + EUC-B: -20.9, P = 0.0011. In adjusted analyses, there was no significant interaction between ED intervention and booster AMET for primary and secondary outcomes. Compared with EUC-ED, Therapist BI reduced number of days using any drug [95% confidence interval (CI) = -0.41, -0.07, P = 0.0422] and weighted drug-days (95% CI = -0.41, -0.08, P = 0.0283). Both Therapist and Computer BI had significantly fewer number of days using marijuana compared to EUC-ED (Therapist BI: 95% CI = -0.42, -0.06, P = 0.0104, Computer BI: 95% CI = -0.34, -0.01, P = 0.0406). Booster effects were not significant. An emergency department-based motivational brief intervention, delivered by a therapist and guided by computer, appears to reduce drug use among adults seeking emergency department care compared with enhanced usual care. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

Reductions in entree energy density increase children's vegetable intake and reduce energy intake

USDA-ARS?s Scientific Manuscript database

The energy density (ED; kcal/g) of an entrée influences children's energy intake (EI), but the effect of simultaneously changing both ED and portion size of an entrée on preschool children's EI is unknown. In this within-subject crossover study, 3- to 5-year-old children (30 boys, 31 girls) in a day...

Nitric oxide synthase inhibition reduces muscle inflammation and necrosis in modified muscle use

NASA Technical Reports Server (NTRS)

Pizza, F. X.; Hernandez, I. J.; Tidball, J. G.

1998-01-01

The objective of this study was to determine the role of nitric oxide in muscle inflammation, fiber necrosis, and apoptosis of inflammatory cells in vivo. The effects of nitric oxide synthase (NOS) inhibition on the concentrations of neutrophils, ED1+ and ED2+ macrophages, apoptotic inflammatory cells, and necrotic muscle fibers in rats subjected to 10 days of hindlimb unloading and 2 days of reloading were determined. Administration of NOS inhibitor N(omega)-nitro-L-arginine methyl ester (L-NAME) significantly reduced the concentrations of neutrophils, ED1+ and ED2+ macrophages, and necrotic fibers in soleus muscle relative to water-treated controls. The concentration of apoptotic inflammatory cells was also significantly lower for L-NAME-treated animals compared with water-treated controls. However, the proportion of the inflammatory cell population that was apoptotic did not differ between L-NAME-treated and control animals, suggesting that L-NAME treatment did not decrease inflammatory cell populations by increasing the frequency of apoptosis. Thus, nitric oxide or one of its intermediates promotes muscle inflammation and fiber necrosis during modified muscle use and plays no more than a minor role in the resolution of muscle inflammation by inducing apoptosis of inflammatory cells.

Implications of bed reduction in an acute psychiatric service.

PubMed

Bastiampillai, Tarun J; Bidargaddi, Niranjan P; Dhillon, Rohan S; Schrader, Geoffrey D; Strobel, Jörg E; Galley, Philip J

2010-10-04

To evaluate the impact of psychiatric inpatient bed closures, accompanied by a training program aimed at enhancing team effectiveness and incorporating data-driven practices, in a mental health service. Retrospective comparison of the changes in services within three consecutive financial years: baseline period - before bed reduction (2006-07); observation period - after bed reduction (2007-08); and intervention period - second year after bed reduction (2008-09). The study was conducted at Cramond Clinic, Queen Elizabeth Hospital, Adelaide. Length of stay, 28-day readmission rates, discharges, bed occupancy rates, emergency department (ED) presentations, ED waiting time, seclusions, locality of treatment, and follow-up in the community within 7days. Reduced bed numbers were associated with reduced length of stay, fewer referrals from the community and subsequently shorter waiting times in the ED, without significant change in readmission rates. A higher proportion of patients was treated in the local catchment area, with improved community follow-up and a significant reduction in inpatient seclusions. Our findings should reassure clinicians concerned about psychiatric bed numbers that service redesign with planned bed reductions will not necessarily affect clinical care, provided data literacy and team training programs are in place to ensure smooth transition of patients across ED, inpatient and community services.

Ground State and Finite Temperature Lanczos Methods

NASA Astrophysics Data System (ADS)

Prelovšek, P.; Bonča, J.

The present review will focus on recent development of exact- diagonalization (ED) methods that use Lanczos algorithm to transform large sparse matrices onto the tridiagonal form. We begin with a review of basic principles of the Lanczos method for computing ground-state static as well as dynamical properties. Next, generalization to finite-temperatures in the form of well established finite-temperature Lanczos method is described. The latter allows for the evaluation of temperatures T>0 static and dynamic quantities within various correlated models. Several extensions and modification of the latter method introduced more recently are analysed. In particular, the low-temperature Lanczos method and the microcanonical Lanczos method, especially applicable within the high-T regime. In order to overcome the problems of exponentially growing Hilbert spaces that prevent ED calculations on larger lattices, different approaches based on Lanczos diagonalization within the reduced basis have been developed. In this context, recently developed method based on ED within a limited functional space is reviewed. Finally, we briefly discuss the real-time evolution of correlated systems far from equilibrium, which can be simulated using the ED and Lanczos-based methods, as well as approaches based on the diagonalization in a reduced basis.

Bone marrow cells stained by azide-conjugated Alexa fluors in the absence of an alkyne label.

PubMed

Lin, Guiting; Ning, Hongxiu; Banie, Lia; Qiu, Xuefeng; Zhang, Haiyang; Lue, Tom F; Lin, Ching-Shwun

2012-09-01

Thymidine analog 5-ethynyl-2'-deoxyuridine (EdU) has recently been introduced as an alternative to 5-bromo-2-deoxyuridine (BrdU) for cell labeling and tracking. Incorporation of EdU into replicating DNA can be detected by azide-conjugated fluors (eg, Alexa-azide) through a Cu(i)-catalyzed click reaction between EdU's alkyne moiety and azide. While this cell labeling method has proven to be valuable for tracking transplanted stem cells in various tissues, we have found that some bone marrow cells could be stained by Alexa-azide in the absence of EdU label. In intact rat femoral bone marrow, ~3% of nucleated cells were false-positively stained, and in isolated bone marrow cells, ~13%. In contrast to true-positive stains, which localize in the nucleus, the false-positive stains were cytoplasmic. Furthermore, while true-positive staining requires Cu(i), false-positive staining does not. Reducing the click reaction time or reducing the Alexa-azide concentration failed to improve the distinction between true- and false-positive staining. Hematopoietic and mesenchymal stem cell markers CD34 and Stro-1 did not co-localize with the false-positively stained cells, and these cells' identity remains unknown.

The case for design and build in piped medical gases.

PubMed

Cruddas, I

1990-10-01

The proposal is not new or radical in that currently many small works are and historical have been carried out implicitly utilising this system. Furthermore, this idea is not suggesting that M&E consultants be omitted from the process only that their role be redefined in terms of approving/checking proposals/installations/commissioning etc. There is an appropriate form of contract already available through JCT '80 why not utilise it? As is being done with boilers, water treatment, lifts etc. etc. The recommendation would improve quality, reduce time and cost, directly apportion accountability and involve the knowledgeable professionals within the industry.

Is healthcare really equal for all? Assessing the horizontal and vertical equity in healthcare utilisation among older Ghanaians.

PubMed

Dei, Vincent; Sebastian, Miguel San

2018-06-20

There is a lack of focused research on the older population in Ghana and about issues pertaining to their access to healthcare services. Furthermore, information is lacking regarding the fairness in the access to these services. This study aimed to ascertain whether horizontal and vertical equity requirements were being met in the healthcare utilisation among older adults aged 50 years and above. This study was based on a secondary cross-sectional data from the World Health Organization's Study on global AGEing (SAGE) and adult health wave 1 conducted from 2007 to 2008 in Ghana. Data on 4304 older adults aged 50 years-plus were analysed. Bivariate and multivariable analyses were carried out to analyse the association between outpatient/inpatient utilisation and (1) socioeconomic status (SES), controlling for need variables (horizontal equity) and (2) need variables, controlling for SES (vertical equity). Odds ratios with 95% confidence intervals were calculated to analyse the association between relevant variables. Horizontal and vertical inequities were found in the utilisation of outpatient services. Inpatient healthcare utilisation was both horizontally and vertically equitable. Women were found to be more likely to use outpatient services than men but had reduced odds of using inpatient services. Possessing a health insurance was also significantly associated with the use of both inpatient and outpatient services. Whilst equity exists in inpatient care utilisation, more needs to be done to achieve equity in the access to outpatient services. The study reaffirms the need to evaluate both the horizontal and vertical dimensions in the assessment of equity in healthcare access. It provides the basis for further research in bridging the healthcare access inequity gap among older adults in Ghana.

Improving asthma care in emergency departments: results of a multihospital collaborative quality initiative in rural western North Carolina.

PubMed

Crane, Steven; Sailer, Douglas; Patch, Steven C

2011-01-01

In North Carolina, nearly one-fourth of persons with asthma visit an emergency department (ED) or urgent care center at least once a year because of an exacerbation of asthma symptoms. The Emergency Department Asthma Program was a quality-improvement initiative designed to better understand the population of patients who use the ED for asthma care in rural western North Carolina and to demonstrate whether EDs at small hospitals could, by implementing National Asthma Education and Prevention Program treatment guidelines, improve asthma care and reduce subsequent asthma-related ED visits. Eight hospitals in western North Carolina participated in the project, which lasted from November 2003 through December 2007. The intervention consisted of a series of individual and structured continuing medical education events directed at ED physicians and staff. Additionally, patients presenting to EDs for asthma-related problems were selected to receive a short patient questionnaire, to determine their basic understanding of asthma and barriers to asthma care; to undergo asthma staging by the treating physician; to receive focused bedside asthma education by a respiratory therapist; and, finally, at the treating physician's discretion, to receive a free packet of asthma medications, including rescue therapy with a beta-agonist and corticosteroid therapy delivered via a metered-dose inhaler, before discharge. During the 37-month project, a total of 1,739 patients presented to the participating EDs for 2,481 asthma-related episodes of care; at 11% of these visits, patients received the intervention, with nearly 100 ED physicians referring patients to the program. Most of the patients using the ED for asthma treatment were judged to have the mildest stages, and nearly half were uninsured or were covered by Medicaid. For only 20% of the visits was a primary care physician or practice identified. The patient intervention did not appear to lessen the rate of return visits for asthma-related symptoms at 30 and 60 days. Selection bias is likely, as patients enrolled in the study were more likely than patients in the target sample to be adults and insured. Because we did not measure ED staff attendance at educational sessions or their knowledge of and attitudes about asthma care before and after the educational program, we cannot draw conclusions about the effectiveness of the program to change their knowledge, attitudes, or behavior. Many patients who use the ED for care appear to have mild, intermittent asthma and do not identify a regular source of primary care. Efforts to improve asthma care on a communitywide basis and to reduce preventable exacerbations should include care provided in EDs, as this may be the only source of asthma care for many asthma patients. The project demonstrated that regional, collaborative performance improvement efforts in EDs are possible but that many barriers exist to this approach.

Explaining transgression in respiratory rate observation methods in the emergency department: A classic grounded theory analysis.

PubMed

Flenady, Tracy; Dwyer, Trudy; Applegarth, Judith

2017-09-01

Abnormal respiratory rates are one of the first indicators of clinical deterioration in emergency department(ED) patients. Despite the importance of respiratory rate observations, this vital sign is often inaccurately recorded on ED observation charts, compromising patient safety. Concurrently, there is a paucity of research reporting why this phenomenon occurs. To develop a substantive theory explaining ED registered nurses' reasoning when they miss or misreport respiratory rate observations. This research project employed a classic grounded theory analysis of qualitative data. Seventy-nine registered nurses currently working in EDs within Australia. Data collected included detailed responses from individual interviews and open-ended responses from an online questionnaire. Classic grounded theory (CGT) research methods were utilised, therefore coding was central to the abstraction of data and its reintegration as theory. Constant comparison synonymous with CGT methods were employed to code data. This approach facilitated the identification of the main concern of the participants and aided in the generation of theory explaining how the participants processed this issue. The main concern identified is that ED registered nurses do not believe that collecting an accurate respiratory rate for ALL patients at EVERY round of observations is a requirement, and yet organizational requirements often dictate that a value for the respiratory rate be included each time vital signs are collected. The theory 'Rationalising Transgression', explains how participants continually resolve this problem. The study found that despite feeling professionally conflicted, nurses often erroneously record respiratory rate observations, and then rationalise this behaviour by employing strategies that adjust the significance of the organisational requirement. These strategies include; Compensating, when nurses believe they are compensating for errant behaviour by enhancing the patient's outcome; Minimalizing, when nurses believe that the patient's outcome would be no different if they recorded an accurate respiratory rate or not and; Trivialising, a strategy that sanctions negligent behaviour and occurs when nurses 'cut corners' to get the job done. Nurses' use these strategies to titrate the level ofemotional discomfort associated with erroneous behaviour, thereby rationalising transgression CONCLUSION: This research reveals that despite continuing education regarding gold standard guidelines for respiratory rate collection, suboptimal practice continues. Ideally, to combat this transgression, a culture shift must occur regarding nurses' understanding of acceptable practice methods. Nurses must receive education in a way that permeates their understanding of the relationship between the regular collection of accurate respiratory rate observations and optimal patient outcomes. Copyright © 2017 Elsevier Ltd. All rights reserved.

Alcohol-related emergency department visits associated with collegiate football games.

PubMed

Shook, Janice; Hiestand, Brian C

2011-01-01

In 2003, after several post-college football game riots, multiple strategies including strict enforcement of open container laws were instituted by the authors' city and university. The authors compared alcohol-related visits to the on-campus emergency department (ED) associated with home football games in 2002 and 2006, hypothesizing that alcohol-related visits should decline. ED patients during home game weekends. Retrospective cohort study comparing the 2002 and 2006 home games-similar seasons wherein the team went undefeated. Logistic regression assessed the impact of environmental and patient characteristics on the likelihood of an ED visit being alcohol related. In total 2,220 visits in 2002 and 2,146 visits in 2006 were reviewed. Alcohol-related visits increased from 2002 (7.9%) to 2006 (9.5%, p = .06). Despite community interventions, the odds of an ED visit being alcohol related increased (odds ratio [OR] 1.3, 95% confidence interval [CI₉₅] 1.06-1.64). Community measures did not reduce alcohol-related visits to the ED.

Randomized trial of pragmatic education for low-risk COPD patients: impact on hospitalizations and emergency department visits.

PubMed

Siddique, Haamid H; Olson, Raymond H; Parenti, Connie M; Rector, Thomas S; Caldwell, Michael; Dewan, Naresh A; Rice, Kathryn L

2012-01-01

Most interventions aimed at reducing hospitalizations and emergency department (ED) visits in patients with chronic obstructive pulmonary disease (COPD) have employed resource-intense programs in high-risk individuals. Although COPD is a progressive disease, little is known about the effectiveness of proactive interventions aimed at preventing hospitalizations and ED visits in the much larger population of low-risk (no known COPD-related hospitalizations or ED visits in the prior year) patients, some of whom will eventually become high-risk. We tested the effect of a simple educational and self-efficacy intervention (n = 2243) versus usual care (n = 2182) on COPD/breathing-related ED visits and hospitalizations in a randomized study of low-risk patients at three Veterans Affairs (VA) medical centers in the upper Midwest. Administrative data was used to track VA admissions and ED visits. A patient survey was used to determine health-related events outside the VA. Rates of COPD-related VA hospitalizations in the education and usual care group were not significantly different (3.4 versus 3.6 admissions per 100 person-years, respectively; 95% CI of difference -1.3 to 1.0, P = 0.77). The much higher patient-reported rates of non-VA hospitalizations for breathing-related problems were lower in the education group (14.0 versus 19.0 per 100 person-years; 95% CI -8.6 to -1.4, P = 0.006). Rates of COPD-related VA ED visits were not significantly different (6.8 versus 5.3; 95% CI -0.1 to 3.0, P = 0.07), nor were non-VA ED visits (32.4 versus 36.5; 95% CI -9.3 to 1.1, P = 0.12). All-cause VA admission and ED rates did not differ. Mortality rates (6.9 versus 8.3 per 100 person-years, respectively; 95% CI -3.0 to 0.4, P = 0.13) did not differ. An educational intervention that is practical for large numbers of low-risk patients with COPD may reduce the rate of breathing-related hospitalizations. Further research that more closely tracks hospitalizations to non-VA facilities is needed to confirm this finding.

A Short-Term Exposure to Tributyltin Blocks Leydig Cell Regeneration in the Adult Rat Testis

PubMed Central

Wu, Xiaolong; Liu, Jianpeng; Duan, Yue; Gao, Shiyu; Lü, Yao; Li, Xiaoheng; Zhu, Qiqi; Chen, Xianwu; Lin, Jing; Ye, Leping; Ge, Ren-Shan

2017-01-01

Background: Tributyltin (TBT) is widely used as an antifouling agent that may cause reproductive toxicity. The mechanism of TBT on Leydig cell development is still unknown. The objective of the present study was to investigate whether a brief exposure to low doses of TBT permanently affects Leydig cell development and to clarify the underlying mechanism. Methods: Adult male Sprague Dawley rats were randomly assigned into four groups and gavaged normal saline (control), 0.1, 1.0, or 10.0 mg/kg/day TBT for a consecutive 10 days, respectively. At the end of TBT treatment, all rats received a single intraperitoneal injection of 75 mg/kg ethane dimethane sulfonate (EDS) to eliminate all of adult Leydig cells. Leydig cells began a developmental regeneration process on post-EDS day 35. The Leydig cell regeneration was evaluated by measuring serum testosterone, luteinizing hormone, and follicle-stimulating hormone levels on post-EDS day 7, 35, and 56, the expression levels of Leydig cell genes, Leydig cell morphology and number and proliferation on post-EDS day 56. Results: TBT significantly reduced serum testosterone levels on post-EDS day 35 and 56 and increased serum luteinizing hormone and follicle-stimulating hormone levels on post-EDS day 56 at ≥1 mg/kg/day. Immunohistochemical staining showed that there were fewer regenerated Leydig cells in the TBT-treated testis on post-EDS day 56. Further study demonstrated that the mRNA or protein levels of Leydig (Lhcgr, Cyp11a1, Hsd3b1, Cyp17a1, and Hsd17b3) and Sertoli cells (Fshr, Dhh, and Sox9) were significantly down-regulated in the TBT-treated testes when compared to the control. Immunofluorescent staining showed that TBT inhibited Leydig cell proliferation as judged by the reduced number of proliferating cyclin nuclear antigen-positive Leydig cells on post-EDS day 35. Conclusion: The present study demonstrated that a short-term TBT exposure blocked Leydig cell developmental regeneration process via down-regulating steroidogenesis-related proteins and inhibiting the proliferation of Leydig cells. PMID:29075189

A Short-Term Exposure to Tributyltin Blocks Leydig Cell Regeneration in the Adult Rat Testis.

PubMed

Wu, Xiaolong; Liu, Jianpeng; Duan, Yue; Gao, Shiyu; Lü, Yao; Li, Xiaoheng; Zhu, Qiqi; Chen, Xianwu; Lin, Jing; Ye, Leping; Ge, Ren-Shan

2017-01-01

Background: Tributyltin (TBT) is widely used as an antifouling agent that may cause reproductive toxicity. The mechanism of TBT on Leydig cell development is still unknown. The objective of the present study was to investigate whether a brief exposure to low doses of TBT permanently affects Leydig cell development and to clarify the underlying mechanism. Methods: Adult male Sprague Dawley rats were randomly assigned into four groups and gavaged normal saline (control), 0.1, 1.0, or 10.0 mg/kg/day TBT for a consecutive 10 days, respectively. At the end of TBT treatment, all rats received a single intraperitoneal injection of 75 mg/kg ethane dimethane sulfonate (EDS) to eliminate all of adult Leydig cells. Leydig cells began a developmental regeneration process on post-EDS day 35. The Leydig cell regeneration was evaluated by measuring serum testosterone, luteinizing hormone, and follicle-stimulating hormone levels on post-EDS day 7, 35, and 56, the expression levels of Leydig cell genes, Leydig cell morphology and number and proliferation on post-EDS day 56. Results: TBT significantly reduced serum testosterone levels on post-EDS day 35 and 56 and increased serum luteinizing hormone and follicle-stimulating hormone levels on post-EDS day 56 at ≥1 mg/kg/day. Immunohistochemical staining showed that there were fewer regenerated Leydig cells in the TBT-treated testis on post-EDS day 56. Further study demonstrated that the mRNA or protein levels of Leydig ( Lhcgr , Cyp11a1, Hsd3b1, Cyp17a1 , and Hsd17b3 ) and Sertoli cells ( Fshr , Dhh , and Sox9 ) were significantly down-regulated in the TBT-treated testes when compared to the control. Immunofluorescent staining showed that TBT inhibited Leydig cell proliferation as judged by the reduced number of proliferating cyclin nuclear antigen-positive Leydig cells on post-EDS day 35. Conclusion: The present study demonstrated that a short-term TBT exposure blocked Leydig cell developmental regeneration process via down-regulating steroidogenesis-related proteins and inhibiting the proliferation of Leydig cells.

Cost Analysis of the STONE Randomized Trial: Can Health Care Costs be Reduced One Test at a Time?

PubMed

Melnikow, Joy; Xing, Guibo; Cox, Ginger; Leigh, Paul; Mills, Lisa; Miglioretti, Diana L; Moghadassi, Michelle; Smith-Bindman, Rebecca

2016-04-01

Decreasing the use of high-cost tests may reduce health care costs. To compare costs of care for patients presenting to the emergency department (ED) with suspected kidney stones randomized to 1 of 3 initial imaging tests. Patients were randomized to point-of-care ultrasound (POC US, least costly), radiology ultrasound (RAD US), or computed tomography (CT, most costly). Subsequent testing and treatment were the choice of the treating physician. A total of 2759 patients at 15 EDs were randomized to POC US (n=908), RAD US, (n=893), or CT (n=958). Mean age was 40.4 years; 51.8% were male. All medical care documented in the trial database in the 7 days following enrollment was abstracted and coded to estimate costs using national average 2012 Medicare reimbursements. Costs for initial ED care and total 7-day costs were compared using nonparametric bootstrap to account for clustering of patients within medical centers. Initial ED visit costs were modestly lower for patients assigned to RAD US: $423 ($411, $434) compared with patients assigned to CT: $448 ($438, $459) (P<0.0001). Total costs were not significantly different between groups: $1014 ($912, $1129) for POC US, $970 ($878, $1078) for RAD US, and $959 ($870, $1044) for CT. Hospital admissions contributed over 50% of total costs, though only 11% of patients were admitted. Mean total costs (and admission rates) varied substantially by site from $749 to $1239. Assignment to a less costly test had no impact on overall health care costs for ED patients. System-level interventions addressing variation in admission rates from the ED might have greater impact on costs.

Real-Time Support of Pediatric Diabetes Self-Care by a Transport Team

PubMed Central

Franklin, Brandi E.; Crisler, S. Crile; Shappley, Rebekah; Armour, Meri M.; McCommon, Dana T.; Ferry, Robert J.

2014-01-01

OBJECTIVE The study seeks to improve access for underserved patients via novel integration of Pedi-Flite (a critical care transport team) and to validate whether this safely enhances diabetes care and effectively expands the endocrine workforce. RESEARCH DESIGN AND METHODS The study retrospectively analyzed pager service use in a cohort of established diabetic patients (n = 979) after inception of Pedi-Flite support. Outcomes included incidence and severity of recurrent diabetic ketoacidosis (DKA) and cost savings generated from reduced referrals to the emergency department (ED) and on-call endocrinologist. We generated descriptive statistics to characterize the study population and ED visits for DKA and constructed logistic regression models to examine associations of pager use and likelihood of ED visitation and nonelective inpatient admission from an ED for DKA. RESULTS Pager users comprised 30% of the patient population. They were younger but had more established diabetes than nonusers. While pager users were 2.75 times more likely than nonusers to visit the ED for DKA (P < 0.0001), their visits were less likely to lead to inpatient admissions (odds ratio 0.58; P < 0.02). More than half (n = 587) of all calls to the pager were resolved without need for further referral. Estimates suggest that 439 ED visits and 115 admissions were avoided at a potential cost savings exceeding 760,000 USD. CONCLUSIONS Integration of a transport service provides a novel, cost-effective approach to reduce disparities in diabetes care. Advantages include scalability, applicability to other disease areas and settings, and low added costs. These findings enrich an emerging evidence base for telephonic care-management models supported by allied health personnel. PMID:23959568

Real-time support of pediatric diabetes self-care by a transport team.

PubMed

Franklin, Brandi E; Crisler, S Crile; Shappley, Rebekah; Armour, Meri M; McCommon, Dana T; Ferry, Robert J

2014-01-01

OBJECTIVE The study seeks to improve access for underserved patients via novel integration of Pedi-Flite (a critical care transport team) and to validate whether this safely enhances diabetes care and effectively expands the endocrine workforce. RESEARCH DESIGN AND METHODS The study retrospectively analyzed pager service use in a cohort of established diabetic patients (n = 979) after inception of Pedi-Flite support. Outcomes included incidence and severity of recurrent diabetic ketoacidosis (DKA) and cost savings generated from reduced referrals to the emergency department (ED) and on-call endocrinologist. We generated descriptive statistics to characterize the study population and ED visits for DKA and constructed logistic regression models to examine associations of pager use and likelihood of ED visitation and nonelective inpatient admission from an ED for DKA. RESULTS Pager users comprised 30% of the patient population. They were younger but had more established diabetes than nonusers. While pager users were 2.75 times more likely than nonusers to visit the ED for DKA (P < 0.0001), their visits were less likely to lead to inpatient admissions (odds ratio 0.58; P < 0.02). More than half (n = 587) of all calls to the pager were resolved without need for further referral. Estimates suggest that 439 ED visits and 115 admissions were avoided at a potential cost savings exceeding 760,000 USD. CONCLUSIONS Integration of a transport service provides a novel, cost-effective approach to reduce disparities in diabetes care. Advantages include scalability, applicability to other disease areas and settings, and low added costs. These findings enrich an emerging evidence base for telephonic care-management models supported by allied health personnel.

Reducing High-Users' Visits to the Emergency Department by a Primary Care Intervention for the Uninsured: A Retrospective Study.

PubMed

Tsai, Meng-Han; Xirasagar, Sudha; Carroll, Scott; Bryan, Charles S; Gallagher, Pamela J; Davis, Kim; Jauch, Edward C

2018-01-01

Reducing avoidable emergency department (ED) visits is an important health system goal. This is a retrospective cohort study of the impact of a primary care intervention including an in-hospital, free, adult clinic for poor uninsured patients on ED visit rates and emergency severity at a nonprofit hospital. We studied adult ED visits during August 16, 2009-August 15, 2011 (preintervention) and August 16, 2011-August 15, 2014 (postintervention). We compared pre- versus post-mean annual visit rates and discharge emergency severity index (ESI; triage and resource use-based, calculated Agency for Healthcare Research and Quality categories) among high-users (≥3 ED visits in 12 months) and occasional users. Annual adult ED visit volumes were 16 372 preintervention (47.5% by high-users), versus 18 496 postintervention. High-users' mean annual visit rates were 5.43 (top quartile) and 0.94 (bottom quartile) preintervention, versus 3.21 and 1.11, respectively, for returning high-users, postintervention (all P < .001). Postintervention, the visit rates of new high-users were lower (lowest and top quartile rates, 0.6 and 3.23) than preintervention high-users' rates in the preintervention period. Visit rates of the top quartile of occasional users also declined. Subgroup analysis of medically uninsured high-users showed similar results. Upon classifying preintervention high-users by emergency severity, postintervention mean ESI increased 24.5% among the lowest ESI quartile, and decreased 12.2% among the top quartile. Pre- and post-intervention sample demographics and comorbidities were similar. The observed reductions in overall ED visit rates, particularly low-severity visits; highest reductions observed among high-users and the top quartile of occasional users; and the pattern of changes in emergency severity support a positive impact of the primary care intervention.

Reducing High-Users’ Visits to the Emergency Department by a Primary Care Intervention for the Uninsured: A Retrospective Study

PubMed Central

Tsai, Meng-Han; Xirasagar, Sudha; Carroll, Scott; Bryan, Charles S.; Gallagher, Pamela J.; Davis, Kim; Jauch, Edward C.

2018-01-01

Reducing avoidable emergency department (ED) visits is an important health system goal. This is a retrospective cohort study of the impact of a primary care intervention including an in-hospital, free, adult clinic for poor uninsured patients on ED visit rates and emergency severity at a nonprofit hospital. We studied adult ED visits during August 16, 2009-August 15, 2011 (preintervention) and August 16, 2011-August 15, 2014 (postintervention). We compared pre- versus post-mean annual visit rates and discharge emergency severity index (ESI; triage and resource use–based, calculated Agency for Healthcare Research and Quality categories) among high-users (≥3 ED visits in 12 months) and occasional users. Annual adult ED visit volumes were 16 372 preintervention (47.5% by high-users), versus 18 496 postintervention. High-users’ mean annual visit rates were 5.43 (top quartile) and 0.94 (bottom quartile) preintervention, versus 3.21 and 1.11, respectively, for returning high-users, postintervention (all P < .001). Postintervention, the visit rates of new high-users were lower (lowest and top quartile rates, 0.6 and 3.23) than preintervention high-users’ rates in the preintervention period. Visit rates of the top quartile of occasional users also declined. Subgroup analysis of medically uninsured high-users showed similar results. Upon classifying preintervention high-users by emergency severity, postintervention mean ESI increased 24.5% among the lowest ESI quartile, and decreased 12.2% among the top quartile. Pre- and post-intervention sample demographics and comorbidities were similar. The observed reductions in overall ED visit rates, particularly low-severity visits; highest reductions observed among high-users and the top quartile of occasional users; and the pattern of changes in emergency severity support a positive impact of the primary care intervention. PMID:29591539

Can Nonurgent Emergency Department Care Costs be Reduced? Empirical Evidence from a U.S. Nationally Representative Sample.

PubMed

Xin, Haichang; Kilgore, Meredith L; Sen, Bisakha Pia; Blackburn, Justin

2015-09-01

A well-functioning primary care system has the capacity to provide effective care for patients to avoid nonurgent emergency department (ED) use and related costs. This study examined how patients' perceived deficiency in ambulatory care is associated with nonurgent ED care costs nationwide. This retrospective cohort study used data from the 2010-2011 Medical Expenditure Panel Survey. This study chose usual source of care, convenience of needed medical care, and patient evaluation of care quality as the main independent variables. The marginal effect following a multivariate logit model was employed to analyze the urgent vs. nonurgent ED care costs in 2011, after controlling for covariates in 2010. The endogeneity was accounted for by the time lag effect and controlling for education levels. Sample weights and variance were adjusted with the survey procedures to make results nationally representative. Patient-perceived poor and intermediate levels of primary care quality had higher odds of nonurgent ED care costs (odds ratio [OR] = 2.22, p = 0.035, and OR = 2.05, p = 0.011, respectively) compared to high-quality care, with a marginal effect (at means) of 13.0% and 11.5% higher predicted probability of nonurgent ED care costs. Costs related to these ambulatory care quality deficiencies amounted to $229 million for private plans (95% confidence interval [CI] $100 million-$358 million), $58.5 million for public plans (95% CI $33.9 million-$83.1 million), and an overall of $379 million (95% CI $229 million-$529 million) nationally. These findings highlight the improvement in ambulatory care quality as the potential target area to effectively reduce nonurgent ED care costs. Copyright © 2015 Elsevier Inc. All rights reserved.

Reducing Emergency Department Utilization Through Engagement in Telemedicine by Senior Living Communities.

PubMed

Gillespie, Suzanne M; Shah, Manish N; Wasserman, Erin B; Wood, Nancy E; Wang, Hongyue; Noyes, Katia; Nelson, Dallas; Dozier, Ann; McConnochie, Kenneth M

2016-06-01

High-intensity telemedicine has been shown to reduce the need for emergency department (ED) care for older adult senior living community (SLC) residents with acute illnesses. We evaluated the effect of SLC engagement in the telemedicine program on ED use rates. We performed a secondary analysis of data from a prospective cohort study evaluating the effectiveness of high-intensity telemedicine for SLC residents. We compared the annual rate of change in ED use among subjects who resided in SLC units that were more engaged in telemedicine services with that among subjects who resided in SLC units that were less engaged in telemedicine and control subjects who lived at facilities without access to telemedicine services. During the study, subjects had 503 telemedicine visits, with 362 (72.0%) in the more engaged SLCs and 141 (28.0%) in the less engaged SLCs. For subjects residing in more engaged SLCs, ED use decreased at an annualized rate of 28% (rate ratio [RR] = 0.72; 95% confidence interval [CI], 0.58-0.89), whereas in the less engaged (RR = 0.962; 95% CI, 0.776-1.19) and control (RR = 0.909, 95% CI, 0.822-1.07) groups there was no significant change in ED use (p = 0.036 for group × time interaction). Individuals residing in more engaged SLCs experienced a greater decrease in ED use compared with subjects residing in less engaged SLCs or those without access to high-intensity telemedicine for acute illnesses. We identified potential factors associated with more engaged SLCs, but further research is needed to understand resident and staff engagement and how to increase it.

The impact of social support on the risk of eating disorders in women exposed to intimate partner violence.

PubMed

Schirk, Dana K; Lehman, Erik B; Perry, Amanda N; Ornstein, Rollyn M; McCall-Hosenfeld, Jennifer S

2015-01-01

Eating disorders (EDs) are often found among women exposed to intimate partner violence (IPV). The role of social support (SS) as a protective factor against ED among IPV-exposed women is not firmly established. The objective of this study is to determine the distribution of risk of EDs among women exposed to IPV and to examine the impact of SS on risk of ED among IPV-exposed women. Women (aged 18-64 years) exposed to IPV during their lifetimes (defined by the Humiliation-Afraid-Rape-Kick instrument) were recruited from primary care and domestic violence service agencies and surveyed on demographics, mood/anxiety disorders, psychosocial/community factors, and strategies used in response to IPV. The Eating Disorder Screen for Primary Care assessed the risk of ED. A modified Medical Outcomes Study Social Support Survey assessed overall functional support (scale range: 0-32; categorized into quartiles). Ordinal logistic regression examined the risk of ED based on SS, controlling for prespecified demographics (age, race/ethnicity, marital status, near-poverty level), and health-related factors significant in bivariate analyses (risky alcohol use). Among 302 women with lifetime IPV, 41 (14%) were at high risk, 127 (42%) were at moderate risk, and 134 (44%) were at low risk of an ED. In bivariate analyses, high risk of an ED was significantly more frequent among women with a low SS score (<19, 24%) versus a high SS score (≥30, 12%) (P=0.03). High risk of an ED was significantly associated with risky alcohol use (18%) versus non-risky alcohol use (13%; P=0.008). In multivariable analysis, a 5-unit increase in overall SS was significantly associated with decreased odds of ED risk (P=0.007). Among IPV-exposed women, low SS is associated with an increased risk of ED. SS may protect against ED by reducing anxiety and promoting positive actions, but further study is needed to confirm this.

Energy density of the Scottish diet estimated from food purchase data: relationship with socio-economic position and dietary targets.

PubMed

Barton, Karen L; Wrieden, Wendy L; Sherriff, Andrea; Armstrong, Julie; Anderson, Annie S

2014-07-14

Frequent consumption of energy-dense foods has been strongly implicated in the global increase of obesity. The World Cancer Research Fund suggests a population-level energy density (ED) goal for diets of 523 kJ/100 g (125 kcal/100 g) as desirable for reducing weight gain and related co-morbidities. However, there is limited information about the ED of diets of contemporary populations. The aims of the present study were to (1) estimate the mean ED of the Scottish diet, (2) assess differences in ED over time by socio-economic position, by household (HH) composition and for HH meeting dietary targets for fat and fruit and vegetables, and (3) assess the relationship between ED and the consumption of foods and nutrients, which are indicative of diet quality. ED of the diet was estimated from food (including milk) from UK food purchase survey data. The average ED of the Scottish diet was estimated as 718 kJ/100 g with no change between the survey periods 2001 and 2009. Individuals living in the most deprived areas had a higher mean ED than those living in the least deprived areas (737 v. 696 kJ/100 g). Single-parent HH had the highest mean ED (765 kJ/100 g) of all the HH surveyed. The mean ED of HH achieving dietary targets for fat and fruit and vegetables was 576 kJ/100 g compared with 731 kJ/100 g for non-achievers. HH within the lowest quintile of ED were, on average, closest to meeting most dietary guidelines. Food purchase data can be used to monitor the quality of the diet in terms of dietary ED of the population and subgroups defined by an area-based measure of socio-economic status.

Promoting learning transfer in post registration education: a collaborative approach.

PubMed

Finn, Frances L; Fensom, Sue A; Chesser-Smyth, Patricia

2010-01-01

Pre-registration nurse education in Ireland became a four year undergraduate honors degree programme in 2002 (Government of Ireland, 2000. The Nursing Education Forum Report. Dublin, Dublin Stationary Office.). Consequently, the Irish Government invested significant resources in post registration nursing education in order to align certificate and diploma trained nurses with the qualification levels of new graduates. However, a general concern amongst academic and clinical staff in the South East of Ireland was that there was limited impact of this initiative on practice. These concerns were addressed through a collaborative approach to the development and implementation of a new part-time post registration degree that incorporated an enquiry and practice based learning philosophy. The principles of learning transfer (Ford, K., 1994. Defining transfer of learning the meaning is in the answers. Adult Learning 5 (4), p. 2214.) underpinned the curriculum development and implementation process with the goal of reducing the theory practice gap. This paper reports on all four stages of the curriculum development process: exploration, design, implementation and evaluation (Quinn, F.M., 2002. Principles and Practices of Nurse Education, fourth ed. Nelson Thornes, Cheltenham), and the subsequent impact of learning transfer on practice development. Eclectic approaches of quantitative and qualitative data collection techniques were utilised in the evaluation. The evaluation of this project to date supports our view that this practice based enquiry curriculum promotes the transfer of learning in the application of knowledge to practice, impacting both student and service development.

Effects of a co-financed interdisciplinary collaboration model in primary health care on service utilisation among patients with musculoskeletal disorders.

PubMed

Hultberg, Eva-Lisa; Lönnroth, Knut; Allebeck, Peter

2007-01-01

In 1994 Sweden introduced a trial legislation allowing co-financing between authorities. The legislation aimed to stimulate new ways of collaboration between health and social care providers. One of the specific objectives was to make management of patients with conditions requiring multidisciplinary care more efficient and reduce costs. This study aims to assess if there were any differences in management of patients with musculoskeletal disorders at health centres applying the trial legislation compared to health centre with conventional care with regards to health services utilisation, health care interventions received, and costs. A comparative prospective study was conducted. Consecutive patients aged 16-64 with musculoskeletal disorders attending the health care centres with (n=107) and without (n=31) co-financing model were interviewed at inclusion and after 6 and 12 months. Number of contacts with professionals and interventions received were registered. Patients at the intervention centres had significantly more contact with physiotherapists and physicians than the controls. Contacts with other services such as social insurance office, social services office or hospitals did not differ significantly between the groups. Costs were higher for the interventions centres. The findings do not suggest that the trial legislation reduced health care utilisation or costs for patients with musculoskeletal disorders.

The antinociceptive effect of intrathecal administration of epibatidine with clonidine or neostigmine in the formalin test in rats.

PubMed

Hama, A T; Lloyd, G K; Menzaghi, F

2001-03-01

The analgesic effect of intrathecal injection of epibatidine, clonidine and neostigmine, compounds that elevate ACh, was examined in the formalin test, a model of post-injury central sensitization in the rat. The compounds were injected alone and in combination. Intrathecal injection of epibatidine alone did not alter pain behaviors, compared to vehicle-treated rats. Intrathecal injection of clonidine dose-dependently reduced tonic pain behaviors (ED(50)+/-95% confidence limits=6.7+/-4.8 microg). The combination of clonidine and epibatidine (C:E), in the ratio of 26:1, dose-dependently reduced tonic pain behaviors; and the ED(50) of C:E was 1.1+/-0.98 microg a significant 6-fold leftward shift of the dose response curve, compared with clonidine alone. The antinociceptive effect of C:E (26:1) was attenuated by pre-treatment with the nAChR antagonist mecamylamine. Neostigmine dose-dependently reduced tonic pain behaviors (ED(50)=1.5+/-1.3 microg). The combination of neostigmine and epibatidine, in a ratio of 8:1, significantly shifted the dose response curve 4-fold to the left (ED(50)=0.4+/-0.3 microg). The effect is mediated in part by the activation of the nAChR and possibly by the enhanced release of ACh. These data demonstrate significant enhancement of the antinociceptive effects of spinally delivered analgesics by a nAChR agonist, suggesting that this class of compounds may have utility as adjuvants when combined with conventional therapeutics.

Patients' and caregivers' beliefs about depression screening and referral in the emergency department.

PubMed

Pailler, Megan E; Cronholm, Peter F; Barg, Frances K; Wintersteen, Matthew B; Diamond, Guy S; Fein, Joel A

2009-11-01

To explore patients' and parents'/caregivers' beliefs about the acceptability of universal depression screening in the emergency department (ED) and their perceptions of the barriers and facilitators to a mental health referral following a positive screen. We conducted semistructured interviews with 60 patients seeking care and 59 caregivers in the ED of an urban children's hospital. Interviews were audiotaped, transcribed, coded, and entered into N6 (version 6.0; QSR, Thousand Oaks, Calif) for coding and content analysis. Patients and caregivers supported the idea of depression screening in the ED, generally viewing screening as a reflection of care and concern. Respondents reported apprehension about stigma, privacy, and provider sensitivity. Introducing the screening concept early in the visit and as part of routine care was believed to reduce stigma. Respondents generally indicated that although they would likely follow through with a referral if given, stigma and denial were viewed as significant barriers. Caregivers also reported that logistical problems such as transportation, insurance, and agency hours created barriers to help seeking, but this could be offset by social supports and information about the agency and the provider. Patients and caregivers generally support depression screening in the pediatric ED but identified several barriers to screening and referral for treatment. Recommendations include introduction of universal screening early in the ED visit, provision of specific information about the meaning of screening results, and support from family and health care providers to help reduce stigma and increase referral acceptability.

Impact of automated dispensing cabinets on medication selection and preparation error rates in an emergency department: a prospective and direct observational before-and-after study.

PubMed

Fanning, Laura; Jones, Nick; Manias, Elizabeth

2016-04-01

The implementation of automated dispensing cabinets (ADCs) in healthcare facilities appears to be increasing, in particular within Australian hospital emergency departments (EDs). While the investment in ADCs is on the increase, no studies have specifically investigated the impacts of ADCs on medication selection and preparation error rates in EDs. Our aim was to assess the impact of ADCs on medication selection and preparation error rates in an ED of a tertiary teaching hospital. Pre intervention and post intervention study involving direct observations of nurses completing medication selection and preparation activities before and after the implementation of ADCs in the original and new emergency departments within a 377-bed tertiary teaching hospital in Australia. Medication selection and preparation error rates were calculated and compared between these two periods. Secondary end points included the impact on medication error type and severity. A total of 2087 medication selection and preparations were observed among 808 patients pre and post intervention. Implementation of ADCs in the new ED resulted in a 64.7% (1.96% versus 0.69%, respectively, P = 0.017) reduction in medication selection and preparation errors. All medication error types were reduced in the post intervention study period. There was an insignificant impact on medication error severity as all errors detected were categorised as minor. The implementation of ADCs could reduce medication selection and preparation errors and improve medication safety in an ED setting. © 2015 John Wiley & Sons, Ltd.

Medium-chain triglyceride-rich enteral nutrition is more effective than low-fat enteral nutrition in rat colitis, but is equal in enteritis.

PubMed

Tsujikawa, T; Ohta, N; Nakamura, T; Yasuoka, T; Satoh, J; Fukunaga, T; Itohi, A; Uda, K; Ihara, T; Andoh, A; Sasaki, M; Fujiyama, Y; Bamba, T

2001-10-01

Although enteral nutrition (EN) therapy for Crohn's disease has been confirmed to be as effective as steroid therapy, the precise mechanism responsible for the effects of EN remains unclear, although some of the therapeutic effects of EN are believed to be due to a low dietary fat content. In order to elucidate the influence of fat in EN, it is important to investigate not only the quantity of fat, but also the source of the fat. We compared two enteral nutritional formulae: Elental (Ajinomoto) (elemental diet; ED), which contains only 1.5% fat, provided as long-chain triglycerides (LCT), versus Twinline (Snow Brand Milk Products) (TL), which contains a high percentage of fat (20.4%), provided mainly as medium-chain triglycerides (MCT). These formulae were tested on rat enteritis and rat colitis induced by trinitrobenzene sulfonic acid (TNBS). Both ED and TL reduced the manifestations of enteritis. TL had a stronger anti-inflammatory effect than ED for colitis. TL also had nutritional advantages as compared with ED, as shown by the total serum protein in the TL group being significantly higher than that in the ED group. The results indicate that intraluminal MCT is suitable as a fat energy source during intestinal inflammation in rats. We suggest that Twinline may be more useful to improve nutritional status and to reduce the mucosal inflammation in rat colitis, but that Twinline is equal in effect to Elental for rat enteritis.

Diagnostic overshadowing and other challenges involved in the diagnostic process of patients with mental illness who present in emergency departments with physical symptoms--a qualitative study.

PubMed

Shefer, Guy; Henderson, Claire; Howard, Louise M; Murray, Joanna; Thornicroft, Graham

2014-01-01

We conducted a qualitative study in the Emergency Departments (EDs) of four hospitals in order to investigate the perceived scope and causes of 'diagnostic overshadowing'--the misattribution of physical symptoms to mental illness--and other challenges involved in the diagnostic process of people with mental illness who present in EDs with physical symptoms. Eighteen doctors and twenty-one nurses working in EDs and psychiatric liaisons teams in four general hospitals in the UK were interviewed. Interviewees were asked about cases in which mental illness interfered with diagnosis of physical problems and about other aspects of the diagnostic process. Interviews were transcribed and analysed thematically. Interviewees reported various scenarios in which mental illness or factors related to it led to misdiagnosis or delayed treatment with various degrees of seriousness. Direct factors which may lead to misattribution in this regard are complex presentations or aspects related to poor communication or challenging behaviour of the patient. Background factors are the crowded nature of the ED environment, time pressures and targets and stigmatising attitudes held by a minority of staff. The existence of psychiatric liaison team covering the ED twenty-four hours a day, seven days a week, can help reduce the risk of misdiagnosis of people with mental illness who present with physical symptoms. However, procedures used by emergency and psychiatric liaison staff require fuller operationalization to reduce disagreement over where responsibilities lie.

New to Care: Demands on a Health System When Homeless Veterans Are Enrolled in a Medical Home Model

PubMed Central

Bourgault, Claire; Johnson, Erin E.; Redihan, Stephen G.; Borgia, Matthew; Aiello, Riccardo; Kane, Vincent

2013-01-01

Objectives. We compared service use among homeless and nonhomeless veterans newly enrolled in a medical home model and identified patterns of use among homeless veterans associated with reductions in emergency department (ED) use. Methods. We used case–control matching with a nested cohort analysis to measure 6-month health services use, new diagnoses, and care use patterns in veterans at the Providence, Rhode Island, Veterans Affairs Medical Center from 2008 to 2011. Results. We followed 127 homeless and 106 nonhomeless veterans. Both groups had similar rates of chronic medical and mental health diagnoses; 25.4% of the homeless and 18.1% of the nonhomeless group reported active substance abuse. Homeless veterans used significantly more primary, mental health, substance abuse, and ED care during the first 6 months. Homeless veterans who accessed primary care at higher rates (relative risk ratio [RRR] = 1.46; 95% confidence interval [CI] = 1.11, 1.92) or who used specialty and primary care (RRR = 10.95; 95% CI = 1.58, 75.78) had reduced ED usage. Homeless veterans in transitional housing or doubled-up at baseline (RRR = 3.41; 95% CI = 1.24, 9.42) had similar reductions in ED usage. Conclusions. Homeless adults had substantial health needs when presenting for care. High-intensity primary care and access to specialty care services could reduce ED use. PMID:24148042

Broad application and optimization of a single wash-step for integrated endotoxin depletion during protein purification.

PubMed

Koziel, David; Michaelis, Uwe; Kruse, Tobias

2018-08-01

Endotoxins contaminate proteins that are produced in E. coli. High levels of endotoxins can influence cellular assays and cause severe adverse effects when administered to humans. Thus, endotoxin removal is important in protein purification for academic research and in GMP manufacturing of biopharmaceuticals. Several methods exist to remove endotoxin, but often require additional downstream-processing steps, decrease protein yield and are costly. These disadvantages can be avoided by using an integrated endotoxin depletion (iED) wash-step that utilizes Triton X-114 (TX114). In this paper, we show that the iED wash-step is broadly applicable in most commonly used chromatographies: it reduces endotoxin by a factor of 10 3 to 10 6 during NiNTA-, MBP-, SAC-, GST-, Protein A and CEX-chromatography but not during AEX or HIC-chromatography. We characterized the iED wash-step using Design of Experiments (DoE) and identified optimal experimental conditions for application scenarios that are relevant to academic research or industrial GMP manufacturing. A single iED wash-step with 0.75% (v/v) TX114 added to the feed and wash buffer can reduce endotoxin levels to below 2 EU/ml or deplete most endotoxin while keeping the manufacturing costs as low as possible. The comprehensive characterization enables academia and industry to widely adopt the iED wash-step for a routine, efficient and cost-effective depletion of endotoxin during protein purification at any scale. Copyright © 2018. Published by Elsevier B.V.

Manipulation of dietary methionine+cysteine and threonine in broilers significantly decreases environmental nitrogen excretion.

PubMed

Donato, D C Z; Sakomura, N K; Silva, E P; Troni, A R; Vargas, L; Guagnoni, M A N; Meda, B

2016-06-01

The intensification of livestock have increased the emission of pollutants to the environment, leading to a growing interest in seeking strategies that minimise these emissions. Studies have shown that it is possible to manipulate diets by reducing CP levels and thus reducing nitrogen (N) excretion, without compromising performance. However, there is no knowledge of any study that has focused on reducing N excretion and relating this reduction to individual amino acids. This study investigated the effect of dietary methionine+cysteine (MC) and threonine (THR), the two most limiting amino acids for broiler production, on nitrogen excretion (NE) and nitrogen deposition (ND) and determined the efficiency of utilisation of both amino acids for protein deposition. Six trials were conducted to measure the NE and ND in broiler chickens during three rearing phases in response to dietary amino acid. The efficiency of utilisation of the amino acids was calculated by linear regression of body protein deposition and the amino acid intake. Despite the differences between sexes and phases, the efficiency of utilisation was the same, being 0.60 and 0.59 for MC and THR, respectively. The rate of NE behaved exponentially, increasing with amino acid intake, and can exceed 50% of N intake, being higher than ND. On average, for a reduction in intake of each unit of MC or THR (mg) there is a reduction of 0.5% of NE. Although this reduction seems low, considering that it corresponds to changes in one amino acid only, the impact on a large scale would be significant. Knowledge of how animals respond to NE and ND/protein deposition according to amino acid dietary content may represent new efforts towards reducing the impact on environment.

Emergency department transfers and hospital admissions from residential aged care facilities: a controlled pre-post design study.

PubMed

Hullick, Carolyn; Conway, Jane; Higgins, Isabel; Hewitt, Jacqueline; Dilworth, Sophie; Holliday, Elizabeth; Attia, John

2016-05-12

Older people living in Residential Aged Care Facilities (RACF) are a vulnerable, frail and complex population. They are more likely than people who reside in the community to become acutely unwell, present to the Emergency Department (ED) and require admission to hospital. For many, hospitalisation carries with it risks. Importantly, evidence suggests that some admissions are avoidable. A new collaborative model of care, the Aged Care Emergency Service (ACE), was developed to provide clinical support to nurses in the RACFs, allowing residents to be managed in place and avoid transfer to the ED. This paper examines the effects of the ACE service on RACF residents' transfer to hospital using a controlled pre-post design. Four intervention RACFs were matched with eight control RACFs based on number of total beds, dementia specific beds, and ratio of high to low care beds in Newcastle, Australia, between March and November 2011. The intervention consisted of a clinical care manual to support care along with a nurse led telephone triage line, education, establishing goals of care prior to ED transfer, case management when in the ED, along with the development of collaborative relationships between stakeholders. Outcomes included ED presentations, length of stay, hospital admission and 28-day readmission pre- and post-intervention. Generalised estimating equations were used to estimate mean differences in outcomes between intervention and controls RACFs, pre- and post-intervention means, and their interaction, accounting for repeated measures and adjusting for matching factors. Residents had a mean age of 86 years. ED presentations ranged between 16 and 211 visits/100 RACF beds/year across all RACFs. There was no overall reduction in ED presentations (OR = 1.17, p = 0.56) with the ACE intervention. However, when compared to the controls, the intervention group reduced their ED length of stay by 45 min (p = 0.0575), and was 40 % less likely to be admitted to hospital, . The latter was highly significant (p = 0.0012). Transfers to ED and admission to hospital are common for residents of RACFs. This study has demonstrated that a complex multi-strategy intervention led by nursing staff can successfully reduce hospital admissions for older people living in Residential Aged Care Facilities. By defining goals of care prior to transfer to the ED, clinicians have the opportunity to better deliver care that patients require. Integrated care requires accountability from multiple stakeholders. The Australian New Zealand Clinical Trials Registration number is ACTRN12616000588493 It was registered on 6(th) May 2016.

A systematic review of management strategies for children's mental health care in the emergency department: update on evidence and recommendations for clinical practice and research.

PubMed

Newton, Amanda S; Hartling, Lisa; Soleimani, Amir; Kirkland, Scott; Dyson, Michele P; Cappelli, Mario

2017-06-01

Children with mental health crises require access to specialised resources and services which are not yet standard in general and paediatric EDs. In 2010, we published a systematic review that provided some evidence to support the use of specialised care models to reduce hospitalisation, return ED visits and length of ED stay. We perform a systematic review to update the evidence base and inform current policy statements. Twelve databases and the grey literature were searched up to January 2015. Seven studies were included in the review (four newly identified studies). These studies compared ED-based strategies designed to assess, treat and/or therapeutically support or manage a mental health presentation. The methodological quality of six studies was assessed using the Cochrane Effective Practice and Organization of Care Risk of Bias tool (one interrupted time series study) and a modified Newcastle-Ottawa Scale (three retrospective cohort and two before-after studies). The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was applied to rate overall evidence quality (high, moderate, low or very low) for individual outcomes from these six studies. An additional study evaluated the psychometric properties of a clinical instrument and was assessed using criteria developed by the Society of Pediatric Psychology Assessment Task Force (well-established, approaching well-established or promising assessment). There is low to very low overall evidence quality that: (1) use of screening laboratory tests to medically clear mental health patients increases length of ED stay and costs, but does not increase the risk of clinical management or disposition change if not conducted; and (2) specialised models of ED care reduce lengths of ED stay, security man-hours and restraint orders. One mental health assessment tool of promising quality, the home, education, activities and peers, drugs and alcohol, suicidality, emotions and behaviour, discharge resources (HEADS-ED), has had good accuracy in predicting admission to inpatient psychiatry. Lower-quality data suggest benefits to the use of specialised resources and services for paediatric mental health care in general and paediatric EDs. Experimental evaluation of strategies and the inclusion of patient-reported outcomes will improve confidence in these findings. Additional psychometric studies are needed for the HEADS-ED tool to be considered well established. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Drug safety and the impact of drug warnings: An interrupted time series analysis of diabetes drug prescriptions in Germany and Denmark.

PubMed

Hostenkamp, Gisela; Fischer, Katharina Elisabeth; Borch-Johnsen, Knut

2016-12-01

To analyse the impact of drug safety warnings from the European Medicines Agency (EMA) on drug utilisation and their interaction with information released through national reimbursement bodies. Insurance claims data on anti-diabetic drug prescriptions in primary care in Germany and Denmark were analysed using interrupted time series analysis, with EMA drug warnings for thiazolidinediones (TZDs) in 2007 and 2011 as the intervention. Monthly drug utilisation data per substance in defined daily dosages (DDD) consumed per 1000 insurees were retrieved from the Danish national drug prescriptions register and one large statutory sickness fund in Germany. TZDs were generally reimbursed in Germany but restricted to individual reimbursement in Denmark. Consequently, utilisation of TZDs was much higher in Germany in 2007 compared with Denmark. For rosiglitazone, the drug warning had a significant impact on utilisation, reducing the number of DDD per 1000 insurees per day by -0.0105 in Denmark and -0.0312 in Germany (p-values<0.05). For pioglitazone, neither of the drug warnings had a significant effect on utilisation. The impact of EMA drug warnings differed across countries and might be mediated by information released through national reimbursement bodies and physician associations. Increasing complexity of new drugs and modified approval procedures require a strengthening of information exchange between drug regulation bodies and physicians to ensure patient safety. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Shifting chronic disease management from hospitals to primary care in Estonian health system: analysis of national panel data.

PubMed

Atun, Rifat; Gurol-Urganci, Ipek; Hone, Thomas; Pell, Lisa; Stokes, Jonathan; Habicht, Triin; Lukka, Kaija; Raaper, Elin; Habicht, Jarno

2016-12-01

Following independence from the Soviet Union in 1991, Estonia introduced a national insurance system, consolidated the number of health care providers, and introduced family medicine centred primary health care (PHC) to strengthen the health system. Using routinely collected health billing records for 2005-2012, we examine health system utilisation for seven ambulatory care sensitive conditions (ACSCs) (asthma, chronic obstructive pulmonary disease [COPD], depression, Type 2 diabetes, heart failure, hypertension, and ischemic heart disease [IHD]), and by patient characteristics (gender, age, and number of co-morbidities). The data set contained 552 822 individuals. We use patient level data to test the significance of trends, and employ multivariate regression analysis to evaluate the probability of inpatient admission while controlling for patient characteristics, health system supply-side variables, and PHC use. Over the study period, utilisation of PHC increased, whilst inpatient admissions fell. Service mix in PHC changed with increases in phone, email, nurse, and follow-up (vs initial) consultations. Healthcare utilisation for diabetes, depression, IHD and hypertension shifted to PHC, whilst for COPD, heart failure and asthma utilisation in outpatient and inpatient settings increased. Multivariate regression indicates higher probability of inpatient admission for males, older patient and especially those with multimorbidity, but protective effect for PHC, with significantly lower hospital admission for those utilising PHC services. Our findings suggest health system reforms in Estonia have influenced the shift of ACSCs from secondary to primary care, with PHC having a protective effect in reducing hospital admissions.

Association of emergency department albuterol dispensing with pediatric asthma revisits and readmissions.

PubMed

Hall, A Brad; Novotny, April; Bhisitkul, Donna M; Melton, James; Regan, Tim; Leckie, Maureen

2017-06-01

Although pediatric asthma continues to be a highly studied disease, data to suggest clear strategies to decrease asthma related revisits or readmissions is lacking. The purpose of our study was to assess the effect of emergency department (ED) direct dispensing of beta-agonist metered dose inhalers on pediatric asthma ED revisit and readmission rates. We conducted a retrospective cohort study of pediatric patients discharged from the pediatric ED with a diagnosis of asthma. Our primary outcome measured the rate of asthma revisits to the ED or admissions to the hospital within 28 days. Logistic regression analysis was used to assess ED beta-agonist MDI dispensing and revisit and/or readmission as the outcome. A total of 853 patients met eligibility for inclusion in the study, with 657 enrolled in the Baseline group and 196 enrolled in the ED-MDI group. The Baseline group experienced a revisit and readmission rate of 7.0% (46/657) versus 2.6% (5/196) in the ED-MDI group, (p = 0.026). ED direct dispensing of MDIs was found to be independently associated with a decreased risk of revisit or readmission (odds ratio 0.37; 95% confidence interval 0.14-0.95). In our study, ED direct dispensing of beta-agonist MDIs resulted in a reduction in 28-day revisit and readmission to the hospital. Further studies should be performed to evaluate the economic impact of reducing these revisits and readmissions against the costs of maintaining a dispensing program. Our findings may support modification of asthma programs to include dispensing MDIs from the emergency department.

Construction and evaluation of a self rating scale for stress-induced Exhaustion Disorder, the Karolinska Exhaustion Disorder Scale

PubMed Central

Besèr, Aniella; Sorjonen, Kimmo; Wahlberg, Kristina; Peterson, Ulla; Nygren, Åke; Åsberg, Marie

2014-01-01

Prolonged stress (≥ six months) may cause a condition which has been named exhaustion disorder (ED) with ICD-10 code F43.8. ED is characterised by exhaustion, cognitive problems, poor sleep and reduced tolerance to further stress. ED can cause long term disability and depressive symptoms may develop. The aim was to construct and evaluate a self-rating scale, the Karolinska Exhaustion Disorder Scale (KEDS), for the assessment of ED symptoms. A second aim was to examine the relationship between self-rated symptoms of ED, depression, and anxiety using KEDS and the Hospital Anxiety and Depression Scale (HAD). Items were selected based on their correspondence to criteria for ED as formulated by the Swedish National Board of Health and Welfare (NBHW), with seven response alternatives in a Likert-format. Self-ratings performed by 317 clinically assessed participants were used to analyse the scale’s psychometric properties. KEDS consists of nine items with a scale range of 0–54. Receiver operating characteristics analysis demonstrated that a cut-off score of 19 was accompanied by high sensitivity and specificity (each above 95%) in the discrimination between healthy subjects and patients with ED. Reliability was satisfactory and confirmatory factor analysis revealed that ED, depression and anxiety are best regarded as different phenomena. KEDS may be a useful tool in the assessment of symptoms of Exhaustion Disorder in clinical as well as research settings. There is evidence that the symptom clusters of ED, anxiety and depression, respectively, reflect three different underlying dimensions. PMID:24236500

Missed diagnoses of acute myocardial infarction in the emergency department: variation by patient and facility characteristics.

PubMed

Moy, Ernest; Barrett, Marguerite; Coffey, Rosanna; Hines, Anika L; Newman-Toker, David E

2015-02-01

An estimated 1.2 million people in the US have an acute myocardial infarction (AMI) each year. An estimated 7% of AMI hospitalizations result in death. Most patients experiencing acute coronary symptoms, such as unstable angina, visit an emergency department (ED). Some patients hospitalized with AMI after a treat-and-release ED visit likely represent missed opportunities for correct diagnosis and treatment. The purpose of the present study is to estimate the frequency of missed AMI or its precursors in the ED by examining use of EDs prior to hospitalization for AMI. We estimated the rate of probable missed diagnoses in EDs in the week before hospitalization for AMI and examined associated factors. We used Healthcare Cost and Utilization Project State Inpatient Databases and State Emergency Department Databases for 2007 to evaluate missed diagnoses in 111,973 admitted patients aged 18 years and older. We identified missed diagnoses in the ED for 993 of 112,000 patients (0.9% of all AMI admissions). These patients had visited an ED with chest pain or cardiac conditions, were released, and were subsequently admitted for AMI within 7 days. Higher odds of having missed diagnoses were associated with being younger and of Black race. Hospital teaching status, availability of cardiac catheterization, high ED admission rates, high inpatient occupancy rates, and urban location were associated with lower odds of missed diagnoses. Administrative data provide robust information that may help EDs identify populations at risk of experiencing a missed diagnosis, address disparities, and reduce diagnostic errors.

Brain regions implicated in inhibitory control and appetite regulation are activated in response to food portion size and energy density in children.

PubMed

English, L K; Fearnbach, S N; Lasschuijt, M; Schlegel, A; Anderson, K; Harris, S; Wilson, S J; Fisher, J O; Savage, J S; Rolls, B J; Keller, K L

2016-10-01

Large portions of energy-dense foods drive energy intake but the brain mechanisms underlying this effect are not clear. Our main objective was to investigate brain function in response to food images varied by portion size (PS) and energy density (ED) in children using functional magnetic resonance imaging (fMRI). Blood-oxygen-level-dependent (BOLD) fMRI was completed in 36 children (ages 7-10 years) after a 2-h fast while viewing food images at two levels of PS (Large PS, Small PS) and two levels of ED (High ED, Low ED). Children rated perceived fullness pre- and post-fMRI, as well as liking of images on visual analog scales post-fMRI. Anthropometrics were completed 4 weeks before the fMRI. Large PS vs Small PS and High ED vs Low ED were compared with region-of-interest analyses using Brain Voyager v 2.8. Region-of-interest analyses revealed that activation in the right inferior frontal gyrus (P=0.03) was greater for Large PS vs Small PS. Activation was reduced for High ED vs Low ED in the left hypothalamus (P=0.03). Main effects were no longer significant after adjustment for pre-fMRI fullness and liking ratings (PS, P=0.92; ED, P=0.58). This is the first fMRI study to report increased activation to large portions in a brain region that is involved in inhibitory control. These findings may contribute to understanding why some children overeat when presented with large portions of palatable food.

Neuroprotective and Nerve Regenerative Approaches for Treatment of Erectile Dysfunction after Cavernous Nerve Injury

PubMed Central

Campbell, Jeffrey D.; Burnett, Arthur L.

2017-01-01

Erectile dysfunction (ED) is a significant cause of reduced quality of life in men and their partners. Cavernous nerve injury (CNI) during pelvic surgery results in ED in greater than 50% of patients, regardless of additional patient factors. ED related to CNI is difficult to treat and typically poorly responsive to first- and second-line therapeutic options. Recently, a significant amount of research has been devoted to exploring neuroprotective and neuroregenerative approaches to salvage erectile function in patients with CNI. In addition, therapeutic options such as neuregulins, immunophilin ligands, gene therapy, stem cell therapy and novel surgical strategies, have shown benefit in pre-clinical, and limited clinical studies. In the era of personalized medicine, these new therapeutic technologies will be the future of ED treatment and are described in this review. PMID:28820434

Living on the edge of asthma: A grounded theory exploration.

PubMed

Shaw, Michele R; Oneal, Gail

2014-10-01

Most asthma-related emergency department (ED) visits and hospitalizations for asthma are preventable. Our purpose was to develop a grounded theory to guide interventions to reduce unnecessary hospitalizations and ED visits. Grounded theory inquiry guided interviews of 20 participants, including 13 parents and 7 children. Living on the edge of asthma was the emergent theory. Categories included: balancing, losing control, seeking control, and transforming. The theory provides the means for nurses to understand the dynamic process that families undergo in trying to prevent and then deal with and learn from an acute asthma attack requiring hospitalization or an ED visit. © 2014, Wiley Periodicals, Inc.

Altered Reward Reactivity as a Behavioural Endophenotype in Eating Disorders: A Pilot Investigation in Twins.

PubMed

Kanakam, Natalie; Krug, Isabel; Collier, David; Treasure, Janet

2017-05-01

Altered reward reactivity is a potential risk endophenotype for eating disorders (EDs). The aim of this study was to examine reward reactivity in female twins with EDs and compare it with a twin control group. A sample of 112 twins [n = 51 met lifetime DSM-IV ED criteria (anorexia nervosa n = 26; bulimic disorders n = 24), n = 19 unaffected cotwins and n = 42 control twins] was administered measures assessing reward reactivity, including the Game of Dice Task, the Behavioural Inhibition/Activation (BIS/BAS) Scales and the Appetitive Motivation Scale (AMS). Within pair, correlations for monozygotic and dizygotic twins were calculated and generalised estimating equations compared probands with non-ED cotwins and controls. The BAS and the AMS were reduced in EDs and negatively associated with restrictive symptoms. In addition, monozygotic twins pairs demonstrated significant within pair similarity for the BAS and AMS. Conversely, there was less evidence to support the BIS or risky decision-making as measured by the Game of Dice Task as an endophenotype in EDs. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Desalination of fish sauce by electrodialysis: effect on selected aroma compounds and amino acid compositions.

PubMed

Chindapan, Nathamol; Devahastin, Sakamon; Chiewchan, Naphaporn; Sablani, Shyam S

2011-09-01

Fish sauce is an ingredient that exhibits unique flavor and is widely used by people in Southeast Asia. Fish sauce, however, contains a significant amount of salt (sodium chloride). Recently, electrodialysis (ED) has been successfully applied to reduce salt in fish sauce; however, no information is available on the effect of ED on changes in compounds providing aroma and taste of ED-treated fish sauce. The selected aroma compounds, amino acids, and sensory quality of the ED-treated fish sauce with various salt concentrations were then analyzed. The amounts of trimethylamine, 2,6-dimethylpyrazine, phenols, and all carboxylic acids except for hexanoic acid significantly decreased, whereas benzaldehyde increased significantly when the salt removal level was higher. The amounts of all amino acids decreased with the increased salt removal level. Significant difference in flavor and saltiness intensity among ED-treated fish sauce with various salt concentrations, as assessed by a discriminative test, were observed. Information obtained in this work can serve as a guideline for optimization of a process to produce low-sodium fish sauce by ED. It also forms a basis for further in-depth sensory analysis of low-sodium fish sauce. © 2011 Institute of Food Technologists®

Impacts on Emergency Department Visits from Personal Responsibility Provisions: Evidence from West Virginia's Medicaid Redesign.

PubMed

Gurley-Calvez, Tami; Kenney, Genevieve M; Simon, Kosali I; Wissoker, Douglas

2016-08-01

To examine the impact of a 2007 redesign of West Virginia's Medicaid program, which included an incentive and "nudging" scheme intended to encourage better health care behaviors and reduce Emergency Department (ED) visits. West Virginia Medicaid enrollment and claims data from 2005 to 2010. We utilized a "differences in differences" technique with individual and time fixed effects to assess the impact of redesign on ED visits. Starting in 2007, categorically eligible Medicaid beneficiaries were moved from traditional Medicaid to the new Mountain Health Choices (MHC) Program on a rolling basis, approximating a natural experiment. Members chose between a Basic plan, which was less generous than traditional Medicaid, or an Enhanced plan, which was more generous but required additional enrollment steps. Data were obtained from the West Virginia Bureau for Medical Services. We found that contrary to intentions, the MHC program increased ED visits. Those who selected or defaulted into the Basic plan experienced increased overall and preventable ED visits, while those who selected the Enhanced plan experienced a slight reduction in preventable ED visits; the net effect was an increase in ED visits, as most individuals enrolled in the Basic plan. © Health Research and Educational Trust.

The effects of muscle hypotonia and weakness on balance: a study on Prader-Willi and Ehlers-Danlos syndrome patients.

PubMed

Galli, Manuela; Cimolin, Veronica; Vismara, Luca; Grugni, Graziano; Camerota, Filippo; Celletti, Claudia; Albertini, Giorgio; Rigoldi, Chiara; Capodaglio, Paolo

2011-01-01

Prader-Willi syndrome (PWS) and Ehlers-Danlos syndrome (EDS) are two different genetical disorders both characterized, among other features, by muscular hypotonia. Postural control seems to be impaired in both conditions. The aim of the present study was to quantitatively compare postural control in adult PWS and EDS using stabilometric platform to unveil possible common determinants of impaired balance. We enrolled 11 PWS and 21 EDS adult patients and 20 age-matched controls. They were instructed to maintain an upright standing position for 30s with open eyes (OEs) focusing on a 6 cm black circle positioned at a distance of 1.5m. Both PWS and EDS patients were characterized by higher RANGEML, RANGEAP and trajectory length of CoP values as compared to CG. No statistically differences were found between PWS and EDS in terms of any of these parameters. The results demonstrated that both PWS and EDS are characterized by a severe postural instability. Muscle hypotonia and weakness may account for reduced balance capacity. Quantitative characterization of instability is important to identify, develop and enhance rehabilitation interventions. Copyright © 2011 Elsevier Ltd. All rights reserved.

Recommended next care following hospital-treated self-harm: Patterns and trends over time

PubMed Central

Arensman, Ella; Griffin, Eve; Daly, Caroline; Corcoran, Paul; Cassidy, Eugene; Perry, Ivan J.

2018-01-01

Objective The specific objectives of this study were to examine variation in the care of self-harm patients in hospital settings and to identify the factors that predict recommended next care following self-harm. Methods Data on consecutive presentations to Irish emergency departments (EDs) involving self-harm from the National Self-Harm Registry Ireland from 2004 to 2012 were utilised. Univariate and multivariate regression analyses were performed to assess the associations between patients’ clinical and demographic characteristics, and recommended next care received. Results Across the study period a total 101,904 self-harm presentations were made to hospital EDs, involving 63,457 individuals. Over the course of the study there was a declining number of presentations resulting in patient admission following attendance with self-harm. Recommended next care varied according to hospital location, with general admission rates ranging from 11% to 61% across administrative health regions. Multinomial logistic regression identified that the factor which most strongly affected next care was the presenting hospital. Being male, older age, method, repeat self-harm, time of attendance and residence of the patient were all identified as influencing care received. Psychiatric admission was most common when highly lethal methods of self-harm were used (OR = 4.00, 95% CI, 3.63–4.41). A relatively large proportion of patients left the ED without being seen (15%) and the risk of doing so was highest for self-harm repeaters (1.64, 1.55–1.74 for those with 5+ presentations). Conclusions The extensive hospital variation in recommended next care indicates that management of self-harm patients may be determined more by where they present than by the needs of the patient. The study outcomes underline the need to standardise the clinical management of self-harm patients in general hospital settings. PMID:29494659

Difference in causes and prognostic factors of early death between cohorts with de novo and relapsed acute promyelocytic leukemia.

PubMed

Zhao, Hongli; Zhao, Yanqiu; Zhang, Yingmei; Hou, Jinxiao; Yang, Huiyuan; Cao, Fenglin; Yang, Yiju; Hou, Wenyi; Sun, Jiayue; Jin, Bo; Fu, Jinyue; Li, Haitao; Wang, Ping; Ge, Fei; Zhou, Jin

2018-03-01

Early death (ED) remains the most critical issue in the current care of patients with acute promyelocytic leukemia (APL). Very limited data are available regarding ED in patients with relapsed APL. In this retrospective study, 285 de novo and 79 relapsed patients were included. All patients received single-agent arsenic trioxide as induction therapy. The differences in baseline clinical features, incidence, causes, and prognostic factors of ED were compared between the two patient cohorts. The relapse cohort exhibited a better overall condition than the de novo cohort upon hospital admission. The ED rate in the relapsed patients (24.1%) was somewhat higher than that in the de novo patients (17.9%), although the difference was not significant (P = 0.219). For both cohorts, hemorrhage was the main cause of ED, followed by differentiation syndrome, infection, and other causes. Increased serum creatinine level, older age, male sex, white blood cell (WBC) count > 10 × 10 9 /L, and fibrinogen < 1 g/L were independently risk factors for ED in the de novo patients, whereas WBC count > 10 × 10 9 /L, elevated serum uric acid level, and D-dimer > 4 mg/L were independent risk factors for ED in the relapsed patients. These data furnish clinically relevant information that might be useful for designing more appropriate risk-adapted treatment protocols aimed at reducing ED rate in patients with relapsed APL.

Development of guidelines for giving community presentations about eating disorders: a Delphi study.

PubMed

Doley, Joanna Rachel; Hart, Laura Merilyn; Stukas, Arthur Anthony; Morgan, Amy Joanna; Rowlands, Danielle Lisa; Paxton, Susan Jessica

2017-01-01

Concerns exist around how to talk about eating disorders (EDs) due to evidence that suggests discussing ED symptoms and behaviours may cause or worsen symptoms in vulnerable people. Using expert consensus, we developed a set of guidelines for giving safe community presentations about EDs. Participants with professional ED expertise, and people with lived experience of an ED, were recruited for a Delphi study. N  = 26 panel members rated 367 statements for both a) inclusion in guidelines, and b) their potential to be helpful (increase knowledge, reduce stigma) or harmful (increase stigma, cause/worsen ED symptoms). After each round of the study, statements were classified as endorsed, re-rate, or not endorsed. 208 statements were endorsed by the panel over three rounds. 13 statements were strongly endorsed in the first round, with both people with lived experience and professionals agreeing it is important for presentations to include information on etiology of EDs and to promote help-seeking. Several statements had a high level of disagreement between those with lived experience and professionals, including the idea that presentations should suggest dieting is likely to result in weight gain. The experts were able to develop consensus on a wide range of issues. Panel members, particularly people with lived experience, were sensitive to aspects of presentations that may be harmful to an audience. The guidelines fill an important gap in the literature and provide guidance to those educating the public about EDs; they should, however, be further evaluated to test their efficacy.

Effect of biliary drainage on inducible nitric oxide synthase, CD14 and TGR5 expression in obstructive jaundice rats

PubMed Central

Wang, Zi-Kai; Xiao, Jian-Guo; Huang, Xue-Fei; Gong, Yi-Chun; Li, Wen

2013-01-01

AIM: To investigate the effect of biliary drainage on inducible nitric oxide synthase (iNOS), CD14 and TGR5 expression in rats with obstructive jaundice (OJ). METHODS: Male adult Sprague-Dawley rats were randomly assigned to four groups: OJ, sham operation (SH), internal biliary drainage (ID) and external biliary drainage (ED). Rat models were successfully established by two operations and succumbed for extraction of Kupffer cells (KCs) and liver tissue collection on the 8th and 15th day. KCs were isolated by in situ hepatic perfusion and digested with collagen IV, density gradient centrifuged by percoll reagent and purified by cell culture attachment. The isolated KCs were cultured with the endotoxin lipopolysaccharide (LPS) with and without the addition of ursodeoxycholic acid (UDCA). The expression of iNOS, CD14 and bile acid receptor-TGR5 protein in rat liver tissues was determined by immunohistochemistry. The expression of iNOS and CD14 messenger RNA (mRNA) on the isolated KCs was detected by reverse transcription polymerase chain reaction (PCR) and the TGR5 mRNA level in KCs was measured by real-time quantitative PCR. RESULTS: The iNOS protein was markedly expressed in the liver of OJ rats, but rare expressed in SH rats. After relief of OJ, the iNOS expression was decidedly suppressed in the ID group (ID vs OJ, P < 0.01), but obviously increased in rats of ED (ED vs OJ, P = 0.004). When interfered only with LPS, the expression of iNOS mRNA by KCs was increased in the OJ group compared with the SH group (P = 0.004). After relief of biliary obstruction, the iNOS mRNA expression showed slight changes in the ED group (ED vs OJ, P = 0.71), but dropped in the ID group (ID vs OJ, P = 0.001). Compared with the simple intervention with LPS, the expressions of iNOS mRNA were significantly inhibited in all four groups after interfered with both LPS and UDCA (P < 0.01, respectively). After bile duct ligation, the CD14 protein expression in rat liver was significantly strengthened (OJ vs SH, P < 0.01), but the CD14 mRNA level by KCs was not up-regulated (OJ vs SH, P = 0.822). After relieving the OJ, the expression of CD14 protein was reduced in the ID group (ID vs OJ, P < 0.01), but not reduced in ED group (ED vs OJ, P = 0.591). And then the CD14 mRNA expression was aggravated by ED (ED vs OJ, P < 0.01), but was not significantly different between the ID group and the SH and OJ groups (ID vs SH, P = 0.944; ID vs OJ, P = 0.513, respectively). The expression of TGR5 protein and mRNA increased significantly in OJ rats (OJ vs SH, P = 0.001, respectively). After relief of OJ, ID could reduce the expression of TGR5 protein and mRNA to the levels of SH group (ID vs SH, P = 0.22 and P = 0.354, respectively), but ED could not (ED vs SH, P = 0.001, respectively). CONCLUSION: ID could be attributed to the regulatory function of activation of KCs and release of inflammatory mediators. PMID:23613625

Presence of a Community Health Center and Uninsured Emergency Department Visit Rates in Rural Counties

PubMed Central

Rust, George; Baltrus, Peter; Ye, Jiali; Daniels, Elvan; Quarshie, Alexander; Boumbulian, Paul; Strothers, Harry

2009-01-01

CONTEXT Community health centers (CHCs) provide essential access to a primary care medical home for the uninsured, especially in rural communities with no other primary care safety net. CHCs could potentially reduce uninsured emergency department (ED) visits in rural communities. PURPOSE We compared uninsured ED visit rates between rural counties in Georgia which have a community health center clinic site vs. counties without a CHC presence. METHODS We analyzed data from 100% of ED visits occurring in 117 rural (non-metropolitan statistical area [MSA]) counties in Georgia from 2003-2005. Counties were classified as having a CHC presence if a federally funded (Section 330) community health center had a primary care delivery site in that county throughout the study period. The main outcome measure was uninsured ED visit rates among the uninsured (all-cause ED visits and visits for ambulatory care sensitive conditions). Poisson regression models were used to examine the relationship between ED rates and presence of a CHC. To assure that the effects were unique to the uninsured population, we ran similar analyses on insured ED visits. FINDINGS Counties without a community health center primary care clinic site had 33% higher rates of uninsured all-cause ED visits per 10,000 uninsured population compared with non-CHC counties (rate ratio=1.33, 95% CI=1.11-1.59). Higher ED visit rates remained significant (RR=1.21, 95% CI=1.02-1.42) after adjustment for percent of population below poverty level, percent black, and number of hospitals. Uninsured ED visit rates were also higher for various categories of diagnoses, but remained statistically significant on multivariate analysis only for ambulatory care sensitive conditions (adjusted RR=1.22, 95% CI=1.01-1.47). No such relationship was found for ED visit rates of insured patients (RR=1.06, 95% CI=0.92-1.22). CONCLUSIONS Absence of a community health center is associated with a substantial excess in uninsured ED visits in rural counties, an excess not seen for ED visit rates among the insured. PMID:19166556

Geographic clustering of emergency department presentations for atrial fibrillation and flutter in Alberta, Canada.

PubMed

Rosychuk, Rhonda J; Mariathas, Hensley H; Graham, Michelle M; Holroyd, Brian R; Rowe, Brian H

2015-08-01

Atrial fibrillation and flutter (AFF) are the most common arrhythmias seen in the outpatient setting, and they affect more than 300,000 adult Canadians. The aims of this study were to examine temporal and geographic trends in emergency department (ED) presentations made by adults (age ≥ 35 years) for AFF in Alberta, Canada, from 1999 to 2011. Statistical disease cluster detection techniques were used to identify geographic areas with higher numbers of individuals presenting with AFF and higher numbers of ED presentations for AFF than expected by chance alone. Geographic clusters of individuals with stroke or heart failure follow-up within 365 days of ED presentations for AFF were also identified. All ED presentations for AFF made by individuals aged ≥35 years were extracted from Alberta's Ambulatory Care Classification System. The Alberta Health Care Insurance Plan provided population counts and demographics for the patients presenting (age, sex, year, geographic unit). The Physician Claims File provided non-ED physician claims data after a patient's ED presentation. Statistical analyses included numerical and graphical summaries, directly standardized rates, and statistical disease cluster detection tests. During 12 years, there were 63,395 ED presentations for AFF made by 32,101 individuals. Standardized rates remained relatively stable over time, at about two per 1,000 for individuals presenting to the ED for AFF and about three per 1,000 for ED presentations for AFF. The northern and southeastern parts of the province were identified as clusters of individuals presenting for AFF, and ED presentations for AFF, and several of the areas demonstrated clusters in multiple years. Further, several of the geographic clusters were also identified as potential clusters for stroke or heart failure within 365 days after the ED presentations for AFF. This population-based study spanned 12 fiscal years and showed variations in the number of people presenting to EDs for AFF and the number of ED presentations for AFF over geography. The potential clusters identified may represent geographic areas with higher disease severity or a lower availability of non-ED health services. The clusters are not all likely to have occurred by chance, and further investigation and intervention could occur to reduce ED presentations for AFF. © 2015 by the Society for Academic Emergency Medicine.

Optimal dose of combined rocuronium and cisatracurium during minor surgery

PubMed Central

Park, Woo Young; Choi, Jae Chan; Yun, Hey Jeong; Jeon, Yeong Gwan; Park, Gisoon; Choi, Jong Bum

2018-01-01

Abstract Background: Combined rocuronium and cisatracurium have synergistic effects. We investigated whether reduced doses are effective during coadministration, by monitoring neuromuscular relaxation during surgery. Methods: This randomized, controlled clinical trial was registered at http://clinicaltrials.gov (registration number NCT02495038). The participants were 81 patients scheduled for elective mastoidectomy and tympanoplasty. Participants were assigned to groups, including the intubating dose group (Group I, n = 27; combined ED95 rocuronium and ED95 cisatracurium), the small reduction group (Group S, n = 27; dose reduced by 10% of each ED95), or the large reduction group (Group L, n = 27; dose reduced by 20% of each ED95). Drugs were administered to patients and a timer was started using TOF-Watch monitoring. TOF (train-of-four) was monitored at the ulnar nerve, at a setting of 2 Hz/12 s. We recorded the time to TOF ratio = 0 (onset), time to first TOF ratio > 25% (duration 25%), and TOF 25–75% (recovery index) under total intravenous anesthesia. One-way analysis of variance was used for statistical analyses (α = 0.05, β = 0.2). Results: There were no significant demographic differences between groups. Group L had a longer duration to onset (mean ± standard deviation, 399.3 ± 147.8 seconds) and shorter duration 25% (39.4 ± 6.8 minutes) compared to Group I (212.8 ± 56.0 s and 51.3 ± 8.47 minutes, respectively) and Group S (230.7 ± 60.6 s and 47.9 ± 10.7 minutes, respectively). There were no other significant differences between groups. Conclusion: Our findings contribute to determining clinically effective combinations of rocuronium and cisatracurium, as well as to predicting the pharmacokinetic characteristics of the synergistic effects. We suggest that reducing doses of both drugs by approximately 10% of their respective ED95 values is sufficient to maintain neuromuscular relaxation during minor surgery. PMID:29517695

Web-Based Fully Automated Self-Help With Different Levels of Therapist Support for Individuals With Eating Disorder Symptoms: A Randomized Controlled Trial

PubMed Central

Dingemans, Alexandra E; Spinhoven, Philip; van Ginkel, Joost R; de Rooij, Mark; van Furth, Eric F

2016-01-01

Background Despite the disabling nature of eating disorders (EDs), many individuals with ED symptoms do not receive appropriate mental health care. Internet-based interventions have potential to reduce the unmet needs by providing easily accessible health care services. Objective This study aimed to investigate the effectiveness of an Internet-based intervention for individuals with ED symptoms, called “Featback.” In addition, the added value of different intensities of therapist support was investigated. Methods Participants (N=354) were aged 16 years or older with self-reported ED symptoms, including symptoms of anorexia nervosa, bulimia nervosa, and binge eating disorder. Participants were recruited via the website of Featback and the website of a Dutch pro-recovery–focused e-community for young women with ED problems. Participants were randomized to: (1) Featback, consisting of psychoeducation and a fully automated self-monitoring and feedback system, (2) Featback supplemented with low-intensity (weekly) digital therapist support, (3) Featback supplemented with high-intensity (3 times a week) digital therapist support, and (4) a waiting list control condition. Internet-administered self-report questionnaires were completed at baseline, post-intervention (ie, 8 weeks after baseline), and at 3- and 6-month follow-up. The primary outcome measure was ED psychopathology. Secondary outcome measures were symptoms of depression and anxiety, perseverative thinking, and ED-related quality of life. Statistical analyses were conducted according to an intent-to-treat approach using linear mixed models. Results The 3 Featback conditions were superior to a waiting list in reducing bulimic psychopathology (d=−0.16, 95% confidence interval (CI)=−0.31 to −0.01), symptoms of depression and anxiety (d=−0.28, 95% CI=−0.45 to −0.11), and perseverative thinking (d=−0.28, 95% CI=−0.45 to −0.11). No added value of therapist support was found in terms of symptom reduction although participants who received therapist support were significantly more satisfied with the intervention than those who did not receive supplemental therapist support. No significant differences between the Featback conditions supplemented with low- and high-intensity therapist support were found regarding the effectiveness and satisfaction with the intervention. Conclusions The fully automated Internet-based self-monitoring and feedback intervention Featback was effective in reducing ED and comorbid psychopathology. Supplemental therapist support enhanced satisfaction with the intervention but did not increase its effectiveness. Automated interventions such as Featback can provide widely disseminable and easily accessible care. Such interventions could be incorporated within a stepped-care approach in the treatment of EDs and help to bridge the gap between mental disorders and mental health care services. Trial Registration Netherlands Trial Registry: NTR3646; http://www.trialregister.nl/trialreg/admin/ rctview.asp?TC=3646 (Archived by WebCite at http://www.webcitation.org/6fgHTGKHE) PMID:27317358

ED antibiotic use for acute respiratory illnesses since pneumonia performance measure inception.

PubMed

Fee, Christopher; Metlay, Joshua P; Camargo, Carlos A; Maselli, Judith H; Gonzales, Ralph

2010-01-01

The study aimed to determine if emergency department (ED)-administered antibiotics for patients discharged home with nonpneumonia acute respiratory tract infections (ARIs) have increased since national pneumonia performance measure implementation, including antibiotic administration within 4 hours of arrival. Time series analysis. Six university and 7 Veterans Administration EDs participating in the Improving Antibiotic Use for Acute Care Treatment (IMPAACT) trial (randomized educational intervention to reduce antibiotics for bronchitis). Randomly selected adult (age >18 years) ED visits for acute cough, diagnosed with nonpneumonia ARIs, discharged home during winters (November-February) of 2003 to 2007. Time trend in ED-administered antibiotics, adjusted for patient demographics, comorbidities, vital signs, ED length of stay, IMPAACT intervention status, geographic region, Veterans Administration/university setting, and site and provider level clustering. Six thousand four hundred seventy-six met study criteria. Three hundred ninety-four (6.1%) received ED-administered antibiotics. Emergency department-administered antibiotics did not increase across the study period among all IMPAACT sites (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.76-1.01) after adjusting for age, congestive heart failure history, temperature higher than 100 degrees F, heart rate more than 100, blood cultures obtained, diagnoses, and ED length of stay. The ED-administered antibiotic rate decreased at IMPAACT intervention (OR, 0.80; 95% CI, 0.69-0.93) but not nonintervention sites (OR, 1.04; 95% CI, 0.91-1.19). Adjusted proportions receiving ED-administered antibiotics were 6.1% (95% CI, 2.7%-13.2%) for 2003 to 2004; 4.8% (95% CI, 2.2%-10.0%) for 2004 to 2005; 4.6% (95% CI, 2.7%-7.8%) for 2005 to 2006; and 4.2% (95% CI, 2.2%-8.0%) for 2006 to 2007. Emergency department-administered antibiotics did not increase for patients with acute cough discharged home with nonpneumonia ARIs since pneumonia antibiotic timing performance measure implementation in these academic EDs.

Improving the use of environmental diversity as a surrogate for species representation.

PubMed

Albuquerque, Fabio; Beier, Paul

2018-01-01

The continuous p-median approach to environmental diversity (ED) is a reliable way to identify sites that efficiently represent species. A recently developed maximum dispersion (maxdisp) approach to ED is computationally simpler, does not require the user to reduce environmental space to two dimensions, and performed better than continuous p-median for datasets of South African animals. We tested whether maxdisp performs as well as continuous p-median for 12 datasets that included plants and other continents, and whether particular types of environmental variables produced consistently better models of ED. We selected 12 species inventories and atlases to span a broad range of taxa (plants, birds, mammals, reptiles, and amphibians), spatial extents, and resolutions. For each dataset, we used continuous p-median ED and maxdisp ED in combination with five sets of environmental variables (five combinations of temperature, precipitation, insolation, NDVI, and topographic variables) to select environmentally diverse sites. We used the species accumulation index (SAI) to evaluate the efficiency of ED in representing species for each approach and set of environmental variables. Maxdisp ED represented species better than continuous p-median ED in five of 12 biodiversity datasets, and about the same for the other seven biodiversity datasets. Efficiency of ED also varied with type of variables used to define environmental space, but no particular combination of variables consistently performed best. We conclude that maxdisp ED performs at least as well as continuous p-median ED, and has the advantage of faster and simpler computation. Surprisingly, using all 38 environmental variables was not consistently better than using subsets of variables, nor did any subset emerge as consistently best or worst; further work is needed to identify the best variables to define environmental space. Results can help ecologists and conservationists select sites for species representation and assist in conservation planning.

Mobile integrated health to reduce post-discharge acute care visits: A pilot study.

PubMed

Siddle, Jennica; Pang, Peter S; Weaver, Christopher; Weinstein, Elizabeth; O'Donnell, Daniel; Arkins, Thomas P; Miramonti, Charles

2018-05-01

Mobile Integrated Health (MIH) leverages specially trained paramedics outside of emergency response to bridge gaps in local health care delivery. To evaluate the efficacy of a MIH led transitional care strategy to reduce acute care utilization. This was a retrospective cohort analysis of a quality improvement pilot of patients from an urban, single county EMS, MIH transitional care initiative. We utilized a paramedic/social worker (or social care coordinator) dyad to provide in home assessments, medication review, care coordination, and improve access to care. The primary outcome compared acute care utilization (ED visits, observation stays, inpatient visits) 90days before MIH intervention to 90days after. Of the 203 patients seen by MIH teams, inpatient utilization decreased significantly from 140 hospitalizations pre-MIH to 26 post-MIH (83% reduction, p=0.00). ED and observation stays, however, increased numerically, but neither was significant. (ED 18 to 19 stays, p=0.98; observation stays 95 to 106, p=0.30) Primary care visits increased 15% (p=0.11). In this pilot before/after study, MIH significantly reduces acute care hospitalizations. Copyright © 2017 Elsevier Inc. All rights reserved.

Prevention, identification, and management of post-operative penile implant complications of infection, hematoma, and device malfunction

PubMed Central

O’Rourke, Timothy K.; Erbella, Alexander; Zhang, Yu

2017-01-01

Penile prosthesis implant surgery is an effective management approach for a number of urological conditions, including medication refractory erectile dysfunction (ED). Complications encountered post-operatively include infection, bleeding/hematoma, and device malfunction. Since the 1970s, modifications to these devices have reduced complication rates through improvement in antisepsis and design using antibiotic coatings, kink-resistant tubing, lock-out valves to prevent autoinflation, and modified reservoir shapes. Device survival and complication rates have been investigated predominately by retrospective database-derived studies. This review article focuses on the identification and management of post-operative complications following penile prosthetic and implant surgery. Etiology for ED, surgical technique, and prosthesis type are variable among studies. The most common post-operative complications of infection, bleeding, and device malfunction may be minimized by adherence to consistent technique and standard protocol. Novel antibiotic coatings and standard antibiotic regimen may reduce infection rates. Meticulous hemostasis and intraoperative testing of devices may further reduce need for revision surgery. Additional prospective studies with consistent reporting of outcomes and comparison of surgical approach and prosthesis type in patients with variable ED etiology would be beneficial. PMID:29238663

A National Study of Outpatient Health Care Providers' Effect on Emergency Department Visit Acuity and Likelihood of Hospitalization.

PubMed

Raven, Maria C; Steiner, Faye

2018-06-01

Many policymakers believe that expanding access to outpatient care will reduce emergency department (ED) use. However, outpatient health care providers often refer their patients to EDs for evaluation and management. We examine the factors underlying outpatient provider referral, its effect on ED visit volume, and whether referred ED visits are more likely to result in hospitalization than self-referred visits. We conducted a cross-sectional study of 19,342 adult (>18 years) respondents to the 2012 to 2014 National Health Interview Survey who reported they had visited an ED at least once in the past 12 months, representing an estimated 44,152,870 US adults. We categorized individuals as having been referred to the ED by an outside health care provider if they responded affirmatively to "your health care provider advised you to go" as a reason for their most recent ED visit. We performed descriptive analyses and logistic regressions to examine factors associated with outpatient health care provider referral to the ED. Respondents could choose multiple other reasons for their most recent ED visit, and we used existing Centers for Disease Control and Prevention guidelines to group these reasons into 2 categories: seriousness of the medical condition and lack of access to other providers. Our 2 main outcomes were whether an outpatient health care provider referred an individual to the ED and whether that ED visit resulted in hospitalization. Of the 44,152,870 US adults (18.58%; 95% confidence interval [CI] 18.21% to 18.95%) with one or more ED visits in the previous 12 months, 10,913,271 (24.72%; 95% CI 23.80% to 25.64%) were referred to the ED by an outpatient provider. Respondents who reported their ED visit was due to the seriousness of their medical condition were more likely to be referred to the ED (odds ratio [OR] 2.18; 95% CI 1.91 to 2.49), whereas those reporting a lack of access to other providers were less likely to be referred (OR 0.58; 95% CI 0.52 to 0.64). Visits referred to the ED were more likely to result in hospitalization than self-referrals (OR 2.07; 95% CI 1.87 to 2.31). Almost one quarter of individuals' most recent ED visits were driven by referrals from outpatient health care providers. Being referred to the ED by an outpatient provider is strongly associated with the seriousness of one's medical condition, which also increases the odds of hospitalization compared with ED discharge. After controlling for seriousness of medical condition, ED referral by an outpatient provider continues to have an independent association with hospitalization. Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Neural correlates of the processing of self-referent emotional information in bulimia nervosa.

PubMed

Pringle, A; Ashworth, F; Harmer, C J; Norbury, R; Cooper, M J

2011-10-01

There is increasing interest in understanding the roles of distorted beliefs about the self, ostensibly unrelated to eating, weight and shape, in eating disorders (EDs), but little is known about their neural correlates. We therefore used functional magnetic resonance imaging to investigate the neural correlates of self-referent emotional processing in EDs. During the scan, unmedicated patients with bulimia nervosa (n=11) and healthy controls (n=16) responded to personality words previously found to be related to negative self beliefs in EDs and depression. Rating of the negative personality descriptors resulted in reduced activation in patients compared to controls in parietal, occipital and limbic areas including the amygdala. There was no evidence that reduced activity in patients was secondary to increased cognitive control. Different patterns of neural activation between patients and controls may be the result of either habituation to personally relevant negative self beliefs or of emotional blunting in patients. Copyright © 2011 Elsevier Ltd. All rights reserved.

Experiments with crystal deflectors for high energy ion beams: Electromagnetic dissociation probability for well channeled ions

NASA Astrophysics Data System (ADS)

Scandale, W.; Taratin, A. M.; Kovalenko, A. D.

2013-01-01

The paper presents the current status with the use of the crystal defectors for high energy ion beams. The channeling properties of multicharged ions are discussed. The results of the experiments on the deflection and extraction (collimation) of high energy ion beams with bent crystals performed in the accelerator centers are shortly considered. The analysis of the recent collimation experiment with a Pb nuclei of 270GeV/c per charge at the CERN Super Proton Synchrotron showed that the channeling efficiency was as large as about 90%. For Pb ions of the LHC energies a new mechanism, which can reduce the channeling efficiency, appears. The electromagnetic dissociation (ED) becomes possible for well channeled particles. However, the estimations performed in the paper show that the ED probability is small and should not visibly reduce the collimation efficiency. On the other hand, the aligned crystal gives the possibility to study the ED processes of heavy nuclei in the conditions when nuclear interactions are fully suppressed.

Liability of emergency physicians for studies ordered in the emergency department: court cases and legal defenses.

PubMed

Moore, Gregory P

2011-02-01

Laboratory tests are frequently ordered in the Emergency Department (ED), with results returning at a later time. Emergency physicians (EPs) are frequently held liable when the test results are not followed-up. Recent legal malpractice cases are presented to provide examples of the medical-legal risks encountered when poor patient outcomes occur because the results of laboratory tests and other studies done in the ED are not followed-up and communicated to the patient. Emergency physicians are obligated to follow-up with patients when the results of laboratory and radiographic studies ordered in the ED are returned at a later time, and EPs are liable for any poor outcome if there is no follow-up. Appropriate follow-up mechanisms must be in place to improve patient outcomes and reduce the risk for the physician. Knowledge of the legal concepts of contributory negligence and comparative fault allows EPs to place themselves in an optimal position for a legal defense if a challenge is raised. It is imperative that abnormal results of tests done for ED evaluation and orders must be properly noted and followed-up. Optimal communication and relay of information to both the patient and the primary physician will reduce physician liability and enhance patient outcomes. Published by Elsevier Inc.

Bending The Spending Curve By Altering Care Delivery Patterns: The Role Of Care Management Within A Pioneer ACO.

PubMed

Hsu, John; Price, Mary; Vogeli, Christine; Brand, Richard; Chernew, Michael E; Chaguturu, Sreekanth K; Weil, Eric; Ferris, Timothy G

2017-05-01

Accountable care organizations (ACOs) appear to lower medical spending, but there is little information on how they do so. We examined the impact of patient participation in a Pioneer ACO and its care management program on rates of emergency department (ED) visits and hospitalizations and on Medicare spending. We used data for the period 2009-14, exploiting naturally staggered program entry to create concurrent controls to help isolate the program effects. The care management program (the ACO's primary intervention) targeted beneficiaries with elevated but modifiable risks for future spending. ACO participation had a modest effect on spending, in line with previous estimates. Participation in the care management program was associated with substantial reductions in rates for hospitalizations and both all and nonemergency ED visits, as well as Medicare spending, when compared to preparticipation levels and to rates and spending for a concurrent sample of beneficiaries who were eligible for but had not yet started the program. Rates of ED visits and hospitalizations were reduced by 6 percent and 8 percent, respectively, and Medicare spending was reduced by 6 percent. Targeting beneficiaries with modifiable high risks and shifting care away from the ED represent viable mechanisms for altering spending within ACOs. Project HOPE—The People-to-People Health Foundation, Inc.

Inequalities in public health care delivery in Zambia

PubMed Central

2014-01-01

Background Access to adequate health services that is of acceptable quality is important in the move towards universal health coverage. However, previous studies have revealed inequities in health care utilisation in the favour of the rich. Further, those with the greatest need for health services are not getting a fair share. In Zambia, though equity in access is extolled in government documents, there is evidence suggesting that those needing health services are not receiving their fair share. This study seeks therefore, to assess if socioeconomic related inequalities/inequities in public health service utilisation in Zambia still persist. Methods The 2010 nationally representative Zambia Living Conditions and Monitoring Survey data are used. Inequality is assessed using concentration curves and concentrations indices while inequity is assessed using a horizontal equity index: an index of inequity across socioeconomic status groups, based on standardizing health service utilisation for health care need. Public health services considered include public health post visits, public clinic visits, public hospital visits and total public facility visits. Results There is evidence of pro-poor inequality in public primary health care utilisation but a pro-rich inequality in hospital visits. The concentration indices for public health post visits and public clinic visits are −0.28 and −0.09 respectively while that of public hospitals is 0.06. After controlling for need, the pro-poor distribution is maintained at primary facilities and with a pro-rich distribution at hospitals. The horizontal equity indices for health post and clinic are estimated at −0.23 and −0.04 respectively while that of public hospitals is estimated at 0.11. A pro-rich inequity is observed when all the public facilities are combined (horizontal equity index = 0.01) though statistically insignificant. Conclusion The results of the paper point to areas of focus in ensuring equitable access to health services especially for the poor and needy. This includes strengthening primary facilities that serve the poor and reducing access barriers to ensure that health care utilisation at higher-level facilities is distributed in accordance with need for it. These initiatives may well reduce the observed inequities and accelerate the move towards universal health coverage in Zambia. PMID:24645826

Equality in Maternal and Newborn Health: Modelling Geographic Disparities in Utilisation of Care in Five East African Countries.

PubMed

Ruktanonchai, Corrine W; Ruktanonchai, Nick W; Nove, Andrea; Lopes, Sofia; Pezzulo, Carla; Bosco, Claudio; Alegana, Victor A; Burgert, Clara R; Ayiko, Rogers; Charles, Andrew Sek; Lambert, Nkurunziza; Msechu, Esther; Kathini, Esther; Matthews, Zoë; Tatem, Andrew J

2016-01-01

Geographic accessibility to health facilities represents a fundamental barrier to utilisation of maternal and newborn health (MNH) services, driving historically hidden spatial pockets of localized inequalities. Here, we examine utilisation of MNH care as an emergent property of accessibility, highlighting high-resolution spatial heterogeneity and sub-national inequalities in receiving care before, during, and after delivery throughout five East African countries. We calculated a geographic inaccessibility score to the nearest health facility at 300 x 300 m using a dataset of 9,314 facilities throughout Burundi, Kenya, Rwanda, Tanzania and Uganda. Using Demographic and Health Surveys data, we utilised hierarchical mixed effects logistic regression to examine the odds of: 1) skilled birth attendance, 2) receiving 4+ antenatal care visits at time of delivery, and 3) receiving a postnatal health check-up within 48 hours of delivery. We applied model results onto the accessibility surface to visualise the probabilities of obtaining MNH care at both high-resolution and sub-national levels after adjusting for live births in 2015. Across all outcomes, decreasing wealth and education levels were associated with lower odds of obtaining MNH care. Increasing geographic inaccessibility scores were associated with the strongest effect in lowering odds of obtaining care observed across outcomes, with the widest disparities observed among skilled birth attendance. Specifically, for each increase in the inaccessibility score to the nearest health facility, the odds of having skilled birth attendance at delivery was reduced by over 75% (0.24; CI: 0.19-0.3), while the odds of receiving antenatal care decreased by nearly 25% (0.74; CI: 0.61-0.89) and 40% for obtaining postnatal care (0.58; CI: 0.45-0.75). Overall, these results suggest decreasing accessibility to the nearest health facility significantly deterred utilisation of all maternal health care services. These results demonstrate how spatial approaches can inform policy efforts and promote evidence-based decision-making, and are particularly pertinent as the world shifts into the Sustainable Goals Development era, where sub-national applications will become increasingly useful in identifying and reducing persistent inequalities.

Equality in Maternal and Newborn Health: Modelling Geographic Disparities in Utilisation of Care in Five East African Countries

PubMed Central

Ruktanonchai, Nick W.; Nove, Andrea; Lopes, Sofia; Pezzulo, Carla; Bosco, Claudio; Alegana, Victor A.; Burgert, Clara R.; Ayiko, Rogers; Charles, Andrew SEK; Lambert, Nkurunziza; Msechu, Esther; Kathini, Esther; Matthews, Zoë; Tatem, Andrew J.

2016-01-01

Background Geographic accessibility to health facilities represents a fundamental barrier to utilisation of maternal and newborn health (MNH) services, driving historically hidden spatial pockets of localized inequalities. Here, we examine utilisation of MNH care as an emergent property of accessibility, highlighting high-resolution spatial heterogeneity and sub-national inequalities in receiving care before, during, and after delivery throughout five East African countries. Methods We calculated a geographic inaccessibility score to the nearest health facility at 300 x 300 m using a dataset of 9,314 facilities throughout Burundi, Kenya, Rwanda, Tanzania and Uganda. Using Demographic and Health Surveys data, we utilised hierarchical mixed effects logistic regression to examine the odds of: 1) skilled birth attendance, 2) receiving 4+ antenatal care visits at time of delivery, and 3) receiving a postnatal health check-up within 48 hours of delivery. We applied model results onto the accessibility surface to visualise the probabilities of obtaining MNH care at both high-resolution and sub-national levels after adjusting for live births in 2015. Results Across all outcomes, decreasing wealth and education levels were associated with lower odds of obtaining MNH care. Increasing geographic inaccessibility scores were associated with the strongest effect in lowering odds of obtaining care observed across outcomes, with the widest disparities observed among skilled birth attendance. Specifically, for each increase in the inaccessibility score to the nearest health facility, the odds of having skilled birth attendance at delivery was reduced by over 75% (0.24; CI: 0.19–0.3), while the odds of receiving antenatal care decreased by nearly 25% (0.74; CI: 0.61–0.89) and 40% for obtaining postnatal care (0.58; CI: 0.45–0.75). Conclusions Overall, these results suggest decreasing accessibility to the nearest health facility significantly deterred utilisation of all maternal health care services. These results demonstrate how spatial approaches can inform policy efforts and promote evidence-based decision-making, and are particularly pertinent as the world shifts into the Sustainable Goals Development era, where sub-national applications will become increasingly useful in identifying and reducing persistent inequalities. PMID:27561009

Eating disorders: predictors of change in the quality of life of caregivers.

PubMed

Las Hayas, Carlota; Padierna, Jesús Ángel; Bilbao, Amaia; Martín, Josune; Muñoz, Pedro; Quintana, Jose María

2014-03-30

Eating disorders (EDs) have a strong impact on the quality of life (QoL) of caregivers. This study explores the longitudinal changes in the QoL of ED caregivers at 1 (T1; n=109) and 2 years (T2; n=32) follow-up, and identifies predictors of improvement at 1-year follow-up. ED outpatients also completed a battery of tests at T1 (n=69) and T2 (n=11). Multivariate hierarchical linear mixed models were used, in which the caregivers' 1-year changes in QoL, anxiety and depression scores were analysed as the dependent variables. Predictor variables were the caregivers' perception of burden, perception of the severity of the patient's ED, kinship data, and the ED person's scores on QoL, anxiety depression and ED symptoms. Higher scores in mental health and low perception of burden at baseline predicted improved caregiver QoL at 1-year follow-up. The caregivers' QoL improved if the perception of burden decreased over time and if depression of the patient improved. The results suggest that interventions directed to reduce the caregivers' perception of burden and to improve the mental health of the ED patients would lead to improved caregiver QoL. The high attrition rate at T2 made prediction analyses unviable. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Health information exchange reduces repeated diagnostic imaging for back pain.

PubMed

Bailey, James E; Pope, Rebecca A; Elliott, Elizabeth C; Wan, Jim Y; Waters, Teresa M; Frisse, Mark E

2013-07-01

This study seeks to determine whether health information exchange reduces repeated diagnostic imaging and related costs in emergency back pain evaluation. This was a longitudinal data analysis of health information exchange patient-visit data. All repeated emergency department (ED) patient visits for back pain with previous ED diagnostic imaging to a Memphis metropolitan area ED between August 1, 2007, and July 31, 2009, were included. Use of a regional health information exchange by ED personnel to access the patient's record during the emergency visit was the primary independent variable. Main outcomes included repeated lumbar or thoracic diagnostic imaging (radiograph, computed tomography [CT], or magnetic resonance imaging [MRI]) and total patient-visit estimated cost. One hundred seventy-nine (22.4%) of the 800 qualifying repeated back pain visits resulted in repeated diagnostic imaging (radiograph 84.9%, CT 6.1%, and MRI 9.5%). Health information exchange use in the study population was low, at 12.5%, and health care providers as opposed to administrative/nursing staff accounted for 80% of the total health information exchange use. Health information exchange use by any ED personnel was associated with reduced repeated diagnostic imaging (odds ratio 0.36; 95% confidence interval 0.18 to 0.71), as was physician or nurse practitioner health information exchange use (odds ratio 0.47; 95% confidence interval 0.23 to 0.96). No cost savings were associated with health information exchange use because of increased CT imaging when health care providers used health information exchange. Health information exchange use is associated with 64% lower odds of repeated diagnostic imaging in the emergency evaluation of back pain. Health information exchange effect on estimated costs was negligible. More studies are needed to evaluate specific strategies to increase health information exchange use and further decrease potentially unnecessary diagnostic imaging and associated costs of care. Copyright © 2013 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

Points of Influence for Lethal Means Counseling and Safe Gun Storage Practices.

PubMed

Runyan, Carol W; Brooks-Russell, Ashley; Betz, Marian E

2018-06-07

Counseling about reducing access to lethal means of suicide, especially firearms, is a recommended practice in emergency departments (EDs) but does not occur routinely. Understanding influencers of decisions makers in health care (ED nurse leaders, mental health providers) and temporary firearm storage (law enforcement and gun retailers) could enhance practice. We surveyed these 4 groups in the 8-state region of the Mountain West. For ED nurse leaders (n = 190), hospital legal, risk management, and quality improvement representatives, and the ED nursing director were most often cited as influential, whereas mental health providers (n = 67) cited their own team. Law enforcement officials (n = 448) identified the overall community and leaders of mental health or general health organizations as influential. Firearm retailers (n = 95) cited local law enforcement and national firearm organizations. Advocacy from influential groups may encourage efforts to provide lethal means counseling and temporary off-site storage of firearms for suicide prevention.

Impact of expression of EMP enzymes on glucose metabolism in Zymomonas mobilis.

PubMed

Chen, Rachel Ruizhen; Agrawal, Manoj; Mao, Zichao

2013-06-01

Zymomonas mobilis is the only known microorganism that utilizes the Entner-Doudoroff (ED) pathway anaerobically. In this work, we investigated whether the overexpression of a phosphofructokinase (PFK), the only missing Embden-Meyerhof-Parnas (EMP) pathway enzyme, could establish the pathway in this organism. Introduction of a pyrophosphate-dependent PFK, along with co-expression of homologous fructose-1,6-bisphosphate aldolase and triosephosphate isomerase, did not result in an EMP flux to any appreciable level. However, the metabolism of glucose was impacted significantly. Eight percent of glucose was metabolized to form a new metabolite, dihydroxyacetone. Reducing flux through the ED pathway by as much as 40 % through antisense of a key enzyme, ED aldolase, did not result in a fully functional EMP pathway, suggesting that the ED pathway, especially the lower arm, downstream from glyceraldehyde-3-phosphate, is very rigid, possibly due to redox balance.

Day care for dementia patients from a family caregiver's point of view: a questionnaire study on expected quality and predictors of utilisation - Part II.

PubMed

Donath, Carolin; Winkler, Angelika; Graessel, Elmar; Luttenberger, Katharina

2011-04-13

The investigation of the predictive variables for utilisation of day care and the views of family caregivers of dementia patients about quality of day care are the goals of this work. The cross-sectional study was carried out as an anonymous written survey of family caregivers of dementia patients in Germany. Participants were 404 family caregivers of dementia patients, of these 128 were users of day care, 269 were non-users and 7 gave no details about utilisation. Qualitative and quantitative data were analysed using qualitative content analysis and binary logistic regression analysis. The assessment of how helpful day care is for the individual care situation and the age of the family caregiver are significant predictors for utilisation of day care. Caregivers most frequently cited a programme of activities suited to the abilities of the dementia patients as quality criterion. In order to reduce the number of those caregivers who think they don't need day care compared with the number who really don't need it, caregivers should be transparently informed of the relevant advantages and quality principles of using day care. According to caregivers' wishes, the organisation of day care centres must include activities suited for dementia patients.

Substance use and self-harm: a cross-sectional study of the prevalence, correlates and patterns of medical service utilisation among patients admitted to a South African hospital.

PubMed

Breet, Elsie; Bantjes, Jason; Lewis, Ian

2018-03-06

Substance use is a potentially modifiable risk factor for suicidal behaviour. Little is known about the epidemiology of substance use among self-harm patients in South Africa. This study set out to collect epidemiological data about the prevalence, correlates, and patterns of medical service utilisation among self-harm patients who used substances at the time of self-injury. Data from 238 consecutive self-harm patients treated at an urban hospital in South Africa were analysed using bivariate and multivariate statistics. Approximately 20% of patients reported substance use at the time of self-harm. When compared to other self-harm patients, higher rates of patients who had used substances: had depressed levels of consciousness on admission; utilised more medical resources and required longer hospital admissions; cited relationship difficulties and financial concerns as reasons for their self-harm; reported a previous episode of self-harm; and intended to die as a result of their injuries. Although the observed differences were not statistically significant (p > 0.05), the proportional differences were congruent with international literature. Acute use of substances among self-harm patients warrants more focused research and clinical attention particularly in the context of reducing utilisation of scarce medical resources.

Household training vs. mass campaigns: a better method of health communication for preventing malaria.

PubMed

Chourasia, Mehul Kumar; Abraham, Vinod J; John, Jacob

2014-10-01

Malaria is endemic in several states of India with high tribal population. Effective use of long-lasting insecticide treated bed nets (LLITNs) can reduce the burden of malaria in these settings. This study assessed the knowledge and behaviour regarding malaria in a tribal population and compared two health education strategies for enhancing effective utilisation of bed nets. A community-based intervention study was carried out among 218 households in two villages. One community received household level training on effective utilisation of LLITNs while the others received training in a mass campaign and outcomes were measured after 2 months. The study showed that the proportion utilising LLITNs was significantly higher among those receiving household level training as compared to those who received the mass campaign. Household level training appears to be a more effective form of health education for improving knowledge and promoting use of LLITNs in these isolated community groups. © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

Controlling chromium slag pollution utilising scavengers: a case of Shandong Province, China.

PubMed

Liu, Changhao; Côté, Raymond P

2015-04-01

The problem of chromium slag pollution is a great challenge for China. It is now an urgent task for China to take effective measures to eliminate chromium slag pollution. This article examines the case of the treatment of chromium slag in Shandong Province and explores how chromium slag pollution can be eliminated in Shandong Province. It shows that the chromium slag stockpiled by the chemical plants was successfully utilised by local steel companies, who act as 'scavenger companies'. The driving mechanism, seeking a potential 'scavenger company' within the local region and the role of the local government on the case of Shandong Province are discussed. This article concludes that local steel companies can be utilised to effectively and efficiently treat the chromium slag while benefiting the steel companies. The local governments need to play multiple roles in solving the problem of chromium slag pollution. Seeking and identifying 'scavenger companies' within a region could be an important approach to reducing pollution within the region. © The Author(s) 2015.

Construction and evaluation of a self rating scale for stress-induced exhaustion disorder, the Karolinska Exhaustion Disorder Scale.

PubMed

Besèr, Aniella; Sorjonen, Kimmo; Wahlberg, Kristina; Peterson, Ulla; Nygren, Ake; Asberg, Marie

2014-02-01

Prolonged stress (≥ six months) may cause a condition which has been named exhaustion disorder (ED) with ICD-10 code F43.8. ED is characterised by exhaustion, cognitive problems, poor sleep and reduced tolerance to further stress. ED can cause long term disability and depressive symptoms may develop. The aim was to construct and evaluate a self-rating scale, the Karolinska Exhaustion Disorder Scale (KEDS), for the assessment of ED symptoms. A second aim was to examine the relationship between self-rated symptoms of ED, depression, and anxiety using KEDS and the Hospital Anxiety and Depression Scale (HAD). Items were selected based on their correspondence to criteria for ED as formulated by the Swedish National Board of Health and Welfare (NBHW), with seven response alternatives in a Likert-format. Self-ratings performed by 317 clinically assessed participants were used to analyse the scale's psychometric properties. KEDS consists of nine items with a scale range of 0-54. Receiver operating characteristics analysis demonstrated that a cut-off score of 19 was accompanied by high sensitivity and specificity (each above 95%) in the discrimination between healthy subjects and patients with ED. Reliability was satisfactory and confirmatory factor analysis revealed that ED, depression and anxiety are best regarded as different phenomena. KEDS may be a useful tool in the assessment of symptoms of Exhaustion Disorder in clinical as well as research settings. There is evidence that the symptom clusters of ED, anxiety and depression, respectively, reflect three different underlying dimensions. © 2013 The Authors. Scandinavian Journal of Psychology published by Scandinavian Psychological Associations and John Wiley & Sons Ltd.

Dedicated Pediatricians in Emergency Department: Shorter Waiting Times and Lower Costs

PubMed Central

Melo, Manuel Rocha; Ferreira-Magalhães, Manuel; Flor-Lima, Filipa; Rodrigues, Mariana; Severo, Milton; Almeida-Santos, Luis; Caldas-Afonso, Alberto; Barros, Pedro Pita; Ferreira, António

2016-01-01

Background Dedicated pediatricians in emergency departments (EDs) may be beneficial, though no previous studies have assessed the related costs and benefits/harms. We aimed to evaluate the net benefits and costs of dedicated emergency pediatricians in a pediatric ED. Methods Cost-consequences analysis of visits to a pediatric ED of a tertiary hospital. Two pediatric ED Medical Teams (MT) were compared: MT-A (May–September 2012), with general pediatrics physicians only; and MT-B (May–September 2013), with emergency dedicated pediatricians. The main outcomes analyzed were relevant clinical outcomes, patient throughput time and costs. Results We included 8,694 children in MT-A and 9,417 in MT-B. Medication use in the ED increased from 42.3% of the children in MT-A to 49.6% in MT-B; diagnostic tests decreased from 24.2% in MT-A to 14.3% in MT-B. Hospitalization increased from 1.3% in MT-A to 3.0% in MT-B; however, there was no significant difference in diagnosis-related group relative weight of hospitalized children in MT-A and MT-B (MT-A, 0.979; MT-B, 1.075). No differences were observed in ED readmissions or in patients leaving without being seen by a physician. The patient throughput time was significantly shorter in MT-B, with faster times to first medical observation. Within the cost domains analyzed, the total expenditures per children observed in the ED were 16% lower in MT-B: 37.87 euros in MT-A; 31.97 euros in MT-B. Conclusion The presence of dedicated emergency pediatricians in a pediatric ED was associated with significantly lower waiting times in the ED, reduced costs, and similar clinical outcomes. PMID:27564093

Heart failure education in the emergency department markedly reduces readmissions in un- and under-insured patients.

PubMed

Asthana, Vishwaratn; Sundararajan, Miel; Ackah, Ruth Linda; Karun, Vivek; Misra, Arunima; Pritchett, Allison; Bugga, Pallavi; Siler-Fisher, Angela; Peacock, William Frank

2018-03-21

Heart failure (HF) readmissions are a longstanding national healthcare issue for both hospitals and patients. Our purpose was to evaluate the efficacy of a structured, educational intervention targeted towards un- and under-insured emergency department (ED) HF patients. HF patients presenting to the ED for care were enrolled between July and December 2015 as part of an open label, interventional study, using a parallel observational control group. Eligible patients provided informed consent, had an established HF diagnosis, and were hemodynamically stable. Intervention patients received a standardized educational intervention in the ED waiting room before seeing the emergency physician, and a 30-day telephone follow-up. Primary and secondary endpoints were 30- and 90-day ED and hospital readmission rates, as well as days alive and out of hospital (DAOH) respectively. Of the 94 patients enrolled, median age was 58.4 years; 40.4% were female, and 54.3% were African American. Intervention patients (n = 45) experienced a 47.8% and 45.3% decrease in ED revisits (P = 0.02 &P < 0.001), and 60.0% and 47.4% decrease in hospital readmissions (P = 0.049 &P = 0.007) in the 30 and 90 days pre- versus post-intervention respectively. Control patients (n = 49) had no change in hospital readmissions or 30-day ED revisits, but experienced a 36.6% increase in 90-day ED revisits (P = 0.03). Intervention patients also saw a 59.2% improvement in DAOH versus control patients (P = 0.03). An ED educational intervention markedly decreases ED and hospital readmissions in un- and under-insured HF patients. Copyright © 2018 Elsevier Inc. All rights reserved.

Effect of certificate of need law on emergency department length of stay.

PubMed

Paul, Jomon Aliyas; Ni, Huan; Bagchi, Aniruddha

2014-10-01

The impact of the Certificate of Need (CON) law on Emergency Department (ED) care remains elusive in the academic literature. We study the impact of CON law on ED Length of Stay (LOS). We examine ED LOS to detect any statistically significant difference between CON and non-CON states. We then estimate the effects of CON law on ED LOS by treating CON as an exogenous (endogenous) variable. We find that the CON legislation positively impacts ED care by reducing ED LOS (95% confidence interval [CI] -61.3 to -10.3), and we can't reject the hypothesis that the CON legislation can be treated as an exogenous variable in our model. An increase in the stringency of the CON law (measured by the threshold on equipment expenditure that is subject to a CON review) tends to diminish this positive impact on ED LOS (95% CI 9.9-68.0). The party affiliation of the Governor (95% CI 10.3-37.5), the political environment as a function of the agreement on voting between state senators (95% CI-64.8 to -12.9), proportion of young population (0-17 years) when compared with the elderly (>65 years) (95% CI-2299.7 to -184.1), proportion of population covered by privately purchased insurance (95% CI-819.3 to -59.9), etc., are found to significantly impact ED LOS in a state. This study provides a better understanding of the impact of CON law on ED care, which extends the previous literature that has mainly focused on CON effects on inpatient care. Copyright © 2014 Elsevier Inc. All rights reserved.

An empirical/theoretical model with dimensionless numbers to predict the performance of electrodialysis systems on the basis of operating conditions.

PubMed

Karimi, Leila; Ghassemi, Abbas

2016-07-01

Among the different technologies developed for desalination, the electrodialysis/electrodialysis reversal (ED/EDR) process is one of the most promising for treating brackish water with low salinity when there is high risk of scaling. Multiple researchers have investigated ED/EDR to optimize the process, determine the effects of operating parameters, and develop theoretical/empirical models. Previously published empirical/theoretical models have evaluated the effect of the hydraulic conditions of the ED/EDR on the limiting current density using dimensionless numbers. The reason for previous studies' emphasis on limiting current density is twofold: 1) to maximize ion removal, most ED/EDR systems are operated close to limiting current conditions if there is not a scaling potential in the concentrate chamber due to a high concentration of less-soluble salts; and 2) for modeling the ED/EDR system with dimensionless numbers, it is more accurate and convenient to use limiting current density, where the boundary layer's characteristics are known at constant electrical conditions. To improve knowledge of ED/EDR systems, ED/EDR models should be also developed for the Ohmic region, where operation reduces energy consumption, facilitates targeted ion removal, and prolongs membrane life compared to limiting current conditions. In this paper, theoretical/empirical models were developed for ED/EDR performance in a wide range of operating conditions. The presented ion removal and selectivity models were developed for the removal of monovalent ions and divalent ions utilizing the dominant dimensionless numbers obtained from laboratory scale electrodialysis experiments. At any system scale, these models can predict ED/EDR performance in terms of monovalent and divalent ion removal. Copyright © 2016 Elsevier Ltd. All rights reserved.

New guidelines for geriatric EDs: guidance focused on boosting environment, care processes.

PubMed

2014-05-01

A cadre of prominent medical groups, including the ACEP, ENA, AGS, and SAEM, has unveiled a comprehensive set of Geriatric Emergency Department Guidelines to aid hospitals that are either in the process of opening senior-focused EDs or revamping their policies and procedures to better meet the needs of an aging population. The guidelines offer recommendations related to staffing, infrastructure, education, and transition-of-care strategies. In addition, they outline a host of screenings that studies have shown are beneficial for older adults. Experts note that hospital systems around the country have already opened 50 geriatric EDs, with many more facilities in development. Guideline authors state that the guidelines take an evidence-based approach to managing senior patients. While more cost and outcomes data are needed, experts say that senior-focused improvements to emergency care can reduce admissions and return visits to the ED while also boosting patient satisfaction. Future efforts will focus on prioritizing the guideline recommendations so that ED administrators concerned with improving senior care will tackle the most important changes first.

Pain control methods in use and perceived effectiveness by patients with Ehlers-Danlos syndrome: a descriptive study.

PubMed

Arthur, Karen; Caldwell, Karen; Forehand, Samantha; Davis, Keith

2016-01-01

The purpose of this study was to assess the pain control methods in use by patients who have Ehlers-Danlos Syndrome (EDS), a group of connective tissue disorders, and their perceived effectiveness. This descriptive study involved 1179 adults diagnosed with EDS who completed an anonymous on-line survey. The survey consisted of demographics information, the Patient Reported Outcomes Measurement Information System (PROMIS) Pain-Behavior, PROMIS Pain-Interference, and Neuro QOL Satisfaction with Social Roles and Activities scales, as well as a modified version of the Pain Management Strategies Survey. Respondents reported having to seek out confirmation of their EDS diagnosis with multiple healthcare providers, which implies the difficulty many people with EDS face when trying to gain access to appropriate treatment. Patients with EDS experience higher levels of pain interference and lower satisfaction with social roles and activities compared to national norms. Among the treatment modalities in this study, those perceived as most helpful for acute pain control were opioids, surgical interventions, splints and braces, avoidance of potentially dangerous activities and heat therapy. Chronic pain treatments rated as most helpful were opioids, splints or braces and surgical interventions. For methods used for both acute and chronic pain, those perceived as most helpful were opioids, massage therapies, splints or braces, heat therapy and avoiding potentially dangerous activities. EDS is a complex, multi-systemic condition that can be difficult to diagnose and poses challenges for healthcare practitioners who engage with EDS patients in holistic care. Improved healthcare provider knowledge of EDS is needed, and additional research on the co-occurring diagnoses with EDS may assist in comprehensive pain management for EDS patients. Ehlers-Danlos Syndrome (EDS) is a group of connective tissue disorders associated with defective production of collagen, which can dramatically reduce musculoskeletal functioning by symptoms of joint laxity and frequent dislocations eventually leading to disability. Respondents to an on-line survey reported having to seek out confirmation of their EDS diagnosis with multiple physicians, which implies the difficulty many people with EDS face when trying to gain access to appropriate treatment. Participants with EDS reported the most helpful methods for managing acute pain were opioids, surgical interventions, splints and braces, heat therapy, nerve blocks and physical therapy, while chronic pain was treated most effectively with opioids, heat therapy, splints or braces and surgical interventions.

The Association of Health Literacy With Preventable Emergency Department Visits: A Cross-sectional Study.

PubMed

Balakrishnan, Meenakshi P; Herndon, Jill Boylston; Zhang, Jingnan; Payton, Thomas; Shuster, Jonathan; Carden, Donna L

2017-09-01

Policymakers argue that emergency department (ED) visits for conditions preventable with high-quality outpatient care contribute to waste in the healthcare system. However, access to ambulatory care is uneven, especially for vulnerable populations like minorities, the poor, and those with limited health literacy. The impact of limited health literacy on ED visits that are preventable with timely, high-quality ambulatory care is unknown. The objective was to determine the association of health literacy with preventable ED visits. We conducted an observational cross-sectional study of potentially preventable ED visits (outcome) among adults (≥18 years old) in an ED serving an urban community. We assessed health literacy (predictor) through structured interviews with the Rapid Estimate of Adult Literacy in Medicine (REALM). We recorded age, sex, race, employment, payer, marital and health status, and number of comorbidities through structured interviews or electronic record review. We identified potentially preventable ED visits in the 2 years before the index ED visit by applying Agency for Healthcare Research and Quality technical specifications to identify ambulatory care sensitive conditions using ED discharge diagnoses in hospital administrative data. We used Poisson regression to evaluate the number of preventable ED visits among patients with limited (REALM < 61) versus adequate (REALM ≥ 61) health literacy after adjusting for covariates. Of 1,201 participants, 709 (59%) were female, 370 (31%) were African American, mean age was 41.6 years, and 394 (33%) had limited health literacy. Of 4,444 total ED visits, 423 (9.5%) were potentially preventable. Of these, 260 (61%) resulted in hospital admission and 163 (39%) were treat and release. After covariates were adjusted for, patients with limited literacy had 2.3 (95% confidence interval [CI] = 1.7-3.1) times the number of potentially preventable ED visits resulting in hospital admission compared to individuals with adequate health literacy, 1.4 (95% CI = 1.0-2.0) times the number of treat-and-release visits, and 1.9 (95% CI = 1.5-2.4) times the number of total preventable ED visits. Our results suggest that the ED may be an important site to deploy universal literacy-sensitive precautions and to test literacy-sensitive interventions with the goal of reducing the burden of potentially preventable ED visits on patients and the healthcare system. © 2017 by the Society for Academic Emergency Medicine.

Mobile health care operations and return on investment in predominantly underserved children with asthma: the breathmobile program.

PubMed

Morphew, Tricia; Scott, Lyne; Li, Marilyn; Galant, Stanley P; Wong, Webster; Garcia Lloret, Maria I; Jones, Felita; Bollinger, Mary Elizabeth; Jones, Craig A

2013-08-01

Underserved populations have limited access to care. Improved access to effective asthma care potentially improves quality of life and reduces costs associated with emergency department (ED) visits. The purpose of this study is to examine return on investment (ROI) for the Breathmobile Program in terms of improved patient quality-adjusted life years saved and reduced costs attributed to preventable ED visits for 2010, with extrapolation to previous years of operation. It also examines cost-benefit related to reduced morbidity (ED visits, hospitalizations, and school absenteeism) for new patients to the Breathmobile Program during 2008-2009 who engaged in care (≥3 visits). This is a retrospective analysis of data for 15,986 pediatric patients, covering 88,865 visits, participating in 4 Southern California Breathmobile Programs (November 16, 1995-December 31, 2010). The ROI calculation expressed the cost-benefit ratio as the net benefits (ED costs avoided+relative value of quality-adjusted life years saved) over the per annum program costs (∼$500,000 per mobile). The ROI across the 4 California programs in 2010 was $6.73 per dollar invested. Annual estimated emergency costs avoided in the 4 regions were $2,541,639. The relative value of quality-adjusted life years saved was $24,381,000. For patients new to the Breathmobile Program during 2008-2009 who engaged in care (≥3 visits), total annual morbidity costs avoided per patient were $1395. This study suggests that mobile health care is a cost-effective strategy to deliver medical care to underserved populations, consistent with the Triple Aims of Therapy.

Medical-attention injuries in community Australian football: a review of 30 years of surveillance data from treatment sources.

PubMed

Ekegren, Christina L; Gabbe, Belinda J; Finch, Caroline F

2015-03-01

In recent reports, Australian football has outranked other team sports in the frequency of hospitalizations and emergency department (ED) presentations. Understanding the profile of these and other "medical-attention" injuries is vital for developing preventive strategies that can reduce health costs. The objective of this review was to describe the frequency and profile of Australian football injuries presenting for medical attention. A systematic search was carried out to identify peer-reviewed articles and reports presenting original data about Australian football injuries from treatment sources (hospitals, EDs, and health-care clinics). Data extracted included injury frequency and rate, body region, and nature and mechanism of injury. Following literature search and review, 12 publications were included. In most studies, Australian football contributed the greatest number of injuries out of any sport or recreation activity. Hospitals and EDs reported a higher proportion of upper limb than lower limb injuries, whereas the opposite was true for sports medicine clinics. In hospitals, fractures and dislocations were most prevalent out of all injuries. In EDs and clinics, sprains/strains were most common in adults and superficial injuries were predominant in children. Most injuries resulted from contact with other players or falling. The upper limb was the most commonly injured body region for Australian football presentations to hospitals and EDs. Strategies to prevent upper limb injuries could reduce associated public health costs. However, to understand the full extent of the injury problem in football, treatment source surveillance systems should be supplemented with other datasets, including community club-based collections.

Hypercaloric Diet Establishes Erectile Dysfunction in Rat: Mechanisms Underlying the Endothelial Damage

PubMed Central

de Souza, Iara L. L.; Barros, Bárbara C.; de Oliveira, Giuliana A.; Queiroga, Fernando R.; Toscano, Lydiane T.; Silva, Alexandre S.; Silva, Patrícia M.; Interaminense, Leylliane F. L.; Cavalcante, Fabiana de Andrade; da Silva, Bagnólia A.

2017-01-01

Obesity is characterized by an excessive increase in body mass, leading to endothelial damage that may favor the development of erectile dysfunction (ED). ED is defined as the inability to achieve or maintain a penile erection long enough to have a sexual intercourse. In this context, different ED models were developed, however the high price of special animals or the long period to establish the disease has limited studies in this field. Therefore, this study proposed to establish and characterize a novel model of ED in rats associated to a hypercaloric diet consumption. Animals were randomly divided into control group (CG), which received a standard diet, and obese group (OG), fed with a hypercaloric diet during 8 weeks. Rat's erectile function was evaluated in vivo and in vitro. Food and caloric intake of OG were reduced compared to CG, due to an increased diet energy efficiency. However, OG presented an increased body mass, inguinal, retroperitoneal and epididymal adipose tissues, as well as body adiposity index at the end of experimental protocol. In erectile function analysis, there was a decrease in the number and the latency of penile erections in OG. Additionally, the contractile reactivity of corpus cavernosum was increased in OG, favoring penile detumescence and related to a reduced nitric oxide bioavailability and an increased in contractile prostaglandins levels as a consequence of endothelial damage. Moreover, the endothelium-relaxation reactivity of corpus cavernosum was attenuated in OG associated to the oxidative stress. Thus, it was provided a model for advances in sexual dysfunction field and drug discovery for ED treatment. PMID:29085300

Reductions in emergency department visits after primary healthcare use of the UK National Poisons Information Service.

PubMed

Elamin, Muhammad E M O; James, David A; Holmes, Peter; Jackson, Gillian; Thompson, John P; Sandilands, Euan A; Bradberry, Sally; Thomas, Simon H L

2018-05-01

Suspected poisoning is a common cause of hospital admission internationally. In the United Kingdom, the National Poisons Information Service (NPIS), a network of four poisons units, provides specialist advice to health professionals on the management of poisoning by telephone and via its online poisoning information and management database, TOXBASE ® . To demonstrate the impact of NPIS telephone advice and TOXBASE ® guidance on poisoning-related referrals to emergency departments (ED) from primary healthcare settings. A telephone survey of primary healthcare providers calling the NPIS and an online survey of TOXBASE ® primary care users were conducted to evaluate the effect of these services on poisoning-related ED referrals. Enquirers were asked to indicate whether referral was needed before and after using these information sources. The number of cases considered by enquirers appropriate for ED referral was reduced from 1178 (58.1%) before to 819 (40.4%) after the provision of telephone advice for 2028 cases (absolute reduction 17.7%, 95% CI 14.6, 20.7%) and from 410 (48.2%) before to 341 (40.1%) after consideration of TOXBASE ® guidance for 851 cases (absolute reduction 8.1%, 95% CI 3.3, 12.9%). By extrapolating these figures over a full year, it is estimated that these services prevent approximately 41,000 ED referrals annually. The use of NPIS services significantly reduced ED referrals from primary healthcare services with resulting avoided healthcare costs exceeding the current annual NPIS budget. Further studies are needed to evaluate other potential benefits of accessing NPIS services.

The effects of publishing emergency department wait time on patient utilization patterns in a community with two emergency department sites: a retrospective, quasi-experiment design.

PubMed

Xie, Bin; Youash, Sabrina

2011-06-14

Providing emergency department (ED) wait time information to the public has been suggested as a mechanism to reduce lengthy ED wait times (by enabling patients to select the ED site with shorter wait time), but the effects of such a program have not been evaluated. We evaluated the effects of such a program in a community with two ED sites. Descriptive statistics for wait times of the two sites before and after the publication of wait time information were used to evaluate the effects of the publication of wait time information on wait times. Multivariate logistical regression was used to test whether or not individual patients used published wait time to decide which site to visit. We found that the rates of wait times exceeding 4 h, and the 95th percentile of wait times in the two sites decreased after the publication of wait time information, even though the average wait times experienced a slight increase. We also found that after controlling for other factors, the site with shorter wait time had a higher likelihood of being selected after the publication of wait time information, but there was no such relationship before the publication. These findings were consistent with the hypothesis that the publication of wait time information leads to patients selecting the site with shorter wait time. While publishing ED wait time information did not improve average wait time, it reduced the rates of lengthy wait times.

Right to know: reducing risks of fecal pathogen exposure for ED patients and staff.

PubMed

Delaney, Molly Bridget

2014-07-01

The purpose of this article is to review the literature regarding the multiple challenges that contribute to ED bedside toileting and examine best practices that will reduce fecal exposure, cross-contamination among patients, and employee splash injuries. We searched the Cumulative Index to Nursing and Allied Health Literature, MEDLINE, and Cochrane database for information about the multiple challenges involved in bedside toileting, using the following search terms: bedside toileting, gastroenteritis, macerator, sluice machine, fecal pathogen exposure, and splash injury. In addition, costs and benefits of reusable versus disposable bedside toileting equipment were compared and contrasted. Emergency departments have a higher exposure rate to fecal pathogens with current methods of bedside toileting. Short incubation periods may not allow the proper lead time needed for patients to access primary care providers. As a result, emergency departments and urgent care centers become a likely point of entry into the health care system. Although most inpatient rooms have built-in bathrooms, most emergency departments and outpatient examination rooms do not. Although many patients are ambulatory, restrictive monitoring equipment is required. For safety reasons, staff must bring toileting equipment to the bedsides of both ambulatory and non-ambulatory patients. Hopper dependence creates longer walking distances and delays. These delays may lead to incontinence events, skin breakdown, more frequent bed changes, and higher linen and labor costs. Reusable bedside toileting equipment is associated with at-risk behaviors. Examples are procrastination and sanitization shortcuts. These behaviors risk cross-contamination of patients especially when urgent situations require equipment to be reused in the interim. ED patients and staff are 5 times more likely to undergo fecal exposure. The 5 phases of ED bedside toileting at which risks occur are as follows: equipment setup, transport of human waste to drainage areas, transfer of waste, pre-cleaning, and equipment disinfection. Therefore it is imperative that ED staff have a full understanding of hazardous materials involved, know safer bedside toileting practices, and have safer equipment available to protect all involved. Upgrading our knowledge, equipment, and practices must become a higher priority for ED leadership. The East Bank Emergency Department of the University of Minnesota Medical Center, Fairview, will be moving toward 100% disposable bedside commode pails in addition to disposable bedpans, currently in use. On the basis of a literature review to understand best-practice ED bedside toileting, the following article was created. As a result of our learning, the University of Minnesota Medical Center emergency staff has designed, patented, and developed a landfill-compliant disposable commode pail that absorbs waste while reducing splashes and spills. Disposable commode pails (bags) are conveniently wall mounted for quick availability, and "at-risk behavior" is reduced. Advantages are all point-of-care. Both setup and waste treatment and disposal start and end at the bedside. The advantages are faster response times, reduction of soiled linens and bed changes, prevention of incontinence and skin breakdown events, and reduced splash injuries or pathogen transmission. Patient satisfaction improves with shorter bedside toileting delays. Employee satisfaction increases with reduced human waste handling. The cost of each unit is comparable to an adult overnight diaper. Bariatric commode pails or bags are in the planning phase, and a "green" disposable commode pail, made from biodegradable corn byproducts, will be made available at a higher cost. Copyright © 2014 Emergency Nurses Association. Published by Mosby, Inc. All rights reserved.

Traditional Chinese medical therapy for erectile dysfunction

PubMed Central

Li, Hao; Jiang, Hongyang

2017-01-01

Traditional Chinese medicine (TCM), including acupuncture and Chinese herbs, is used as an alternative therapy to increase the curative effect for erectile dysfunction (ED). A large number of studies have been conducted to investigate the effect and mechanism of TCM for treating ED. The therapeutic effect of acupuncture on ED is still controversial at present. However, some Chinese herbs exhibited satisfying outcomes and they might improve erectile function by activating nitric oxide synthase (NOS)-cyclic guanosine monophosphate (cGMP) pathway, increasing cyclic adenosine monophosphate (cAMP) expression, elevating testosterone level, reducing intracellular Ca2+ concentration, down-regulating transforming growth factor β1 (TGFβ1)/Smad2 signaling pathway, or ameliorating the oxidative stress. PMID:28540226

ED becomes 'lean' and cuts LBTC, LOS times.

PubMed

2008-04-01

Lean manufacturing techniques, first developed by Toyota, can be successfully adapted to help improve processes in your ED. St. Luke's Episcopal Hospital in Houston, has used Lean to reduce median length of stay, frequency of diversions, and the percentage of patients who left before treatment was complete (LBTC). Here's why "Lean" can help improve the performance of your ED: It enables you and your staff to see things from the patient's point of view. Lean tools enable you to view the status of your department in real-time and to compare that status with your performance goals. Exercises help identify areas where your processes break down and determine the most likely solutions.

An observational study of emergency department utilization among enrollees of Minnesota Health Care Programs: financial and non-financial barriers have different associations.

PubMed

Shippee, Nathan D; Shippee, Tetyana P; Hess, Erik P; Beebe, Timothy J

2014-02-08

Emergency department (ED) use is costly, and especially frequent among publicly insured populations in the US, who also disproportionately encounter financial (cost/coverage-related) and non-financial/practical barriers to care. The present study examines the distinct associations financial and non-financial barriers to care have with patterns of ED use among a publicly insured population. This observational study uses linked administrative-survey data for enrollees of Minnesota Health Care Programs to examine patterns in ED use-specifically, enrollee self-report of the ED as usual source of care, and past-year count of 0, 1, or 2+ ED visits from administrative data. Main independent variables included a count of seven enrollee-reported financial concerns about healthcare costs and coverage, and a count of seven enrollee-reported non-financial, practical barriers to access (e.g., limited office hours, problems with childcare). Covariates included health, health care, and demographic measures. In multivariate regression models, only financial concerns were positively associated with reporting ED as usual source of care, but only non-financial barriers were significantly associated with greater ED visits. Regression-adjusted values indicated notable differences in ED visits by number of non-financial barriers: zero non-financial barriers meant an adjusted 78% chance of having zero ED visits (95% C.I.: 70.5%-85.5%), 15.9% chance of 1(95% C.I.: 10.4%-21.3%), and 6.2% chance (95% C.I.: 3.5%-8.8%) of 2+ visits, whereas having all seven non-financial barriers meant a 48.2% adjusted chance of zero visits (95% C.I.: 30.9%-65.6%), 31.8% chance of 1 visit (95% C.I.: 24.2%-39.5%), and 20% chance (95% C.I.: 8.4%-31.6%) of 2+ visits. Financial barriers were associated with identifying the ED as one's usual source of care but non-financial barriers were associated with actual ED visits. Outreach/literacy efforts may help reduce reliance on/perception of ED as usual source of care, whereas improved targeting/availability of covered services may help curb frequent actual visits, among publicly insured individuals.

Abstinence from prolonged ethanol exposure affects plasma corticosterone, glucocorticoid receptor signaling and stress-related behaviors.

PubMed

Somkuwar, Sucharita S; Vendruscolo, Leandro F; Fannon, McKenzie J; Schmeichel, Brooke E; Nguyen, Tran Bao; Guevara, Jasmin; Sidhu, Harpreet; Contet, Candice; Zorrilla, Eric P; Mandyam, Chitra D

2017-10-01

Alcohol dependence is linked to dysregulation of the hypothalamic-pituitary-adrenal axis. Here, we investigated effects of repeated ethanol intoxication-withdrawal cycles (using chronic intermittent ethanol vapor inhalation; CIE) and abstinence from CIE on peak and nadir plasma corticosterone (CORT) levels. Irritability- and anxiety-like behaviors as well as glucocorticoid receptors (GR) in the medial prefrontal cortex (mPFC) were assessed at various intervals (2h-28d) after cessation of CIE. Results show that peak CORT increased during CIE, transiently decreased during early abstinence (1-11d), and returned to pre-abstinence levels during protracted abstinence (17-27d). Acute withdrawal from CIE enhanced aggression- and anxiety-like behaviors. Early abstinence from CIE reduced anxiety-like behavior. mPFC-GR signaling (indexed by relative phosphorylation of GR at Ser211) was transiently decreased when measured at time points during early and protracted abstinence. Further, voluntary ethanol drinking in CIE (CIE-ED) and CIE-naïve (ED) rats, and effects of CIE-ED and ED on peak CORT levels and mPFC-GR were investigated during acute withdrawal (8h) and protracted abstinence (28d). CIE-ED and ED increased peak CORT during drinking. CIE-ED and ED decreased expression and signaling of mPFC-GR during acute withdrawal, an effect that was reversed by systemic mifepristone treatment. CIE-ED and ED demonstrate robust reinstatement of ethanol seeking during protracted abstinence and show increases in mPFC-GR expression. Collectively, the data demonstrate that acute withdrawal from CIE produces robust alterations in GR signaling, CORT and negative affect symptoms which could facilitate excessive drinking. The findings also show that CIE-ED and ED demonstrate enhanced relapse vulnerability triggered by ethanol cues and these changes are partially mediated by altered GR expression in the mPFC. Taken together, transition to alcohol dependence could be accompanied by alterations in mPFC stress-related pathways that may increase negative emotional symptoms and increase vulnerability to relapse. Copyright © 2017 Elsevier Ltd. All rights reserved.

Comparison of secure messaging application (WhatsApp) and standard telephone usage for consultations on Length of Stay in the ED. A prospective randomized controlled study.

PubMed

Gulacti, Umut; Lok, Ugur

2017-07-19

Consultation, the process of an Emergency Physician seeking an opinion from other specialties, occurs frequently in the Emergency Department (ED). The aim of this study was to determine the effect of secure messaging application (WhatsApp) usage for medical consultations on Emergency Department Length of Stay (ED LOS) and consult time. We conducted a prospective, randomized controlled trial in the ED using allocation concealment over three months. Consultations requested in the ED were allocated into two groups: consultations requested via the secure messaging application and consultations requested by telephone as verbal. A total of 439 consultations requested in the ED were assessed for eligibility and 345 were included in the final analysis: 173 consultations were conducted using secure messaging application and 172 consultations were conducted using standard telephone communications. The median ED LOS was 240 minutes (IQR:230-270, 95% CI:240 to 255.2) for patients in the secure messaging application group and 277 minutes (IQR:270-287.8, 95% CI:277 to 279) for patients in the telephone group. The median total ED LOS was significantly lower among consults conducted using Secure messaging application relative to consults conducted by telephone (median dif: -30, 95%CI:-37to-25, p<0.0001). The median consult time was 158 minutes (IQR:133 to 177.25, 95% CI:150 to 169) for patients in the Secure messaging application group and 170 minutes (IQR:165 to 188.5, 95% CI:170-171) for patients in the Telephone group (median dif: -12, 95%CI:-19 to-7,p<0.0001). Consultations completed without ED arrival was 61.8% in the secure messaging group and 33.1% in the Telephone group (dif: 28.7, 95% CI:48.3 to 66, p<0.001). Use of secure messaging application for consultations in the ED reduces the total ED LOS and consultation time. Consultation with secure messaging application eliminated more than half of in-person ED consultation visits.

The effects of new pricing and copayment schemes for pharmaceuticals in South Korea.

PubMed

Lee, Iyn-Hyang; Bloor, Karen; Hewitt, Catherine; Maynard, Alan

2012-01-01

This study examined the effect of new Korean pricing and copayment schemes for pharmaceuticals (1) on per patient drug expenditure, utilisation and unit prices of overall pharmaceuticals; (2) on the utilisation of essential medications and (3) on the utilisation of less costly alternatives to the study medication. Interrupted time series analysis using retrospective observational data. The increasing trend of per patient drug expenditure fell gradually after the introduction of a new copayment scheme. The segmented regression model suggested that per patient drug expenditure might decrease by about 12% 1 year after the copayment increase, compared with the absence of such a policy, with few changes in overall utilisation and unit prices. The level of savings was much smaller when the new price scheme was included, while the effects of a price cut were inconclusive due to the short time period before an additional policy change. Based on the segmented regression models, we estimate that the number of patients filling their antihyperlipidemics prescriptions decreased by 18% in the corresponding period. Those prescribed generic and brand-named antihyperlipidemics declined by around 16 and 19%, respectively, indicating little evidence of generic substitution resulting from the copayment increase. Few changes were found in the use of antihypertensives. The policies under consideration appear to contain costs not by the intended mechanisms, such as substituting generics for brand name products, but by reducing patients' access to costly therapies regardless of clinical necessity. Thus, concerns were raised about potentially compromising overall health and loss of equity in pharmaceutical utilisation. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

Shifting chronic disease management from hospitals to primary care in Estonian health system: analysis of national panel data

PubMed Central

Atun, Rifat; Gurol–Urganci, Ipek; Hone, Thomas; Pell, Lisa; Stokes, Jonathan; Habicht, Triin; Lukka, Kaija; Raaper, Elin; Habicht, Jarno

2016-01-01

Background Following independence from the Soviet Union in 1991, Estonia introduced a national insurance system, consolidated the number of health care providers, and introduced family medicine centred primary health care (PHC) to strengthen the health system. Methods Using routinely collected health billing records for 2005–2012, we examine health system utilisation for seven ambulatory care sensitive conditions (ACSCs) (asthma, chronic obstructive pulmonary disease [COPD], depression, Type 2 diabetes, heart failure, hypertension, and ischemic heart disease [IHD]), and by patient characteristics (gender, age, and number of co–morbidities). The data set contained 552 822 individuals. We use patient level data to test the significance of trends, and employ multivariate regression analysis to evaluate the probability of inpatient admission while controlling for patient characteristics, health system supply–side variables, and PHC use. Findings Over the study period, utilisation of PHC increased, whilst inpatient admissions fell. Service mix in PHC changed with increases in phone, email, nurse, and follow–up (vs initial) consultations. Healthcare utilisation for diabetes, depression, IHD and hypertension shifted to PHC, whilst for COPD, heart failure and asthma utilisation in outpatient and inpatient settings increased. Multivariate regression indicates higher probability of inpatient admission for males, older patient and especially those with multimorbidity, but protective effect for PHC, with significantly lower hospital admission for those utilising PHC services. Interpretation Our findings suggest health system reforms in Estonia have influenced the shift of ACSCs from secondary to primary care, with PHC having a protective effect in reducing hospital admissions. PMID:27648258

Radiology response in the emergency department during a mass casualty incident: a retrospective study of the two terrorist attacks on 22 July 2011 in Norway.

PubMed

Young, Victoria Solveig; Eggesbø, Heidi B; Gaarder, Christine; Næss, Pål Aksel; Enden, Tone

2017-07-01

To describe the use of radiology in the emergency department (ED) in a trauma centre during a mass casualty incident, using a minimum acceptable care (MAC) strategy in which CT was restricted to potentially severe head injuries. We retrospectively studied the initial use of imaging on patients triaged to the trauma centre following the twin terrorist attacks in Norway on 22 July 2011. Nine patients from the explosion and 15 from the shooting were included. Fourteen patients had an Injury Severity Score >15. During the first 15 h, 22/24 patients underwent imaging in the ED. All 15 gunshot patients had plain films taken in the ED, compared to three from the explosion. A CT was performed in 18/24 patients; ten of these were completed in the ED and included five non-head CTs, the latter representing deviations from the MAC strategy. No CT referrals were delayed or declined. Mobilisation of radiology personnel resulted in a tripling of the staff. Plain film and CT capacity was never exceeded despite deviations from the MAC strategy. An updated disaster management plan will require the radiologist to cancel non-head CTs performed in the ED until no additional MCI patients are expected. • Minimum acceptable care (MAC) should replace normal routines in mass casualty incidents. • MAC implied reduced use of imaging in the emergency department (ED). • CT in ED was restricted to suspected severe head injuries during MAC. • The radiologist should cancel all non-head CTs in the ED during MAC.

Emergency department clinical redesign, team-based care and improvements in hospital performance: A time series analysis.

PubMed

Dinh, Michael M; Green, Timothy C; Bein, Kendall J; Lo, Serigne; Jones, Aaron; Johnson, Terence

2015-08-01

The objective was to evaluate the impact of an ED clinical redesign project that involved team-based care and early senior assessment on hospital performance. This was an interrupted time series analysis performed using daily hospital performance data 6 months before and 8 months after the implementation of the clinical redesign intervention that involved Emergency Consultant-led team-based care, redistribution of ED beds and implementation of a senior nursing coordination roles in the ED. The primary outcome was the daily National Emergency Access Target (NEAT) performance (proportion of total daily ED presentations that were admitted to an inpatient ward or discharged from ED within 4 h of arrival). Secondary outcomes were daily ALOS in ED, inpatient Clinical Emergency Response System (CERS) calls and hospital mortality. Autoregressive Integrated Moving Average analysis was used to model NEAT performance. Hospital mortality was modelled using negative binomial regression. After adjusting for patient volume, inpatient admissions, ambulance, hospital occupancy, weekends ED Consultant numbers, weekends and underlying trends, there was a 17% improvement in NEAT associated with the post-intervention period (95% CI 12, 19% P < 0.001). There was no change in the number of CERS calls and the median daily hospital mortality rate reduced from 1.04% to 0.96% (P = 0.025). An ED-focused clinical redesign project was associated with a 17% improvement in NEAT performance with no evidence of an increase in clinical deterioration on inpatient wards and evidence for an improvement in hospital mortality. © 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Eating disorders in children and adolescents: state of the art review.

PubMed

Campbell, Kenisha; Peebles, Rebecka

2014-09-01

Despite their high prevalence, associated morbidity and mortality, and available treatment options, eating disorders (EDs) continue to be underdiagnosed by pediatric professionals. Many adolescents go untreated, do not recover, or reach only partial recovery. Higher rates of EDs are seen now in younger children, boys, and minority groups; EDs are increasingly recognized in patients with previous histories of obesity. Medical complications are common in both full and subthreshold EDs and affect every organ system. No single cause of EDs has emerged, although neurobiological and genetic predispositions are emerging as important. Recent treatment paradigms acknowledge that they are not caused by families or chosen by patients. EDs present differently in pediatric populations, and providers should have a high index of suspicion using new Diagnostic and Statistical Manual, 5th edition diagnostic criteria because early intervention can affect prognosis. Outpatient family-based treatment focused on weight restoration, reducing blame, and empowering caregivers has emerged as particularly effective; cognitive behavioral therapy, individual therapy, and higher levels of care may also be appropriate. Pharmacotherapy is useful in specific contexts. Full weight restoration is critical, often involves high-calorie diets, and must allow for continued growth and development; weight maintenance is typically inappropriate in pediatric populations. Physical, nutritional, behavioral, and psychological health are all metrics of a full recovery, and pediatric EDs have a good prognosis with appropriate care. ED prevention efforts should work toward aligning with families and understanding the impact of antiobesity efforts. Primary care providers can be key players in treatment success. Copyright © 2014 by the American Academy of Pediatrics.

Accidental pharmacological poisonings in young children: population-based study in three settings.

PubMed

Bell, Jane C; Bentley, Jason P; Downie, Catriona; Cairns, Rose; Buckley, Nicholas A; Katelaris, Annette; Pearson, Sallie-Anne; Nassar, Natasha

2018-01-15

Pharmacological poisonings in young children are avoidable. Previous studies report calls to poisons centres, presentations to emergency departments (ED) or hospital admissions. There are limited data assessing concurrent management of poisonings across all three settings. We aimed to describe accidental pharmacological poisonings in young children across our Poisons Information Centre (PIC), EDs and hospitals. A population-based study in New South Wales, Australia, of PIC calls, ED presentations and hospital admissions for accidental pharmacological poisoning in children aged <5 years, 2007-2013. We examined trends, medicines responsible and subsequent management. Medicines were coded using ICD10-AM diagnosis codes (T36-50). Over 2007-2013, pharmacological poisonings accounted for 67,816 PIC calls, 7739 ED presentations and 2082 admissions. Rates (per 10,000 children) of PIC calls declined from 220 to 178; ED presentations were stable (∼22-24), with a decrease in emergency cases offset by an increase in semi- or non-urgent presentations; hospital admissions declined (8-5). Most PIC calls related to "non-opioid analgesics" (25%), and "topical agents" (18%). Nearly every day, one child aged <5 years was admitted to hospital for poisoning. "Benzodiazepines", "other and unspecified antidepressants", "uncategorised antihypertensives", and "4-aminophenol derivatives" accounted for over one-third of all admissions. Most PIC calls (90%) were advised to stay home, 6% referred to hospital. One-quarter of ED presentations resulted in admission. Poisonings reported to PIC and hospitals declined, however, non-urgent ED presentations increased. Strategies to reduce therapeutic errors and access to medicines, and education campaigns to improve Poisons Centre call rates to prevent unnecessary ED presentations are needed.

A systematic review of the effects of neuromodulation on eating and body weight: evidence from human and animal studies.

PubMed

McClelland, Jessica; Bozhilova, Natali; Campbell, Iain; Schmidt, Ulrike

2013-11-01

Eating disorders (ED) are chronic and sometimes deadly illnesses. Existing treatments have limited proven efficacy, especially in the case of adults with anorexia nervosa (AN). Emerging neural models of ED provide a rationale for more targeted, brain-directed interventions. This systematic review has examined the effects of neuromodulation techniques on eating behaviours and body weight and assessed their potential for therapeutic use in ED. All articles in PubMed, PsychInfo and Web of Knowledge were considered and screened against a priori inclusion/exclusion criteria. The effects of repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation, vagus nerve stimulation (VNS) and deep brain stimulation (DBS) were examined across studies in ED samples, other psychiatric and neurological disorders, and animal models. Sixty studies were identified. There is evidence for ED symptom reduction following rTMS and DBS in both AN and bulimia nervosa. Findings from studies of other psychiatric and neurological disorders and from animal studies demonstrate that increases in food intake and body weight can be achieved following DBS and that VNS has potential value as a means of controlling eating and inducing weight loss. Neuromodulation tools have potential for reducing ED symptomatology and related behaviours, and for altering food intake and body weight. In response to such findings, and emerging neural models of ED, treatment approaches are highly unlikely to remain 'brainless'. More research is required to evaluate the potential of neuromodulation procedures for improving long-term outcomes in ED. Copyright © 2013 John Wiley & Sons, Ltd and Eating Disorders Association.

The association between muscle strength and activity limitations in patients with the hypermobility type of Ehlers-Danlos syndrome: the impact of proprioception.

PubMed

Scheper, Mark; Rombaut, Lies; de Vries, Janneke; De Wandele, Inge; van der Esch, Martin; Visser, Bart; Malfait, Franciska; Calders, Patrick; Engelbert, Raoul

2017-07-01

The patients diagnosed with Ehlers-Danlos Syndrome Hypermobility Type (EDS-HT) are characterized by pain, proprioceptive inacuity, muscle weakness, potentially leading to activity limitations. In EDS-HT, a direct relationship between muscle strength, proprioception and activity limitations has never been studied. The objective of the study was to establish the association between muscle strength and activity limitations and the impact of proprioception on this association in EDS-HT patients. Twenty-four EDS-HT patients were compared with 24 controls. Activity limitations were quantified by Health Assessment Questionnaire (HAQ), Six-Minute Walk test (6MWT) and 30-s chair-rise test (30CRT). Muscle strength was quantified by handheld dynamometry. Proprioception was quantified by movement detection paradigm. In analyses, the association between muscle strength and activity limitations was controlled for proprioception and confounders. Muscle strength was associated with 30CRT (r = 0.67, p = <0.001), 6MWT (r = 0.58, p = <0.001) and HAQ (r = 0.63, p= <0.001). Proprioception was associated with 30CRT (r = 0.55, p < 0.001), 6MWT (r = 0.40, p = <0.05) and HAQ (r = 0.46, p < 0.05). Muscle strength was found to be associated with activity limitations, however, proprioceptive inacuity confounded this association. Muscle strength is associated with activity limitations in EDS-HT patients. Joint proprioception is of influence on this association and should be considered in the development of new treatment strategies for patients with EDS-HT. Implications for rehabilitation Reducing activity limitations by enhancing muscle strength is frequently applied in the treatment of EDS-HT patients. Although evidence regarding treatment efficacy is scarce, the current paper confirms the rationality that muscle strength is an important factor in the occurrence of activity limitations in EDS-HT patients. Although muscle strength is the most dominant factor that is associated with activity limitations, this association is confounded by proprioception. In contrast to common belief proprioception was not directly associated with activity limitations but confounded this association. Controlling muscle strength on the bases of proprioceptive input may be more important for reducing activity limitations than just enhancing sheer muscle strength.

Randomized trial of pragmatic education for low-risk COPD patients: impact on hospitalizations and emergency department visits

PubMed Central

Siddique, Haamid H; Olson, Raymond H; Parenti, Connie M; Rector, Thomas S; Caldwell, Michael; Dewan, Naresh A; Rice, Kathryn L

2012-01-01

Background: Most interventions aimed at reducing hospitalizations and emergency department (ED) visits in patients with chronic obstructive pulmonary disease (COPD) have employed resource-intense programs in high-risk individuals. Although COPD is a progressive disease, little is known about the effectiveness of proactive interventions aimed at preventing hospitalizations and ED visits in the much larger population of low-risk (no known COPD-related hospitalizations or ED visits in the prior year) patients, some of whom will eventually become high-risk. Methods: We tested the effect of a simple educational and self-efficacy intervention (n = 2243) versus usual care (n = 2182) on COPD/breathing-related ED visits and hospitalizations in a randomized study of low-risk patients at three Veterans Affairs (VA) medical centers in the upper Midwest. Administrative data was used to track VA admissions and ED visits. A patient survey was used to determine health-related events outside the VA. Results: Rates of COPD-related VA hospitalizations in the education and usual care group were not significantly different (3.4 versus 3.6 admissions per 100 person-years, respectively; 95% CI of difference −1.3 to 1.0, P = 0.77). The much higher patient-reported rates of non-VA hospitalizations for breathing-related problems were lower in the education group (14.0 versus 19.0 per 100 person-years; 95% CI −8.6 to −1.4, P = 0.006). Rates of COPD-related VA ED visits were not significantly different (6.8 versus 5.3; 95% CI −0.1 to 3.0, P = 0.07), nor were non-VA ED visits (32.4 versus 36.5; 95% CI −9.3 to 1.1, P = 0.12). All-cause VA admission and ED rates did not differ. Mortality rates (6.9 versus 8.3 per 100 person-years, respectively; 95% CI −3.0 to 0.4, P = 0.13) did not differ. Conclusion: An educational intervention that is practical for large numbers of low-risk patients with COPD may reduce the rate of breathing-related hospitalizations. Further research that more closely tracks hospitalizations to non-VA facilities is needed to confirm this finding. PMID:23118535

RNA Viruses that Cause Hemorrhagic, Encephalitic, and Febrile Disease

DTIC Science & Technology

1990-01-01

doses to levels that are subopti- effective dose (ED,0) values for Rift Valley mal for cures in other bunyavirus mouse Fever ( RVF ) virus (ED,, = 80 g...serum protein and AST Etiologic Agent (SGOT) identified in the placebo group by logistic regression], utilizing a stepwise lo- RVF , an old-world...treatment of H FRS in this study. Treatment reduced mortality RVF , distributed throughout sub-Saharan and improved several important aspects of Africa

Associations of Caffeinated Beverage Consumption and Screen Time with Excessive Daytime Sleepiness in Korean High School Students.

PubMed

Jun, Nuri; Lee, Aeri; Baik, Inkyung

2017-01-01

The present study investigated caffeinated beverage consumption and screen time in the association with excessive daytime sleepiness (EDS) and sleep duration. We conducted a cross-sectional study including 249 Korean male high school students. These participants responded to a questionnaire inquiring the information on lifestyle factors, consumption of caffeinated beverages, time spent for screen media, and sleep duration as well as to the Epworth Sleepiness Scale (ESS) questionnaire. EDS was defined as ESS scores of 9 or greater. Students with EDS consumed greater amount of chocolate/cocoa drinks and spent longer time for a TV and a mobile phone than those without EDS (p < 0.05). In addition, students with short sleep (≤ 6 hours) consumed greater amount of coffee than others whereas students with long sleep (> 8 hours) consumed greater amount of chocolate/cocoa drinks than others (p < 0.05). Screen time did not differ according to the categories of sleep duration. Although these findings do not support causal relationships, they suggest that screen time is associated with EDS, but not with sleep duration, and that consumption of certain types of caffeinated beverages is associated with EDS and sleep duration. Adolescents may need to reduce screen time and caffeine consumption to improve sleep quality and avoid daytime sleepiness.

Association Between Objectively Measured Physical Activity and Erectile Dysfunction among a Nationally Representative Sample of American Men.

PubMed

Loprinzi, Paul D; Edwards, Meghan

2015-09-01

Emerging work suggests an inverse association between physical activity and erectile dysfunction (ED). The majority of this cross-sectional research comes from convenience samples and all studies on this topic have employed self-report physical activity methodology. Therefore, the purpose of this brief-report, confirmatory research study was to examine the association between objectively measured physical activity and ED in a national sample of Americans. Data from the 2003-2004 National Health and Nutrition Examination Survey were used. Six hundred ninety-two adults between the ages of 50 and 85 years (representing 33.2 million adults) constituted the analytic sample. Participants wore an ActiGraph 7164 accelerometer (ActiGraph, Pensacola, FL, USA) for up to 7 days with ED assessed via self-report. The main outcome measure used was ED assessed via self-report. After adjustments, for every 30 min/day increase in moderate-to-vigorous physical activity, participants had a 43% reduced odds of having ED (odds ratioadjusted  = 0.57; 95% confidence interval: 0.40-0.81; P = 0.004). This confirmatory study employing an objective measure of physical activity in a national sample suggests an inverse association between physical activity and ED. © 2015 International Society for Sexual Medicine.

On-Line Derivatization Gas Chromatography Ion Trap Mass Spectrometry for Determination of Endocrine Disruptors in Surface Water

DOE Office of Scientific and Technical Information (OSTI.GOV)

Tzing, Shin-Hwa; Chang, Jia-Yaw; Ling, Yong-Chien

2004-03-31

A method has been developed for the determination of endocrine disruptors (EDs) (containing hydroxyl groups) in surface water from different sources. The surface water samples from different sites including school and local dormitory sewage effluents, lake water and river water were collected and analyzed. In this method, the pretreated sample is directly analyzed by GC-MS using on-line derivatization, where tetramethylammonium hydroxide (TMA-OH) was used as the derivatizing agent. Use of large-volume direct sample introduction (DSI) and co-injection of the sample and TMAOH avoids external contaminations as observed in conventional derivatization protocols. Additionally, the use of chemical ionization (CI) and CI-MS/MSmore » could enable detection of EDs at lower concentrations and reduce the matrices' interference thereby enhancing detection sensitivity of EDs for quantification. In this work, the use of dichloromethane as CI reagent for EDs is reported for the first time and could detect EDs to concentrations as low as 0.5 pg/mL. The recovery ranged from 74 to 112 % and the relative standard derivations for replicate analyses ranged from 5 to 17 %. We hope that this method will be applicable for routine analysis of EDs with hydroxyl functional groups.« less

Mechanisms for the development of esophageal atresia.

PubMed

Orford, J; Manglick, P; Cass, D T; Tam, P P

2001-07-01

There is no universally accepted theory to explain esophageal embryology and the abnormal development that produces esophageal atresia. The impact of Adriamycin administration on the pathogenesis of esophageal atresia was studied in the rat model of VATER association, from embryonic day (ED) 10 to ED 13. Tissues in the ED10 Adriamycin-exposed embryos displayed less cell proliferation as shown by the reduced population of MIB-5-labelled cells. Cell apoptosis that is characteristic of the normal ED 12 lateral epithelial folds of the foregut (the prospective site of tracheoesophageal septation) was absent in the foregut of the Adriamycin-exposed embryo. Histologic examination of the ED 11-exposed embryo showed the presence of abnormal notochord that was stretched, split, or tethered to the foregut. This contrasts with the normal embryo in which the notochord was localized in close vicinity of the ventral part of the neural tube and separated from the foregut by ample amount of mesenchyme. The abnormal localization of the notochord was accompanied by the lack of down-regulation of the sonic hedgehog (Shh) activity in the prospective site of future tracheoesophageal separation in the exposed ED 12 embryo. The authors proposed that the ectopic location of the notochord leads to the disruption in Shh signalling that may underpin the development of esophageal atresia. Copyright 2001 by W.B. Saunders Company.

Macrophage invasion does not contribute to muscle membrane injury during inflammation

NASA Technical Reports Server (NTRS)

Tidball, J. G.; Berchenko, E.; Frenette, J.

1999-01-01

Previous observations have shown that neutrophil invasion precedes macrophage invasion during muscle inflammation and that peak muscle injury is observed at the peak of ED1+ macrophage invasion. We tested the hypothesis that neutrophil invasion causes subsequent invasion by ED1+ macrophages and that ED1+ macrophages then contribute significantly to muscle membrane injury during modified muscle use. Rat hindlimbs were unloaded for 10 days followed by reloading by normal ambulation to induce inflammation. Membrane injury was measured by assaying Evans blue-bound serum protein influx through membrane lesions. Muscle neutrophil populations increased significantly during the first 2 h of reloading but ED1+ macrophages did not increase until 24 h. Neutrophil invasion was uncoupled from subsequent macrophage invasion by reloading rat hindlimbs for 2 h to cause neutrophil invasion, followed by resuspension for hours 2-24. This produced similar increases in neutrophil concentration as measured in muscles continuously reloaded for 24 h without causing an increase in macrophages. However, resuspension did not reduce the extent of muscle damage compared with that occurring in muscles that were reloaded continuously for 24 h. Thus, muscle invasion by neutrophils is not sufficient to cause invasion by ED1+ macrophages. In addition, muscle membrane injury that occurs during reloading is independent of invasion by ED1+ macrophages.

Influence of non-preferred foot technical training in reducing lower limbs functional asymmetry among young football players.

PubMed

Guilherme, José; Garganta, Júlio; Graça, Amândio; Seabra, André

2015-01-01

The functional asymmetry of the lower limbs has been regarded as a relevant factor of the performance of football players. We purposed to ascertain whether a specific technical training programme for the non-preferred foot has implications in the increasing utilisation rate of the respective member during the game. Young football players (n = 71) were randomly divided into experimental group (N = 35; 14.37 ± 1.94 years) and control group (N = 36; 14.50 ± 1.81 years). The study was developed into three stages: first, assessment of the index utilisation of both limbs during the game; second, application of a technical training programme that includes the drilling of specific motor skills exclusively directed to the non-preferred foot; and third, assessment of the new rate of both limbs' utilisation after the predefined six months. The main findings were: (1) the use of the non-preferred foot increased significantly with the technical training programme in the experimental group and remained constant in the control group; (2) the use of the preferred foot decreased significantly in the experimental group and remained similar in control group. We concluded that a systematic and specific technical training for the non-preferred foot increases its use and reduces functional asymmetry in game situation, consequently improving the player's performance.

Incidence, Risk Factors, and Costs for Hospital Returns After Total Joint Arthroplasties.

PubMed

Sibia, Udai S; Mandelblatt, Abigail E; Callanan, Maura A; MacDonald, James H; King, Paul J

2017-02-01

Unplanned hospital returns after total joint arthroplasty (TJA) reduce any cost savings in a bundled reimbursement model. We examine the incidence, risk factors, and costs for unplanned emergency department (ED) visits and readmissions within 30 days of index TJA. We retrospectively reviewed a consecutive series of 655 TJAs (382 total knee arthroplasty and 273 total hip arthroplasty) performed between April 2014 and March 2015. Preoperative diagnosis was osteoarthritis of the hip or knee (97%) or avascular necrosis of the hip (3%). Hospital costs were recorded for each ED visit and readmission episode. Of the 655 TJAs reviewed, 55 (8.4%) returned to the hospital. Of these hospital returns, 35 patients (5.3%) returned for a total of 36 unplanned ED visits whereas the remaining 20 patients (3.1%) presented 22 readmissions within 30 days of index TJA. The 2 most common reasons for unplanned ED visits were postoperative pain/swelling (36%) and medication-related side effects (22%). Avascular necrosis of the hip was a significant risk factor for an unplanned ED visit (7.27 odds ratio [OR], 95% confidence interval [CI] 1.67-31.61, P = .008). Multiple logistic regression analysis revealed the following risk factors for readmission: body mass index (1.10 OR, 95% CI 1.02-1.78, P = .013), comorbidity >2 (2.07 OR, 95% CI 1.06-6.95, P = .037), and prior total knee arthroplasty (2.61 OR, 95% CI 1.01-6.72, P = .047). Ambulating on the day of surgery trended toward a lower risk for readmission (0.13 OR, 95% CI 0.02-1.10, P = .061). The 2 most common reasons for readmission were ileus (23%) and cellulitis (18%). The total cost associated with unplanned ED visits were $15,427 whereas costs of readmissions totaled $142,654. Unplanned ED visits and readmissions in the forthcoming bundled payments reimbursement model will reduce cost savings from rapid recovery protocols for TJA. Identifying and mitigating preventable causes of unplanned visits and readmissions will be critical to improving care and controlling costs. Copyright © 2016 Elsevier Inc. All rights reserved.

The Alvarado score should be used to reduce emergency department length of stay and radiation exposure in select patients with abdominal pain.

PubMed

Coleman, Jamie J; Carr, Bryan W; Rogers, Tyrone; Field, Matthew S; Zarzaur, Ben L; Savage, Stephanie A; Hammer, Peter M; Brewer, Brian L; Feliciano, David V; Rozycki, Grace S

2018-06-01

Abdominal pain is the common reason patients seek treatment in emergency departments (ED), and computed tomography (CT) is frequently used for diagnosis; however, length of stay (LOS) in the ED and risks of radiation remain a concern. The hypothesis of this study was the Alvarado score (AS) could be used to reduce CT scans and decrease ED LOS for patients with suspected acute appendicitis (AA). A retrospective review of patients who underwent CT to rule out AA from January 1, 2015, to December 31, 2015, was performed. Patient demographics, medical history, ED documentation, operative interventions, complications, and LOS were all collected. Alvarado score was calculated from the medical record. Time to CT completion was calculated from times the patient was seen by ED staff, CT order, and CT report. Four hundred ninety-two patients (68.1% female; median age, 33 years) met the inclusion criteria. Most CT scans (70%) did not have findings consistent with AA. Median AS for AA on CT scan was 7, compared with 3 for negative CT (p < 0.001). One hundred percent of female patients with AS of 10 and males with AS of 9 or greater had AA confirmed by surgical pathology. Conversely, 5% or less of female patients with AS of 2 or less and 0% of male patients with AS of 1 or less were diagnosed with AA. One hundred six (21.5%) patients had an AS within these ranges and collectively spent 10,239 minutes in the ED from the time of the CT order until the radiologist's report. Males with an AS of 9 or greater and females with AS of 10 should be considered for treatment of AA without imaging. Males with AS of 1 or less and females with AS of 2 or less can be safely discharged with follow-up. Using AS, a significant proportion of patients can avoid the radiation risk, the increased cost, and increased ED LOS associated with CT. Diagnostic IV, therapeutic IV.

Evaluation of erectile dysfunction risk factors in young male survivors of colorectal cancer.

PubMed

Sendur, Mehmet A N; Aksoy, Sercan; Ozdemir, Nuriye Y; Yaman, Sebnem; Yazici, Ozan; Bulent Akinci, Muhammed; Uncu, Dogan; Zengin, Nurullah; Altundag, Kadri

2014-01-01

Improved long-term survival of colorectal cancer patients (CRC) treated with surgery and/or chemotherapy ± radiotherapy (RT) has led to increased awareness of long-term side effects, including effecting sexual life, which can ultimately affect the quality of life in these patients. Because the absolute risk factors of erectile dysfunction (ED) have not been defined in CRC patients, the aim of this research was to identify the severity and the absolute risk factors of ED in male CRC survivors. The medical records of 61 male survivors of CRC treated with surgery and/or chemotherapy ± RT were retrieved from the medical oncology outpatient clinics during routine follow-up visits in 2011-2012. Patients older than 55 years and those with ED history before diagnosis were excluded. International Index of Erectile Function (IIEF) questionnaire was filled in by the patients. The patient mean age was 47.6±6.7 years (range 18-55) at the time of filling in the questionnaire. According to the International Index of Erectile Function (IIEF) score, 83.6% of the patients had some degree of ED. The risk factors of erectile dysfunction were advancing age (p=0.01), tumor location (p=0.01), type of surgery (p=0.02), presence of stoma (p=0.03)) and RT (p=0.005). Chemotherapy didn't impact ED (p=0.46). Also, there was no significant correlation between smoking status, hypertension, diabetes mellitus, cardiovascular disease, stage of the tumor and ED. Also hormonal disturbances such as serum FSH, LH and testesterone levels did not affect the presence of ED. Overall, 83.6% of the male CRC survivors had some degree of ED according to the IIEF. The risk factors of ED were advancing age, tumor location, type of operation, presence of stoma and RT. Clinicians should be aware of these risk factors to offer their patients adequate treatment options and also come up with new treatment strategies necessary to reduce further ED in CRC survivors.

Early social deprivation impairs pair bonding and alters serum corticosterone and the NAcc dopamine system in mandarin voles.

PubMed

Yu, Peng; An, Shucheng; Tai, Fadao; Wang, Jianli; Wu, Ruiyong; Wang, Bo

2013-12-01

Early life stress has a long-term negative impact on emotion, learning, memory and adult sexual behavior, and these deficits most likely impair pair bonding. Here, we investigated whether early social deprivation (ED) affects the formation of pair bonds in socially monogamous mandarin voles (Microtus mandarinus). In a partner preference test (PPT), ED-reared adult females and males did not show a preference for their partner, spent more time exploring the cage of an unfamiliar animal and directed high levels of aggression toward unfamiliar animals. In social interaction test, ED increased exploring behavior only in females, but increased movement around the partner and reduced inactivity in both males and females. Three days of cohabitation did not alter serum corticosterone levels in ED-reared males, but increased corticosterone levels in males that received bi-parental care (PC). Interestingly, serum corticosterone levels in ED- and PC-reared females declined after cohabitation. ED significantly increased basal serum corticosterone levels in males, but had no effect on females. ED significantly up-regulated the levels of dopamine and the mRNA expression of dopamine 1-type receptor (D1R) in the nucleus accumbens (NAcc) in females and males. ED suppressed dopamine 2-type receptor mRNA (D2R) expression in females, but increased this in males. After three days of cohabitation, levels of D1R mRNA and D2R mRNA expression changed in opposite directions in PC-reared voles, but in the same direction in ED-reared males, and only the expression of D2R mRNA increased in ED-reared females. Our results indicate that early social deprivation inhibits pair bonding at adulthood. This inhibition is possibly associated with sex-specific alterations in serum corticosterone, levels of dopamine and mRNA expression of two types of dopamine receptors in the NAcc. Copyright © 2013 Elsevier Ltd. All rights reserved.

Association Between the Opening of Retail Clinics and Low-Acuity Emergency Department Visits.

PubMed

Martsolf, Grant; Fingar, Kathryn R; Coffey, Rosanna; Kandrack, Ryan; Charland, Tom; Eibner, Christine; Elixhauser, Anne; Steiner, Claudia; Mehrotra, Ateev

2017-04-01

We assess whether the opening of retail clinics near emergency departments (ED) is associated with decreased ED utilization for low-acuity conditions. We used data from the Healthcare Cost and Utilization Project State Emergency Department Databases for 2,053 EDs in 23 states from 2007 to 2012. We used Poisson regression models to examine the association between retail clinic penetration and the rate of ED visits for 11 low-acuity conditions. Retail clinic "penetration" was measured as the percentage of the ED catchment area that overlapped with the 10-minute drive radius of a retail clinic. Rate ratios were calculated for a 10-percentage-point increase in retail clinic penetration per quarter. During the course of a year, this represents the effect of an increase in retail clinic penetration rate from 0% to 40%, which was approximately the average penetration rate observed in 2012. Among all patients, retail clinic penetration was not associated with a reduced rate of low-acuity ED visits (rate ratio=0.999; 95% confidence interval=0.997 to 1.000). Among patients with private insurance, there was a slight decrease in low-acuity ED visits (rate ratio=0.997; 95% confidence interval=0.994 to 0.999). For the average ED in a given quarter, this would equal a 0.3% reduction (95% confidence interval 0.1% to 0.6%) in low-acuity ED visits among the privately insured if retail clinic penetration rate increased by 10 percentage points per quarter. With increased patient demand resulting from the expansion of health insurance coverage, retail clinics may emerge as an important care location, but to date, they have not been associated with a meaningful reduction in low-acuity ED visits. Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

A Patient-Centered Transitional Care Case Management Program: Taking Case Management to the Streets and Beyond.

PubMed

Lovelace, Derenda; Hancock, Diane; Hughes, Sabrina S; Wyche, Phyllis R; Jenkins, Claire; Logan, Cindy

In 2011, the Hunter Holmes McGuire Veterans Administration Medical Center (VAMC) in Richmond, VA, had a cumulative readmission rate and emergency department (ED) revisits for discharged Veterans of 1 in 5. In 2012, a transitional care program (TCP) was implemented to improve care coordination and outcomes among Veterans, with an emphasis on geriatric patients with chronic disease. This TCP was created with an interdisciplinary approach using intensive case management interventions, with a goal of reducing Veteran ED and hospital revisits by 30%. To examine the impact of the McGuire VAMC TCP on Veteran ED and hospital utilization and costs. Veterans being discharged to home following an inpatient admission, ED visit, and/or short rehab stay. The primary means of identifying patients for the program is through daily screening of the previous 24-hour admission and ED report, which the inpatient nurse practitioner performs. She completes an extensive review of each Veteran's electronic medical record to determine the number of ED visits and inpatient admissions at the VAMC and in the community. Initial criteria for consideration in the program included the following: more than two hospital admissions and/or ED visits in the past 90 days or at high risk for readmission based on a Care Assessment Need score of greater than 95. Two hundred Veterans participated in the program in fiscal year (FY) 2013, with 146 participating in FY 2014. A retrospective chart review of Veterans participating in the TCP in FYs 2013 and 2014 was conducted, with a focus on number of admissions and ED visits 90 days prior to admission to the TCP and 90 days following TCP admission. Average admission and ED costs for this VA were calculated to determine cost savings from pre- to post-90 days of admission and ED visits. Veterans who obtained TCP services in FYs 2013 and 2014 experienced a 67% decrease in hospital admissions and a 61% decrease in ED visits in the 90 days following participation in this program compared with the 90 days prior to participation. This produced an estimated net savings of $3,823,673 in medical center costs. In addition, registered nurse case managers (RN CMs) noted improved patient compliance and satisfaction with care and the licensed clinical social worker noted reduced caregiver burden. The results of this program demonstrate how using an interdisciplinary approach to develop patient-centered transition plans of care through intensive case management interventions improves resource utilization with substantial financial savings. This program represents a feasible option for other VAMCs as well as civilian hospitals seeking to provide cost-effective transitional care to patients upon discharge and prevent untimely readmissions. With an RN CM at the hub of patient care, this program successfully demonstrates the value of smooth care transitions.

Screening and detection of delirium in older ED patients: performance of the modified Confusion Assessment Method for the Emergency Department (mCAM-ED). A two-step tool.

PubMed

Hasemann, Wolfgang; Grossmann, Florian F; Stadler, Rahel; Bingisser, Roland; Breil, Dieter; Hafner, Martina; Kressig, Reto W; Nickel, Christian H

2017-12-30

Delirium is frequent in older Emergency Department (ED) patients, but detection rates for delirium in the ED are low. To aid in identifying delirium, we developed and implemented a two-step systematic delirium screening and assessment tool in our ED: the modified Confusion Assessment Method for the Emergency Department (mCAM-ED). Components of the mCAM-ED include: (1) screening for inattention, the main feature of delirium, which was performed with the Months Backwards Test (MBT); (2) delirium assessment based on a structured interview with questions from the Mental Status Questionnaire by Kahn et al. and the Comprehension Test by Hart et al. The aims of our study are (1) to investigate the performance criteria of the mCAM-ED tool in a consecutive sample of older ED patients, (2) to evaluate the performance of the mCAM-ED in patients with and without dementia and (3) to test whether this tool is efficient in keeping evaluation time to a minimum and reducing screening and assessment burden on the patient. For this prospective validation study, we recruited a consecutive sample of ED patients aged 65 and older during an 11-day period in November 2015. Trained nurses assessed patients with the mCAM-ED. Results were compared to the reference standard [i.e. the geriatricians' delirium diagnosis based on the criteria of the Text Revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)]. Performance criteria were computed. We included 286 consecutive ED patients aged 65 and older. The median age was 80.02 (Q 1  = 72.15; Q 3  = 86.76), 58.7% of included patients were female, 14.3% had dementia. We found a delirium prevalence of 7.0%. In patients with dementia, specificity and positive likelihood ratio were lower. When compared to the reference standard, delirium assessment with the mCAM-ED has a 0.98 specificity and a 39.9 positive likelihood ratio. In 80.0% of all cases, the first step of the mCAM-ED, i.e. screening for inattention with the MBT, took less than 30 s. On average, the complete mCAM-ED assessment required 3.2 (SD 2.0), 5.6 (SD 3.2), and 6.2 (SD 2.3) minutes in cognitively unimpaired patients, patients with dementia and patients with dementia or delirium, respectively. The mCAM-ED is able to efficiently rule out delirium as well as confirm the diagnosis of delirium in elderly patients with and without dementia and applies minimal screening and assessment burden on the patient.

Preventing violence-related injuries in England and Wales: a panel study examining the impact of on-trade and off-trade alcohol prices.

PubMed

Page, Nicholas; Sivarajasingam, Vaseekaran; Matthews, Kent; Heravi, Saeed; Morgan, Peter; Shepherd, Jonathan

2017-02-01

To examine the influence of real on-trade and off-trade alcohol prices and socioeconomic and environmental factors on rates of violence-related emergency department (ED) attendances in England and Wales over an 8-year period. Anonymised injury data which included attendance date, age and gender of patients aged over 18 years who reported injury in violence were collected from a structured sample of 100 EDs across England and Wales between 1 January 2005 and 31 December 2012. Alcohol prices and socioeconomic measures were obtained from the UK Office for National Statistics. Panel techniques were used to derive a statistical model. Real on-trade (β=-0.661, p<0.01) and off-trade (β=-0.277, p<0.05) alcohol prices were negatively related with rates of violence-related ED attendance among the adult population of England and Wales, after accounting for the effects of regional poverty, income inequality, youth spending power and seasonal effects. It is estimated that over 6000 fewer violence-related ED attendances per year in England and Wales would result from a 1% increase in both on-trade and off-trade alcohol prices above inflation. Of the variables studied, changes in regional poverty and income inequality had the greatest effect on violence-related ED attendances in England and Wales. Small increases in the price of alcohol, above inflation, in both markets, would substantially reduce the number of patients attending EDs for treatment of violence-related injuries in England and Wales. Reforming the current alcohol taxation system may be more effective at reducing violence-related injury than minimum unit pricing. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Using Queuing Theory and Simulation Modelling to Reduce Waiting Times in An Iranian Emergency Department

PubMed Central

Haghighinejad, Hourvash Akbari; Kharazmi, Erfan; Hatam, Nahid; Yousefi, Sedigheh; Hesami, Seyed Ali; Danaei, Mina; Askarian, Mehrdad

2016-01-01

Background: Hospital emergencies have an essential role in health care systems. In the last decade, developed countries have paid great attention to overcrowding crisis in emergency departments. Simulation analysis of complex models for which conditions will change over time is much more effective than analytical solutions and emergency department (ED) is one of the most complex models for analysis. This study aimed to determine the number of patients who are waiting and waiting time in emergency department services in an Iranian hospital ED and to propose scenarios to reduce its queue and waiting time. Methods: This is a cross-sectional study in which simulation software (Arena, version 14) was used. The input information was extracted from the hospital database as well as through sampling. The objective was to evaluate the response variables of waiting time, number waiting and utilization of each server and test the three scenarios to improve them. Results: Running the models for 30 days revealed that a total of 4088 patients left the ED after being served and 1238 patients waited in the queue for admission in the ED bed area at end of the run (actually these patients received services out of their defined capacity). The first scenario result in the number of beds had to be increased from 81 to179 in order that the number waiting of the “bed area” server become almost zero. The second scenario which attempted to limit hospitalization time in the ED bed area to the third quartile of the serving time distribution could decrease the number waiting to 586 patients. Conclusion: Doubling the bed capacity in the emergency department and consequently other resources and capacity appropriately can solve the problem. This includes bed capacity requirement for both critically ill and less critically ill patients. Classification of ED internal sections based on severity of illness instead of medical specialty is another solution. PMID:26793727

Positive interaction of the β2-agonist CHF 4226.01 with budesonide in the control of bronchoconstriction induced by acetaldehyde in the guinea-pigs

PubMed Central

Rossoni, Giuseppe; Manfredi, Barbara; Razzetti, Roberta; Civelli, Maurizio; Bongrani, Stefano; Berti, Ferruccio

2005-01-01

Pretreatment of anaesthetized guinea-pigs with either CHF 4226.01 (8-hydroxy-5-[(1R)-1-hydroxy-2-[N-[(1R)-2-(p-methoxyphenyl)-1-methylethyl]amino]ethyl] carbostyril hydrochloride), formoterol or budesonide reduced acetaldehyde (AcCHO)-evoked responses in the lungs with a rank order of potency CHF 4226.01 (ED50 values, from 1.88 to 3.31 pmol) > formoterol (ED50 values, from 3.03 to 5.51 pmol) ≫ budesonide (ED50 values, from 335 to 458 nmol). The duration of action of CHF 4226.01 in antagonizing the airway obstruction elicited by AcCHO was also substantially longer than formoterol (area under the curve) at 10 pmol, 763±58 and 480±34, respectively; P<0.01). Continuous infusion of a subthreshold dose of AcCHO enhanced the intratracheal pressure (ITP) increases caused by subsequent challenges with substance P (from 9.7±0.8 to 27.5±1.6 cm H2O as a peak, P<0.001). Pretreatment with either CHF 4226.01 or formoterol prevented the sensitizing effect of AcCHO on substance P responses (ED50 values, 2.85 and 6.11 pmol, respectively; P<0.01). The ED50 value of budesonide (396 nmol) in preventing AcCHO-evoked ITP increase was reduced when this glucocorticoid was combined with 0.1 pmol CHF 4226.01 (ED50 76 nmol; P<0.001). CHF 4226.01/budesonide was two-fold more effective (P<0.01) than the formoterol/budesonide combination. These results suggest that CHF 4226.01/budesonide, by optimizing each other's beneficial potential in the control of pulmonary changes caused by AcCHO in the guinea-pigs, may represent a new fixed combination in asthma. PMID:15655502

Excessive daytime sleepiness and falls among older men and women: cross-sectional examination of a population-based sample.

PubMed

Hayley, Amie C; Williams, Lana J; Kennedy, Gerard A; Holloway, Kara L; Berk, Michael; Brennan-Olsen, Sharon L; Pasco, Julie A

2015-07-05

Excessive daytime sleepiness (EDS) has been associated with an increased risk for falls among clinical samples of older adults. However, there is little detailed information among population-representative samples. The current study aimed to assess the relationship between EDS and falls among a cohort of population-based older adults. This study assessed 367 women aged 60-93 years (median 72, interquartile range 65-79) and 451 men aged 60-92 years (median 73, interquartile range 66-80) who participated in the Geelong Osteoporosis Study between the years 2001 and 2008. Falls during the prior year were documented via self-report, and for men, falls risk score was obtained using an Elderly Fall Screening Test (EFST). Sleepiness was assessed using the Epworth Sleepiness Scale (ESS), and scores of  ≥ 10 indicated EDS. Differences among those with and without EDS in regard to falls were tested using logistic regression models. Among women, 50 (13.6%) individuals reported EDS. Women with EDS were more likely to report a fall, and were more likely to report the fall occurring outside. EDS was similarly associated with an increased risk of a fall following adjustment for use of a walking aid, cases of nocturia and antidepressant medication use (adjusted OR = 2.54, 95% CI 1.24-5.21). Multivariate modelling revealed antidepressant use (current) as an effect modifier (p < .001 for the interaction term). After stratifying the data by antidepressant medication use, the association between EDS and falls was sustained following adjustment for nocturia among antidepressant non-users (adjusted OR = 2.63, 95% CI 1.31-5.30). Among men, 72 (16.0%) individuals reported EDS. No differences were detected for men with and without EDS in regard to reported falls, and a trend towards significance was noted between EDS and a high falls risk as assessed by the EFST (p = 0.06), however, age explained this relationship (age adjusted OR = 2.20, 95% CI 1.03-1.10). For women, EDS is independently associated with at least one fall during the previous year, and this is more likely to occur whilst located outside. Amelioration of EDS may assist in improving functional outcomes among these individuals by reducing the risk for falls.

A clinical approach to the assessment and management of co-morbid eating disorders and substance use disorders

PubMed Central

2013-01-01

Introduction Research has shown that eating disorder (ED) patients who abuse substances demonstrate worse ED symptomatology and poorer outcomes than those with EDs alone, including increased general medical complications and psychopathology, longer recovery times, poorer functional outcomes and higher relapse rates. This article provides a broad overview of the prevalence, aetiology, assessment and management of co-morbid EDs and substance use disorders (SUDs). Review The co-occurrence of EDs and SUDs is high. The functional relationship between EDs and SUDs vary within and across ED subtypes, depends on the class of substance, and needs to be carefully assessed for each patient. Substances such as caffeine, tobacco, insulin, thyroid medications, stimulants or over the counter medications (laxatives, diuretics) may be used to aid weight loss and/or provide energy, and alcohol or psychoactive substances could be used for emotional regulation or as part of a pattern of impulsive behaviour. A key message conveyed in the current literature is the importance of screening and assessment for co-morbid SUDs and EDs in patients presenting with either disorder. There is a paucity of treatment studies on the management of co-occurring EDs and SUDs. Overall, the literature indicates that the ED and SUD should be addressed simultaneously using a multi-disciplinary approach. The need for medical stabilization, hospitalization or inpatient treatment needs to be assessed based on general medical and psychiatric considerations. Common features across therapeutic interventions include psycho-education about the aetiological commonalities, risks and sequelae of concurrent ED behaviours and substance abuse, dietary education and planning, cognitive challenging of eating disordered attitudes and beliefs, building of skills and coping mechanisms, addressing obstacles to improvement and the prevention of relapse. Emphasis should be placed on building a collaborative therapeutic relationship and avoiding power struggles. Cognitive behavioural therapy has been frequently used in the treatment of co-morbid EDs and SUDs, however there are no randomized controlled trials. More recently evidence has been found for the efficacy of dialectical behavioural therapy in reducing both ED and substance use behaviours. Conclusion Future research would benefit from a meta-analysis of the current research in order to better understand the relationships between these two commonly co-occurring disorders. PMID:24200300

A clinical approach to the assessment and management of co-morbid eating disorders and substance use disorders.

PubMed

Gregorowski, Claire; Seedat, Soraya; Jordaan, Gerhard P

2013-11-07

Research has shown that eating disorder (ED) patients who abuse substances demonstrate worse ED symptomatology and poorer outcomes than those with EDs alone, including increased general medical complications and psychopathology, longer recovery times, poorer functional outcomes and higher relapse rates. This article provides a broad overview of the prevalence, aetiology, assessment and management of co-morbid EDs and substance use disorders (SUDs). The co-occurrence of EDs and SUDs is high. The functional relationship between EDs and SUDs vary within and across ED subtypes, depends on the class of substance, and needs to be carefully assessed for each patient. Substances such as caffeine, tobacco, insulin, thyroid medications, stimulants or over the counter medications (laxatives, diuretics) may be used to aid weight loss and/or provide energy, and alcohol or psychoactive substances could be used for emotional regulation or as part of a pattern of impulsive behaviour. A key message conveyed in the current literature is the importance of screening and assessment for co-morbid SUDs and EDs in patients presenting with either disorder. There is a paucity of treatment studies on the management of co-occurring EDs and SUDs. Overall, the literature indicates that the ED and SUD should be addressed simultaneously using a multi-disciplinary approach. The need for medical stabilization, hospitalization or inpatient treatment needs to be assessed based on general medical and psychiatric considerations. Common features across therapeutic interventions include psycho-education about the aetiological commonalities, risks and sequelae of concurrent ED behaviours and substance abuse, dietary education and planning, cognitive challenging of eating disordered attitudes and beliefs, building of skills and coping mechanisms, addressing obstacles to improvement and the prevention of relapse. Emphasis should be placed on building a collaborative therapeutic relationship and avoiding power struggles. Cognitive behavioural therapy has been frequently used in the treatment of co-morbid EDs and SUDs, however there are no randomized controlled trials. More recently evidence has been found for the efficacy of dialectical behavioural therapy in reducing both ED and substance use behaviours. Future research would benefit from a meta-analysis of the current research in order to better understand the relationships between these two commonly co-occurring disorders.

Replica exchange enveloping distribution sampling (RE-EDS): A robust method to estimate multiple free-energy differences from a single simulation.

PubMed

Sidler, Dominik; Schwaninger, Arthur; Riniker, Sereina

2016-10-21

In molecular dynamics (MD) simulations, free-energy differences are often calculated using free energy perturbation or thermodynamic integration (TI) methods. However, both techniques are only suited to calculate free-energy differences between two end states. Enveloping distribution sampling (EDS) presents an attractive alternative that allows to calculate multiple free-energy differences in a single simulation. In EDS, a reference state is simulated which "envelopes" the end states. The challenge of this methodology is the determination of optimal reference-state parameters to ensure equal sampling of all end states. Currently, the automatic determination of the reference-state parameters for multiple end states is an unsolved issue that limits the application of the methodology. To resolve this, we have generalised the replica-exchange EDS (RE-EDS) approach, introduced by Lee et al. [J. Chem. Theory Comput. 10, 2738 (2014)] for constant-pH MD simulations. By exchanging configurations between replicas with different reference-state parameters, the complexity of the parameter-choice problem can be substantially reduced. A new robust scheme to estimate the reference-state parameters from a short initial RE-EDS simulation with default parameters was developed, which allowed the calculation of 36 free-energy differences between nine small-molecule inhibitors of phenylethanolamine N-methyltransferase from a single simulation. The resulting free-energy differences were in excellent agreement with values obtained previously by TI and two-state EDS simulations.

Changes in Emergency Department Utilization After Early Medicaid Expansion in California.

PubMed

Sabik, Lindsay M; Cunningham, Peter J; Tehrani, Ali Bonakdar

2017-06-01

Medicaid expansions aim to improve access to primary care, which could reduce nonemergent (NE) use of the emergency department (ED). In contrast, Medicaid enrollees use the ED more than other groups, including the uninsured. Thus, the expected impact of Medicaid expansion on ED use is unclear. To estimate changes in total and NE ED visits as a result of California's early Medicaid expansion under the Affordable Care Act. In addition to overall changes in the number of visits, changes by payer and safety net hospital status are examined. We used a quasi-experimental approach to examine changes in ED utilization, comparing California expansion counties to comparison counties from California and 2 other states in the same region that did not implement Medicaid expansion during the study period. Regression estimates show no significant change in total number of ED visits following expansion. Medicaid visits increased by 145 visits per hospital-quarter in the first year following expansion and 242 visits subsequent to the first year, whereas visits among uninsured patients decreased by 129 visits per hospital-quarter in the first year and 175 visits in subsequent years, driven by changes at safety net hospitals. We also observe an increase in NE visits per hospital-quarter paid for by Medicaid, and a significant decrease in uninsured NE visits. Medicaid expansions in California were associated with increases in ED visits paid for by Medicaid and declines in uninsured visits. Expansion was also associated with changes in NE visits among Medicaid enrollees and the uninsured.

Trends in Preventable Inpatient and Emergency Department Utilization in California Between 2012 and 2015: The Role of Health Insurance Coverage and Primary Care Supply.

PubMed

Cunningham, Peter; Sheng, Yaou

2018-06-01

Expansions of health insurance coverage tend to increase hospital emergency department (ED) utilization and inpatient admissions. However, provisions in the Affordable Care Act that expanded primary care supply were intended in part to offset the potential for increased hospital utilization. To examine the association between health insurance coverage, primary care supply, and ED and inpatient utilization, and to assess how both factors contributed to trends in utilization in California between 2012 and 2015. Population-based measures of ED and inpatient utilization, insurance coverage, and primary care supply were constructed for California counties for the years 2012 through 2015. Fixed effects regression analysis is used to examine the association between health insurance coverage, primary care supply, and rates of preventable ED and inpatient utilization. Higher levels of Medicaid coverage in a county are associated with higher levels of preventable ED and inpatient utilization, although greater numbers of primary care practitioners and Federally Qualified Health Centers reduce this type of utilization. Increases in coverage accelerated a long-term increase in ED visits and prevented an even larger decrease in inpatient admissions, but changes in coverage do not fully explain these underlying trends. Increases in primary care supply offset the effects of coverage changes only modestly. Policymakers should not overstate the impact of the Affordable Care Act on increasing ED visits, and should focus on better understanding the underlying factors that are driving the trends.

The influence of a major sporting event upon emergency department attendances; A retrospective cross-national European study.

PubMed

Hughes, Helen E; Colón-González, Felipe J; Fouillet, Anne; Elliot, Alex J; Caserio-Schonemann, Céline; Hughes, Thomas C; Gallagher, Naomh; Morbey, Roger A; Smith, Gillian E; Thomas, Daniel Rh; Lake, Iain R

2018-01-01

Major sporting events may influence attendance levels at hospital emergency departments (ED). Previous research has focussed on the impact of single games, or wins/losses for specific teams/countries, limiting wider generalisations. Here we explore the impact of the Euro 2016 football championships on ED attendances across four participating nations (England, France, Northern Ireland, Wales), using a single methodology. Match days were found to have no significant impact upon daily ED attendances levels. Focussing upon hourly attendances, ED attendances across all countries in the four hour pre-match period were statistically significantly lower than would be expected (OR 0.97, 95% CI 0.94-0.99) and further reduced during matches (OR 0.94, 95% CI 0.91-0.97). In the 4 hour post-match period there was no significant increase in attendances (OR 1.01, 95% CI 0.99-1.04). However, these impacts were highly variable between individual matches: for example in the 4 hour period following the final, involving France, the number of ED attendances in France increased significantly (OR 1.27, 95% CI 1.13-1.42). Overall our results indicate relatively small impacts of major sporting events upon ED attendances. The heterogeneity observed makes it difficult for health providers to predict how major sporting events may affect ED attendances but supports the future development of compatible systems in different countries to support cross-border public health surveillance.

The Impact of Visibility on Teamwork, Collaborative Communication, and Security in Emergency Departments: An Exploratory Study.

PubMed

Gharaveis, Arsalan; Hamilton, D Kirk; Pati, Debajyoti; Shepley, Mardelle

2017-01-01

The aim of this study was to examine the influence of visibility on teamwork, collaborative communication, and security issues in emergency departments (EDs). This research explored whether with high visibility in EDs, teamwork and collaborative communication can be improved while the security issues will be reduced. Visibility has been regarded as a critical design consideration and can be directly and considerably impacted by ED's physical design. Teamwork is one of the major related operational outcomes of visibility and involves nurses, support staff, and physicians. The collaborative communication in an ED is another important factor in the process of care delivery and affects efficiency and safety. Furthermore, security is a behavioral factor in ED designs, which includes all types of safety including staff safety, patient safety, and the safety of visitors and family members. This qualitative study investigated the impact of visibility on teamwork, collaborative communication, and security issues in the ED. One-on-one interviews and on-site observation sessions were conducted in a community hospital. Corresponding data analysis was implemented by using computer plan analysis, observation and interview content, and theme analyses. The findings of this exploratory study provided a framework to identify visibility as an influential factor in ED design. High levels of visibility impact productivity and efficiency of teamwork and communication and improve the chance of lowering security issues. The findings of this study also contribute to the general body of knowledge about the effect of physical design on teamwork, collaborative communication, and security.

The influence of a major sporting event upon emergency department attendances; A retrospective cross-national European study

PubMed Central

Colón-González, Felipe J.; Fouillet, Anne; Elliot, Alex J.; Caserio-Schonemann, Céline; Hughes, Thomas C.; Gallagher, Naomh; Morbey, Roger A.; Smith, Gillian E.; Thomas, Daniel Rh.; Lake, Iain R.

2018-01-01

Major sporting events may influence attendance levels at hospital emergency departments (ED). Previous research has focussed on the impact of single games, or wins/losses for specific teams/countries, limiting wider generalisations. Here we explore the impact of the Euro 2016 football championships on ED attendances across four participating nations (England, France, Northern Ireland, Wales), using a single methodology. Match days were found to have no significant impact upon daily ED attendances levels. Focussing upon hourly attendances, ED attendances across all countries in the four hour pre-match period were statistically significantly lower than would be expected (OR 0.97, 95% CI 0.94–0.99) and further reduced during matches (OR 0.94, 95% CI 0.91–0.97). In the 4 hour post-match period there was no significant increase in attendances (OR 1.01, 95% CI 0.99–1.04). However, these impacts were highly variable between individual matches: for example in the 4 hour period following the final, involving France, the number of ED attendances in France increased significantly (OR 1.27, 95% CI 1.13–1.42). Overall our results indicate relatively small impacts of major sporting events upon ED attendances. The heterogeneity observed makes it difficult for health providers to predict how major sporting events may affect ED attendances but supports the future development of compatible systems in different countries to support cross-border public health surveillance. PMID:29898000

Utilisation of inorganic salts in fungal crop disease management in the U.K.

PubMed

Deliopoulos, T; Kettlewell, P S; Hare, M C

2009-01-01

The overaLl aim of the study described in this communication was to utilise the findings of a global scientific and technical literature survey on the use of inorganic salts against crop fungal diseases in order to assess the potential of using these substances to reduce the reliance of UK growers on conventional fungicides. A summary of the main findings of the Literature survey is provided followed by information on the current commercial use of inorganic salt-based products in fungal disease management. Finally, the scope of potential use of inorganic salts on high disease risk crops in the UK is assessed and specific crop/pathogen combinations are prioritised for further research.

Forensic practice in the field of protection of cultural heritage

NASA Astrophysics Data System (ADS)

Kotrlý, Marek; Turková, Ivana

2012-06-01

Microscopic methods play a key role in issues covering analyses of objects of art that are used on the one hand as screening ones, on the other hand they can lead to obtaining data relevant for completion of expertise. Analyses of artworks, gemmological objects and other highly valuable commodities usually do not rank among routine ones, but every analysis is specific, be it e.g. material investigation of artworks, historical textile materials and other antiques (coins, etc.), identification of fragments (from transporters, storage places, etc.), period statues, sculptures compared to originals, analyses of gems and jewellery, etc. A number of analytical techniques may be employed: optical microscopy in transmitted and reflected light, polarization and fluorescence in visible, UV and IR radiation; image analysis, quantitative microspectrophotometry; SEM/EDS/WDS; FTIR and Raman spectroscopy; XRF and microXRF, including mobile one; XRD and microXRD; x-ray backlight or LA-ICP-MS, SIMS, PIXE; further methods of organic analysis are also utilised - GS-MS, MALDI-TOF, etc.

Effects of fisetin on hyperhomocysteinemia-induced experimental endothelial dysfunction and vascular dementia.

PubMed

Hemanth Kumar, Boyina; Arun Reddy, Ravula; Mahesh Kumar, Jerald; Dinesh Kumar, B; Diwan, Prakash V

2017-01-01

This study was designed to investigate the effects of fisetin (FST) on hyperhomocysteinemia (HHcy)-induced experimental endothelial dysfunction (ED) and vascular dementia (VaD) in rats. Wistar rats were randomly divided into 8 groups: control, vehicle control, l-methionine, FST (5, 10, and 25 mg/kg, p.o.), FST-per se (25 mg/kg, p.o.), and donepezil (0.1 mg/kg, p.o.). l-Methionine administration (1.7 g/kg, p.o.) for 32 days induced HHcy. ED and VaD induced by HHcy were determined by vascular reactivity measurements, behavioral analysis using Morris water maze and Y-maze, along with a biochemical and histological evaluation of thoracic aorta and brain tissues. Administration of l-methionine developed behavioral deficits; triggered brain lipid peroxidation (LPO); compromised brain acetylcholinesterase activity (AChE); and reduced the levels of brain superoxide dismutase (SOD), brain catalase (CAT), brain reduced glutathione (GSH), and serum nitrite; and increased serum homocysteine and cholesterol levels. These effects were accompanied by decreased vascular NO bioavailability, marked intimal thickening of the aorta, and multiple necrotic foci in brain cortex. HHcy-induced alterations in the activities of SOD, CAT, GSH, AChE, LPO, behavioral deficits, ED, and histological aberrations were significantly attenuated by treatment with fisetin in a dose-dependent manner. Collectively, our results indicate that fisetin exerts endothelial and neuroprotective effects against HHcy-induced ED and VaD.

Dexmedetomidine use in the ED for control of methamphetamine-induced agitation.

PubMed

Lam, Rex Pui Kin; Yip, Wai Lam; Wan, Chi Keung; Tsui, Matthew Sik Hon

2017-04-01

Chemical restraint is often required to control agitation induced by methamphetamine. Dexmedetomidine is an α-2 adrenergic receptor agonist with sedative, analgesic, and sympatholytic properties. Its use in the emergency department (ED) to control methamphetamine-induced agitation has not been reported. To report two cases of methamphetamine-induced agitation successfully sedated with dexmedetomidine in the ED. The first case was a 42-year-old man with unstable emotion and violent behaviours after smoking methamphetamine. His agitation did not respond to a large cumulative dose of benzodiazepines (10mg of diazepam and 332mg of midazolam) administered over 48h and sedation was achieved with dexmedetomidine. The second case was a 38-year-old methamphetamine user with unstable emotion and recurrent episodes of agitation despite repeated doses of benzodiazepines, whose agitation was controlled with dexmedetomidine infusion. In both cases, dexmedetomidine apparently reduced the dose of benzodiazepines needed to achieve adequate sedation. Transient falls in blood pressure and slowing of the heart rate were noted, which resolved either spontaneously or after reducing the infusion rate without requiring drug treatment. Dexmedetomidine can be considered as an adjunct for chemical restraint when standard treatment fails to control the agitation induced by methamphetamine, but patient's hemodynamic state should be monitored closely during administration. Its efficacy and safety in the ED warrant further evaluation with prospective controlled trials. Copyright © 2016 Elsevier Inc. All rights reserved.

Long-term impacts of recurrent logging and fire in Amazon forests: a modeling study using the Ecosystem Demography Model (ED2)

NASA Astrophysics Data System (ADS)

Longo, M.; Keller, M.; Scaranello, M. A., Sr.; dos-Santos, M. N.; Xu, Y.; Huang, M.; Morton, D. C.

2017-12-01

Logging and understory fires are major drivers of tropical forest degradation, reducing carbon stocks and changing forest structure, composition, and dynamics. In contrast to deforested areas, sites that are disturbed by logging and fires retain some, albeit severely altered, forest structure and function. In this study we simulated selective logging using the Ecosystem Demography Model (ED-2) to investigate the impact of a broad range of logging techniques, harvest intensities, and recurrence cycles on the long-term dynamics of Amazon forests, including the magnitude and duration of changes in forest flammability following timber extraction. Model results were evaluated using eddy covariance towers at logged sites at the Tapajos National Forest in Brazil and data on long-term dynamics reported in the literature. ED-2 is able to reproduce both the fast (< 5yr) recovery of water, energy fluxes compared to flux tower, and the typical, field-observed, decadal time scales for biomass recovery when no additional logging occurs. Preliminary results using the original ED-2 fire model show that canopy cover loss of forests under high-intensity, conventional logging cause sufficient drying to support more intense fires. These results indicate that under intense degradation, forests may shift to novel disturbance regimes, severely reducing carbon stocks, and inducing long-term changes in forest structure and composition from recurrent fires.

Using transprofessional care in the emergency department to reduce patient admissions: A retrospective audit of medical histories.

PubMed

Morphet, Julia; Griffiths, Debra Lee; Crawford, Kimberley; Williams, Allison; Jones, Tamsin; Berry, Belinda; Innes, Kelli

2016-01-01

The demand for emergency department (ED) services has increased significantly, due to our increasingly ageing population and limited access to primary care. This article reports outcomes from a transprofessional model of care in an ED in Victoria, Australia. Nurses, physiotherapists, social workers, and occupational therapists undertook additional education to increase the range of services they could provide and thereby expedite patient flow through the ED. One hundred patients who received this service were matched against 50 patients who did not. The most common reasons for patient admission were limb injury/limb pain (n = 47, 23.5%) and falls (n = 46, 23.0%). Transprofessional interventions included applying supportive bandages, slings, zimmer splints and controlled ankle motion (CAM) boots, and referral to new services such as case management and mental health teams. The rate of hospital admissions was significantly lower in the transprofessional group (n = 27, 18.0%) than in the reference group (n = 19, 38%, p = 0.005). This group also had a slightly lower re-presentation rate (n = 4, 2.7%) than patients in the reference group (n = 2, 4.0%). There are many benefits that support this model of care that in turn reduces ED overcrowding and work stress. A transprofessional model may offer a creative solution to meeting the varied needs of patients presenting for emergency care.

TH-CD-202-02: A Preliminary Study Evaluating Beam-Hardening Artifact Reduction On CT Direct Electron-Density Images

DOE Office of Scientific and Technical Information (OSTI.GOV)

Li, H; Dolly, S; Zhao, T

Purpose: A prototype reconstruction algorithm that can provide direct electron density (ED) images from single energy CT scans is being currently developed by Siemens Healthcare GmbH. This feature can eliminate the need for kV specific calibration curve for radiation treatemnt planning. An added benefit is that beam-hardening artifacts are also reduced on direct-ED images due to the underlying material decomposition. This study is to quantitatively analyze the reduction of beam-hardening artifacts on direct-ED images and suggest additional clinical usages. Methods: HU and direct-ED images were reconstructed on a head phantom scanned on a Siemens Definition AS CT scanner at fivemore » tube potentials of 70kV, 80kV, 100kV, 120kV and 140kV respectively. From these images, mean, standard deviation (SD), and local NPS were calculated for regions of interest (ROI) of same locations and sizes. A complete analysis of beam-hardening artifact reduction and image quality improvement was conducted. Results: Along with the increase of tube potentials, ROI means and SDs decrease on both HU and direct-ED images. The mean value differences between HU and direct-ED images are up to 8% with absolute value of 2.9. Compared to that on HU images, the SDs are lower on direct-ED images, and the differences are up to 26%. Interestingly, the local NPS calculated from direct-ED images shows consistent values in the low spatial frequency domain for images acquired from all tube potential settings, while varied dramatically on HU images. This also confirms the beam -hardening artifact reduction on ED images. Conclusions: The low SDs on direct-ED images and relative consistent NPS values in the low spatial frequency domain indicate a reduction of beam-hardening artifacts. The direct-ED image has the potential to assist in more accurate organ contouring, and is a better fit for the desired purpose of CT simulations for radiotherapy.« less

Health outcomes associated with smoke exposure in Albuquerque, New Mexico, during the 2011 Wallow fire.

PubMed

Resnick, Adam; Woods, Brian; Krapfl, Heidi; Toth, Barbara

2015-01-01

This study examined the association between PM2.5 levels and emergency department (ED) visits for selected health outcomes in Albuquerque, New Mexico, during the Wallow fire of 2011. Measurements of 24-hour average concentrations of PM2.5 obtained from the City of Albuquerque were used to calculate wildfire smoke exposure in Albuquerque. Daily ED visits were collected by the New Mexico Department of Health from individual nonfederal licensed facilities in the Albuquerque area. Poisson regression was used to assess the relationship between ED visits for selected respiratory and cardiovascular conditions and varying levels of PM2.5 exposure. Albuquerque, New Mexico. Patients visiting an ED for select conditions before, during, and after the wildfire. Relative increase in ED visits for selected conditions during the wildfire period. Analysis of PM2.5 exposure data and ED visits in Albuquerque before and during the Wallow fire indicated that compared with the period prior to the fire, there was an increased risk of ED visits for some respiratory and cardiovascular conditions during heavy smoke conditions, and risk varied by age and sex. The population of 65+ years was especially at risk for increased ED visits. There was a significantly increased risk of ED visits among the 65+ population for asthma (RR [relative rate] = 1.73, 95% confidence interval [CI] = 1.03-2.93) and for diseases of the veins, lymphatic and circulatory system (RR = 1.56, 95% CI = 1.00-2.43). For the age group of 20 to 64 years, there was a statistically significant increase in ED visits for diseases of pulmonary circulation (RR = 2.64, 95% CI = 1.42-4.9) and for cerebrovascular disease (RR = 1.69, 95% CI = 1.03-2.77). High levels of PM2.5 exposure due to the Wallow fire were associated with increased ED visits for respiratory and cardiovascular conditions in Albuquerque. More effective and targeted preventive measures are necessary to reduce morbidity rates associated with wildfire smoke exposure among vulnerable populations.

Efficacy of hospital in the home services providing care for patients admitted from emergency departments: an integrative review.

PubMed

Varney, Jane; Weiland, Tracey J; Jelinek, George

2014-06-01

Increases in emergency department (ED) demand may compromise patient outcomes, leading not only to overcrowding in the ED, increased ED waiting times and increased ED length of stay, but also compromising patient safety; the risk of adverse events is known to rise in the presence of overcrowding. Hospital in the home (HiTH) services may offer one means of reducing ED demand. This integrative review sought to assess the efficacy of admission-avoidance HiTH services that admit patients directly from the ED. Papers published between 1995 and 2013 were identified through searches of Medline, CINAHL and Google. English-language studies that assessed the efficacy of a HiTH service and that recruited at least one-third of the participants directly from the ED were included in the review. A HiTH service was considered one that provided health professional support to patients at home for a time-limited period, thus avoiding the need for hospitalization. Twenty-two articles met the inclusion criteria for this review. The interventions were diverse in terms of the clinical interventions delivered, the range and intensity of health professional input and the conditions treated. The studies included in the review found no effect on clinical outcomes, rates of adverse events or complications, although patient satisfaction and costs were consistently and favourably affected by HiTH treatment. Given evidence suggesting that HiTH services which recruit patients directly from the ED contribute to cost-savings, greater patient satisfaction and safety and efficacy outcomes that are at least equivalent to those associated with hospital-based care, the expansion of such programmes might therefore be considered a priority for policy makers.

Poor Dietary Guidelines Compliance among Low-Income Women Eligible for Supplemental Nutrition Assistance Program-Education (SNAP-Ed).

PubMed

Jun, Shinyoung; Thuppal, Sowmyanarayanan V; Maulding, Melissa K; Eicher-Miller, Heather A; Savaiano, Dennis A; Bailey, Regan L

2018-03-08

The Supplemental Nutrition Assistance Program-Education (SNAP-Ed) program aims to improve nutritional intakes of low-income individuals (<185% poverty threshold). The objective of this study was to describe the compliance with Dietary Guidelines for Americans (DGA) recommendations for fruits, vegetables, and whole grains among SNAP-Ed eligible ( n = 3142) and ineligible ( n = 3168) adult women (19-70 years) nationwide and SNAP-Ed participating women in Indiana ( n = 2623), using the NHANES 2007-2012 and Indiana SNAP-Ed survey data, respectively. Sensitivity analysis further stratified women by race/ethnicity and by current SNAP participation (<130% poverty threshold). Nationally, lower-income women were less likely to meet the fruit (21% vs. 25%) and vegetable (11% vs. 19%) guidelines than higher-income women, but did not differ on whole grains, which were ~5% regardless of income. The income differences in fruit and vegetable intakes were driven by non-Hispanic whites. Fewer SNAP-Ed-eligible U.S. women met fruit (21% vs. 55%) and whole grain (4% vs. 18%) but did not differ for vegetable recommendations (11% vs. 9%) when compared to Indiana SNAP-Ed women. This same trend was observed among current SNAP participants. Different racial/ethnic group relationships with DGA compliance were found in Indiana compared to the nation. Nevertheless, most low-income women in the U.S. are at risk of not meeting DGA recommendations for fruits (79%), vegetables (89%), and whole grains (96%); SNAP-Ed participants in Indiana had higher compliance with DGA recommendations. Increased consumption of these three critical food groups would improve nutrient density, likely reduce calorie consumption by replacing high calorie choices, and improve fiber intakes.

Why patients self-refer to the Emergency Department: A qualitative interview study.

PubMed

Kraaijvanger, Nicole; Rijpsma, Douwe; Willink, Lisa; Lucassen, Peter; van Leeuwen, Henk; Edwards, Michael

2017-06-01

There have been multiple studies investigating reasons for patients to self-refer to the Emergency Department (ED). The majority made use of questionnaires and excluded patients with urgent conditions. The goal of this qualitative study is to explore what motives patients have to self-refer to an ED, also including patients in urgent triage categories. In a large teaching hospital in the Netherlands, a qualitative interview study focusing on reasons for self-referring to the ED was performed. Self-referred patients were included until no new reasons for attending the ED were found. Exclusion criteria were as follows: not mentally able to be interviewed or not speaking Dutch. Patients who were in need of urgent care were treated first, before being asked to participate. Interviews followed a predefined topic guide. Practicing cyclic analysis, the interview topic guide was modified during the inclusion period. Interviews were recorded on an audio recorder, transcribed verbatim, and anonymized. Two investigators independently coded the information and combined the codes into meaningful clusters. Subsequently, these were categorized into themes to build a framework of reasons for self-referral to the ED. Characteristic quotes were used to illustrate the acquired theoretical framework. Thirty self-referred patients were interviewed. Most of the participants were male (63%), with a mean age of 46 years. Two main themes emerged from the interviews that are pertinent to the patients' decisions to attend the ED: (1) health concerns and (2) practical issues. This study found that there are 2 clearly distinctive reasons for self-referral to the ED: health concerns or practical motives. Self-referral because of practical motives is probably most suitable for strategies that aim to reduce inappropriate ED visits. © 2016 John Wiley & Sons, Ltd.

Use of a midstream clean catch mobile application did not lower urine contamination rates in an ED.

PubMed

Jacob, Mary S; Kulie, Paige; Benedict, Cameron; Ordoobadi, Alexander J; Sikka, Neal; Steinmetz, Erika; McCarthy, Melissa L

2018-01-01

Urine microscopy is a common test performed in emergency departments (EDs). Urine specimens can easily become contaminated by different factors, including the collection method. The midstream clean-catch (MSCC) collection technique is commonly used to reduce urine contamination. The urine culture contamination rate from specimens collected in our ED is 30%. We developed an instructional application (app) to show ED patients how to provide a MSCC urine sample. We hypothesized that ED patients who viewed our instructional app would have significantly lower urine contamination rates compared to patients who did not. We prospectively enrolled 257 subjects with a urinalysis and/or urine culture test ordered in the ED and asked them to watch our MSCC instructional app. After prospective enrollment was complete, we retrospectively matched each enrolled subject to an ED patient who did not watch the instructional app. Controls were matched to cases based on gender, type of urine specimen provided, ED visit date and shift. Urinalysis and urine culture contamination results were compared between the matched pairs using McNemar's test. The overall urine culture contamination rate of the 514 subjects was 38%. The majority of the matched pairs had a urinalysis (63%) or urinalysis plus urine culture (35%) test done. There were no significant differences in our urine contamination rates between the matched pairs overall or when stratified by gender, by prior knowledge of the clean catch process or by type of urine specimen. We did not see a lower contamination rate for patients who viewed our instructional app compared to patients who did not. It is possible that MSCC is not effective for decreasing urine specimen contamination. Copyright © 2017 Elsevier Inc. All rights reserved.

Effects of an Oral Elemental Nutritional Supplement on Post-gastrectomy Body Weight Loss in Gastric Cancer Patients: A Randomized Controlled Clinical Trial.

PubMed

Imamura, Hiroshi; Nishikawa, Kazuhiro; Kishi, Kentaro; Inoue, Kentaro; Matsuyama, Jin; Akamaru, Yusuke; Kimura, Yutaka; Tamura, Shigeyuki; Kawabata, Ryohei; Kawada, Junji; Fujiwara, Yoshiyuki; Kawase, Tomono; Fukui, Junichi; Takagi, Mari; Takeno, Atsushi; Shimokawa, Toshio

2016-09-01

Post-gastrectomy weight loss is associated with deterioration in quality of life, and influences the long-term prognosis of gastric cancer patients. We conducted a prospective, randomized controlled, open-label study to examine whether an oral elemental diet (Elental(®), Ajinomoto Pharmaceuticals, Tokyo, Japan; hereafter referred to as ED) prevents postoperative weight loss in post-gastrectomy patients. Patients were randomly divided to receive the ED or control diet. The ED group received 300 kcal of ED plus their regular diet for 6-8 weeks after surgery, starting from the day the patient started a soft rice or equivalent diet after surgery, while the control group received the regular diet alone. The primary endpoint was the percentage of body weight loss (%BWL) from the presurgical body weight to that at 6-8 weeks after surgery. Secondary endpoints were dietary adherence, nutrition-related blood parameters, and adverse events. This study included 112 patients in eight hospitals. The mean treatment compliance rate in the ED group was 68.7 ± 30.4 % (median 81.2 %). The %BWL was significantly different between the ED and control groups (4.86 ± 3.72 vs. 6.60 ± 4.90 %, respectively; p = 0.047). In patients who underwent total gastrectomy, the %BWL was significantly different between the two groups (5.03 ± 3.65 vs. 9.13 ± 5.43 %, respectively; p = 0.012). In multivariate analysis, ED treatment, surgery type, and preoperative performance status were independently associated with %BWL. No significant differences were observed in the other clinical variables. ED supplementation reduced postoperative weight loss in gastric cancer patients undergoing gastrectomy.

Language affects length of stay in emergency departments in Queensland public hospitals.

PubMed

Mahmoud, Ibrahim; Hou, Xiang-Yu; Chu, Kevin; Clark, Michele

2013-01-01

A long length of stay (LOS) in the emergency department (ED) associated with overcrowding has been found to adversely affect the quality of ED care. The objective of this study is to determine whether patients who speak a language other than English at home have a longer LOS in EDs compared to those whose speak only English at home. A secondary data analysis of a Queensland state-wide hospital EDs dataset (Emergency Department Information System) was conducted for the period, 1 January 2008 to 31 December 2010. The interpreter requirement was the highest among Vietnamese speakers (23.1%) followed by Chinese (19.8%) and Arabic speakers (18.7%). There were significant differences in the distributions of the departure statuses among the language groups (Chi-squared=3236.88, P<0.001). Compared with English speakers, the Beta coefficient for the LOS in the EDs measured in minutes was among Vietnamese, 26.3 (95%CI: 22.1-30.5); Arabic, 10.3 (95%CI: 7.3-13.2); Spanish, 9.4 (95%CI: 7.1-11.7); Chinese, 8.6 (95%CI: 2.6-14.6); Hindi, 4.0 (95%CI: 2.2-5.7); Italian, 3.5 (95%CI: 1.6-5.4); and German, 2.7 (95%CI: 1.0-4.4). The final regression model explained 17% of the variability in LOS. There is a close relationship between the language spoken at home and the LOS at EDs, indicating that language could be an important predictor of prolonged LOS in EDs and improving language services might reduce LOS and ease overcrowding in EDs in Queensland's public hospitals.

Language affects length of stay in emergency departments in Queensland public hospitals

PubMed Central

Mahmoud, Ibrahim; Hou, Xiang-yu; Chu, Kevin; Clark, Michele

2013-01-01

BACKGROUND: A long length of stay (LOS) in the emergency department (ED) associated with overcrowding has been found to adversely affect the quality of ED care. The objective of this study is to determine whether patients who speak a language other than English at home have a longer LOS in EDs compared to those whose speak only English at home. METHODS: A secondary data analysis of a Queensland state-wide hospital EDs dataset (Emergency Department Information System) was conducted for the period, 1 January 2008 to 31 December 2010. RESULTS: The interpreter requirement was the highest among Vietnamese speakers (23.1%) followed by Chinese (19.8%) and Arabic speakers (18.7%). There were significant differences in the distributions of the departure statuses among the language groups (Chi-squared=3236.88, P<0.001). Compared with English speakers, the Beta coefficient for the LOS in the EDs measured in minutes was among Vietnamese, 26.3 (95%CI: 22.1–30.5); Arabic, 10.3 (95%CI: 7.3–13.2); Spanish, 9.4 (95%CI: 7.1–11.7); Chinese, 8.6 (95%CI: 2.6–14.6); Hindi, 4.0 (95%CI: 2.2–5.7); Italian, 3.5 (95%CI: 1.6–5.4); and German, 2.7 (95%CI: 1.0–4.4). The final regression model explained 17% of the variability in LOS. CONCLUSION: There is a close relationship between the language spoken at home and the LOS at EDs, indicating that language could be an important predictor of prolonged LOS in EDs and improving language services might reduce LOS and ease overcrowding in EDs in Queensland’s public hospitals. PMID:25215085

Sleep duration and consumption of sugar-sweetened beverages and energy drinks among adolescents.

PubMed

Sampasa-Kanyinga, Hugues; Hamilton, Hayley A; Chaput, Jean-Philippe

2018-04-01

To examine the relationship between sleep duration and consumption of sugar sweetened beverages (SSBs) and energy drinks (EDs) among adolescents. Data on 9,473 adolescents aged 11-20 years were obtained from the 2015 cycle of the Ontario Student Drug Use and Health Survey, a province-wide and cross-sectional school based survey of students in middle and high school. Respondents self-reported their sleep duration and consumption of SSBs and EDs. Those who did not meet the age-appropriate sleep duration recommendation were considered short sleepers. Overall, 81.4% and 12.0% of respondents reported that they had at least one SSBs and EDs in the past week, respectively. Males were more likely than females to consume SSBs and EDs. High school students were more likely than those in middle school to report drinking EDs. After adjusting for multiple covariates, results from logistic regression analyses indicated that short sleep duration was associated with greater odds of SSB consumption in middle school students (odd ratio (OR) = 1.64, 95% confidence interval (CI) = 1.18-2.11), but not those in high school (OR = 1.06, 95% CI = 0.86-1.31). Short sleep duration was associated with greater odds of ED consumption in both middle (OR = 1.60, 95% CI = 1.10-2.34) and high school (OR = 1.78, 95% CI = 1.38-2.30) students. Short sleep duration was associated with consumption of EDs in middle and high school students and with SSBs in middle school students only. Future studies are needed to establish causality and to determine whether improving sleep patterns can reduce the consumption of SSBs and EDs among adolescents. Copyright © 2017 Elsevier Inc. All rights reserved.

The influence of Ehlers-Danlos syndrome - hypermobility type, on motherhood: A phenomenological, hermeneutical study.

PubMed

De Baets, Stijn; Vanhalst, Marieke; Coussens, Marieke; Rombaut, Lies; Malfait, Fransiska; Van Hove, Geert; Calders, Patrick; Vanderstraeten, Guy; van de Velde, Dominique

2017-01-01

The consequences of the Ehlers-Danlos Syndrome hypermobility type (EDS-HT) affect many aspects of daily life. "Living with limitations" is a central theme in the life of patients affected by this heritable disorder of connective tissue. The aim of the present study was to explore the lived experiences of women with EDS-HT concerning diagnosis, influence on daily life and becoming and being a mother. A phenomenological-hermeneutical study, using in-depth interviews. Patients were selected by a purposive sampling strategy. This study shows that the EDS-HT syndrome affects daily life. Ten woman between 31 and 65 years were interviewed. They have between 2 and 5 children. The data analysis results in six themes. (1) Getting a diagnosis is a relief and supports the choice to become a mother; (2) EDS-HT causes emotional distress, imposes a physical burden and has a major impact on social behavior; (3) EDS-HT demands a restructuring of everyday activities; (4) Children's and mothers' expectations do not correspond; (5) Having a supportive social and physical environment is of major importance; (6) The presence of the child reduces the feeling of illness of the mother. The diagnosis of EDS-HT is a catalysing factor in the choice of whether or not to become a mother. EDS-HT has a huge impact on bodily functions, which in turn influences activities and participation. This study gives insight in the activities of daily life of persons with EDS-HT. Health care professionals can be of great importance to help patients in (re)organizing their lives according to the available energy and in supporting their choices. They can help defining goals and setting priorities in daily life. Copyright © 2016 Elsevier Ltd. All rights reserved.

Closing the circle of care: implementation of a web-based communication tool to improve emergency department discharge communication with family physicians.

PubMed

Hunchak, Cheryl; Tannenbaum, David; Roberts, Michael; Shah, Thrushar; Tisma, Predrag; Ovens, Howard; Borgundvaag, Bjug

2015-03-01

Postdischarge emergency department (ED) communication with family physicians is often suboptimal and negatively impacts patient care. We designed and piloted an online notification system that electronically alerts family physicians of patient ED visits and provides access to visitspecific laboratory and diagnostic information. Nine (of 10 invited) high-referring family physicians participated in this single ED pilot. A prepilot chart audit (30 patients from each family physician) determined the baseline rate of paper-based record transmission. A webbased communication portal was designed and piloted by the nine family physicians over 1 year. Participants provided usability feedback via focus groups and written surveys. Review of 270 patient charts in the prepilot phase revealed a 13% baseline rate of handwritten chart and a 44% rate of any information transfer between the ED and family physician offices following discharge. During the pilot, participant family physicians accrued 880 patient visits. Seven and two family physicians accessed online records for 74% and 12% of visits, respectively, an overall 60.7% of visits, corresponding to an overall absolute increase in receipt of patient ED visit information of 17%. The postpilot survey found that 100% of family physicians reported that they were ''often'' or ''always'' aware of patient ED visits, used the portal ''always'' or ''regularly'' to access patients' health records online, and felt that the web portal contributed to improved actual and perceived continuity of patient care. Introduction of a web-based ED visit communication tool improved ED-family physician communication. The impact of this system on improved continuity of care, timeliness of follow-up, and reduced duplication of investigations and referrals requires additional study.

Increased restrictive feeding practices are associated with reduced energy density in 4-6-year-old, multi-ethnic children at ad libitum laboratory test-meals.

PubMed

Sud, Shama; Tamayo, Nina Carmela; Faith, Myles S; Keller, Kathleen L

2010-10-01

Increased reports of restrictive feeding have shown positive relationships to child obesity, however, the mechanism between the two has not been elucidated. This study examined the relationship between reported use of restrictive feeding practices and 4-6-year-old children's self-selected energy density (ED) and total energy intake from an ad libitum, laboratory dinner including macaroni and cheese, string beans, grapes, baby carrots, cheese sticks, pudding, milks, and a variety of sweetened beverages. A second objective explored the relationship between ED and child body mass index (BMI) z-score. Seventy (n=70) healthy children from primarily non-Caucasian and lower socioeconomic status families participated. Mothers completed the Child Feeding Questionnaire (CFQ) to assess restrictive feeding practices. Energy density (kcal/g) values for both foods and drinks (ED(food+drink)) and ED for foods only (ED(foods)) were calculated by dividing the average number of calories consumed by the average weight eaten across 4 meals. Higher maternal restriction was associated with lower ED(food+drink). In overweight and obese children only, higher maternal restriction was associated with lower ED(food). There was a non-significant trend for both ED measures to be negatively associated with child BMI z-score. Overall, restrictive feeding practices were not associated with child BMI z-score. However, when analyzing separate aspects of restriction, parents reported higher use of restricting access to palatable foods but lower use of using palatable foods as rewards with heavier children. Previous reports of positive associations between child obesity and restrictive feeding practices may not apply in predominantly non-Caucasian, lower socioeconomic status cohorts of children.

Do instability markers predict satisfactory reduction and requirement for later surgery in emergency department patients with wrist fracture?

PubMed

Winayak, Amar; Gossat, Alyza; Cooper, Jenny; Ritchie, Peter; Lim, Wei; Klim, Sharon; Kelly, Anne-Maree

2018-02-01

Research suggests that the presence of instability markers in patients with displaced distal radial fractures is associated with poorer outcome. Our aims were to determine whether the presence of previously defined instability markers could predict the likelihood of successful ED reduction and requirement for a secondary procedure after ED reduction. Retrospective cohort study performed by medical record review. Adult ED patients coded as having an isolated wrist fracture and having fracture reduction in ED were eligible for inclusion. Data collected included demographics, history of osteoporosis, mechanism of injury, radiological features on X-rays and performance of a secondary procedure. Outcomes of interest were the rate of successful fracture reduction in ED (against defined radiological criteria), the rate of secondary procedures and the association between the number of defined instability risk factors and successful reduction and performance of a secondary surgical procedure. Analysis was by χ 2 test, receiver operating characteristic curve, logistic regression analyses. Three hundred and nineteen patients were studied; median age 62 years, 77% female. Sixty-five per cent of patients had satisfactory fracture reduction in ED (95% CI 59%-70%). Eighty-six patients underwent a secondary procedure to reduce/stabilise their fracture (28%, 95% CI 23%-33%). Younger age, lack of satisfactory ED reduction and increased number of instability factors were independently predictive of the performance of a secondary procedure. Instability risk factors are common in patients with wrist fractures requiring reduction in ED. The number of instability factors is not a strong predictor of the performance of secondary procedures. © 2017 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Recent advances in the treatment and management of excessive daytime sleepiness.

PubMed

Black, Jed; Duntley, Stephen P; Bogan, Richard K; O'Malley, Mary B

2007-02-01

Excessive daytime sleepiness (EDS) is a prevalent complaint among patients in psychiatric care. Patients with conditions of EDS have often been misdiagnosed with depression due to their complaints of lack of energy, poor concentration, memory disturbance, and a reduced interest in life. Impaired alertness associated with EDS can be detrimental to a person's quality of life by causing decreased work performance, self-consciousness, low self esteem, and social isolation. Excessive sleepiness is also associated with various health problems, comorbid medical and psychiatric conditions, and fatal accidents occurring after the driver has fallen asleep at the wheel. Contributing factors leading to EDS range from insufficient sleep hours to central nervous system-mediated debilitating hypersomnolence. Circadian rhythm disorders, sleep disorders such as obstructive sleep apnea and narcolepsy, and medications that cause sleepiness may also contribute to symptoms of EDS. Recognition of the symptoms of sleep deprivation is essential, as many such patients do not have a clear awareness of their own sleepiness. Treatment options, depending upon the condition, include light therapy or appropriate airway management techniques such as nasal continuous positive airway pressure (CPAP). Occasionally, wakefulness-promoting medications are necessary, particularly in patients with narcolepsy. In this expert roundtable supplement, Stephen P. Duntley, MD, reviews the definition and prevalence of EDS and discusses the contributing factors and consequences of daytime sleepiness. Next, Richard K. Bogan, MD, FCCP, gives an overview of the differential diagnosis of EDS and the assessment tools available for identifying sleepiness in symptomatic patients. Finally, Mary B. O'Malley, MD, PhD, reviews treatment of EDS, including counseling on sleep hygiene and duration of sleep, mechanical treatments, bright-light therapy, and wake-promoting medications.

Personality Traits Predict Emergency Department Utilization Over 3 Years in Older Patients

PubMed Central

Chapman, Benjamin P.; Shah, Manish; Friedman, Bruce; Drayer, Rebecca; Duberstein, Paul R.; Lyness, Jeffrey M.

2009-01-01

Background Emergency department (ED) utilization by older patients has major implications for morbidity, mortality, and health costs, yet its behavioral determinants remain poorly understood. Powerfully tied to health in older adults, the “Big Five” personality traits of neuroticism, extroversion, openness to experience, agreeableness, and conscientiousness may predict ED use. Objectives Investigate the role of personality in prospective ED use among older patients. Research Design Prospective cohort. Subjects Adults aged 65 and older. Measures Participants completed the NEO Five Factor Inventory of personality at baseline, and interviewers administered the Cornell Services Index assessing ED use at baseline and 3 yearly follow-ups. Results Controlling for income, education, gender, age, physician-assessed medical burden and physical functioning, and interviewer-assessed impairments in basic activities of daily living and physical self-maintenance, and depression, lower agreeableness and higher extroversion were each associated with increased odds of an ED visit over the follow-up period. A 1 sample deviation (SD) increase in extroversion (i.e., 50th versus 83rd population percentile) increased the odds of ED use by 51% (adjusted odds ratio [AOR] [95% CI] = 1.51 [1.03-2.21], z = 2.12, N = 923, p = 0.034). A 1-SD decrease in agreeableness (i.e., 50th versus 17th population percentile) increased odds of ED use by 54% (AOR [95% CI] = 1.54 [1.05-2.22], z = -2.25, N = 923, p = 0.034). Conclusion The greater assertiveness and social confidence signified by lower agreeableness and higher extroversion may help older adults overcome potential barriers to the ED. Overly introverted and agreeable older adults may require special encouragement to access the ED—particularly for time-sensitive conditions—to reduce morbidity and mortality. PMID:19461261

Negative predictive value and potential cost savings of acute nuclear myocardial perfusion imaging in low risk patients with suspected acute coronary syndrome: A prospective single blinded study

PubMed Central

Forberg, Jakob L; Hilmersson, Catarina E; Carlsson, Marcus; Arheden, Håkan; Björk, Jonas; Hjalte, Krister; Ekelund, Ulf

2009-01-01

Background Previous studies from the USA have shown that acute nuclear myocardial perfusion imaging (MPI) in low risk emergency department (ED) patients with suspected acute coronary syndrome (ACS) can be of clinical value. The aim of this study was to evaluate the utility and hospital economics of acute MPI in Swedish ED patients with suspected ACS. Methods We included 40 patients (mean age 55 ± 2 years, 50% women) who were admitted from the ED at Lund University Hospital for chest pain suspicious of ACS, and who had a normal or non-ischemic ECG and no previous myocardial infarction. All patients underwent MPI from the ED, and the results were analyzed only after patient discharge. The current diagnostic practice of admitting the included patients for observation and further evaluation was compared to a theoretical "MPI strategy", where patients with a normal MPI test would have been discharged home from the ED. Results Twenty-seven patients had normal MPI results, and none of them had ACS. MPI thus had a negative predictive value for ACS of 100%. With the MPI strategy, 2/3 of the patients would thus have been discharged from the ED, resulting in a reduction of total hospital cost by some 270 EUR and of bed occupancy by 0.8 days per investigated patient. Conclusion Our findings in a Swedish ED support the results of larger American trials that acute MPI has the potential to safely reduce the number of admissions and decrease overall costs for low-risk ED patients with suspected ACS. PMID:19545365

Tertiary paediatric emergency department use in children and young people with cerebral palsy.

PubMed

Meehan, Elaine; Reid, Susan M; Williams, Katrina; Freed, Gary L; Babl, Franz E; Sewell, Jillian R; Rawicki, Barry; Reddihough, Dinah S

2015-10-01

The aim of this study was to describe the pattern of tertiary paediatric emergency department (ED) use in children and young people with cerebral palsy (CP). A retrospective analysis of ED data routinely collected at the two tertiary paediatric hospitals in Victoria, Australia, cross-matched with the Victorian Cerebral Palsy Register. Data pertaining to the ED presentations of 2183 registered individuals born 1993-2008 were obtained. Between 2008 and 2012, 37% (n = 814) of the CP cohort had 3631 tertiary paediatric ED presentations. Overall, 40% (n = 332) of presenters were residing in inner metropolitan Melbourne; 44% (n = 356) in outer Melbourne; and 13% (n = 108) in regional Victoria. Presenters were more likely than non-presenters to be younger, non-ambulant and have epilepsy. In total, 71% of presentations were triaged as Australasian Triage Scale 1-3 (urgent), and 44% resulted in a hospital admission. Disorders of the respiratory, neurological and gastrointestinal systems, and medical device problems were responsible for 72% of presentations. Many of the tertiary paediatric ED presentations in this group were appropriate based on the high admission rate and the large proportion triaged as urgent. However, there is evidence that some families are bypassing local services and travelling long distances to attend the tertiary paediatric ED, even for less urgent complaints that do not require hospital admission. Alternative pathways of care delivery, and strategies to promote the management of common problems experienced by children and young people with CP in non-paediatric EDs or primary care settings, may go some way towards reducing unnecessary tertiary paediatric ED use in this group. © 2015 The Authors. Journal of Paediatrics and Child Health © 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians).

Youth With Autism Spectrum Disorder in the Emergency Department.

PubMed

Lytle, Sarah; Hunt, Andrew; Moratschek, Sonal; Hall-Mennes, Marcie; Sajatovic, Martha

2018-05-08

This comprehensive literature review summarizes reports on emergency department (ED) use by youth with autism spectrum disorder (ASD). We conducted a systematic search of the PubMed, PsycINFO, CINAHL, and EMBASE databases (1985-2016), limited to studies published in English. The following search terms were used: autism, autistic, Asperger, emergency department/room/physician/doctor/treatment/medicine, childhood developmental disorders (pervasive), and emergencies. Our search found 332 articles, of which 12 specifically addressed ED services in ASD youth. Abstracts or full text articles were reviewed for relevance. Case reports, review articles, and studies that reported on adults only or that included youth and adults but did not stratify results by age were excluded. Youth (aged 0-17 years) with ASD were up to 30 times more likely to present to the ED than youth without ASD. Individuals with ASD who visited the ED were older, more likely to have public insurance, and more likely to have nonurgent ED visits. For youth with ASD, up to 13% of visits were for behavioral or psychiatric problems, whereas for youth without ASD less than 2% were for psychiatric problems. ASD youth were more likely to present for externalizing problems or psychotic symptoms. Youth with ASD were also likely to have repeat visits to the ED and more likely to be admitted to a psychiatric unit or medical floor than youth without ASD. This review found significant gaps in the literature related to ED service use by youth with ASD. More research is needed to avoid unnecessary ED utilization and hospitalization, reduce medical costs, and improve outcome for youth with ASD. © Copyright 2018 Physicians Postgraduate Press, Inc.

Regulated deficit irrigation alters anthocyanins, tannins and sensory properties of cabernet sauvignon grapes and wines.

PubMed

Casassa, Luis Federico; Keller, Markus; Harbertson, James F

2015-04-29

Four regulated deficit irrigation (RDI) regimes were applied to Cabernet Sauvignon grapes, which were analyzed for phenolics and also made into wine over three consecutive growing seasons. Relative to an industry standard regime (IS), yield was reduced over the three years by 37% in a full-deficit (FD) regime and by 18% in an early deficit (ED) regime, whereas no yield reduction occurred with a late deficit (LD) regime. Relative to IS, skin anthocyanin concentration (fresh weight basis) was 18% and 24% higher in ED and FD, respectively, whereas no effect was seen in LD. Seed tannin concentration was 3% and 8% higher in ED and FD, respectively, relative to the other two RDI regimes, whereas seed tannin content (amount per berry) was higher in IS than in FD. There were no practically relevant effects on the basic chemistry of the wines. The finished wines showed concentrations of tannins and anthocyanins that generally mirrored observed differences in skin and seed phenolic concentrations, although these were amplified in FD wines. Descriptive sensory analysis of the 2008 wines showed that FD wines were the most saturated in color, with higher purple hue, roughness, dryness and harshness, followed by ED wines, whereas IS and LD wines were less saturated in color and with higher brown and red hues. Overall, FD and ED seemed to yield fruit and wine with greater concentrations of phenolics than IS and LD, with the additional advantage of reducing water usage. However, these apparent benefits need to be balanced out with reductions in crop yields and potential long-term effects associated with pre-véraison water deficits.

Vital Signs: Health Burden and Medical Costs of Nonfatal Injuries to Motor Vehicle Occupants — United States, 2012

PubMed Central

Bergen, Gwen; Peterson, Cora; Ederer, David; Florence, Curtis; Haileyesus, Tadesse; Kresnow, Marcie-jo; Xu, Likang

2014-01-01

Background Motor vehicle crashes are a leading cause of death and injury in the United States. The purpose of this study was to describe the current health burden and medical and work loss costs of nonfatal crash injuries among vehicle occupants in the United States. Methods CDC analyzed data on emergency department (ED) visits resulting from nonfatal crash injuries among vehicle occupants in 2012 using the National Electronic Injury Surveillance System – All Injury Program (NEISS-AIP) and the Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS). The number and rate of all ED visits for the treatment of crash injuries that resulted in the patient being released and the number and rate of hospitalizations for the treatment of crash injuries were estimated, as were the associated number of hospital days and lifetime medical and work loss costs. Results In 2012, an estimated 2,519,471 ED visits resulted from nonfatal crash injuries, with an estimated lifetime medical cost of $18.4 billion (2012 U.S. dollars). Approximately 7.5% of these visits resulted in hospitalizations that required an estimated 1,057,465 hospital days in 2012. Conclusions Nonfatal crash injuries occur frequently and result in substantial costs to individuals, employers, and society. For each motor vehicle crash death in 2012, eight persons were hospitalized, and 100 were treated and released from the ED. Implications for Public Health Public health practices and laws, such as primary seat belt laws, child passenger restraint laws, ignition interlocks to prevent alcohol impaired driving, sobriety checkpoints, and graduated driver licensing systems have demonstrated effectiveness for reducing motor vehicle crashes and injuries. They might also substantially reduce associated ED visits, hospitalizations, and medical costs. PMID:25299606

Scribes in an Australian private emergency department: A description of physician productivity.

PubMed

Walker, Katherine; Ben-Meir, Michael; O'Mullane, Phebe; Phillips, David; Staples, Margaret

2014-12-01

The study aims to determine if trained scribes in an Australian ED can assist emergency physicians (EPs) to work with increased productivity. This was a pilot, prospective, observational study conducted at a private ED in Melbourne. A scribe is a trained assistant who works with an EP and performs non-clinical tasks that reduce the time spent providing clinical care for patients. Shifts with and without a scribe were compared. The primary outcomes were patients per hour per doctor and billings per patient. Additional analyses included total patient time in ED; individual doctor productivity; time to see a doctor; time on ambulance bypass; and complaints/issues identified with scribes. There was an overall increase in doctor consultations per hour of 0.32 patients (95% confidence interval (CI) 0.17, 0.47). This varied between doctors from an increase in patients per hour of 0.16 (95% CI -0.09, 0.40) to 0.65 (95% CI 0.41, 0.89). Billings per patient were increased (AUD15.24; 95% CI -AUD18.51, AUD48.99), but the increase was not statistically significant; time to see a doctor reduced by 22 min (95% CI 11, 33); bypass episodes reduced by 66 min per shift (95% CI 11, 122), total patient ED stay remained constant. In this pilot study, scribe usage was feasible, and overall improvements in consultations per hour were seen. Overall income improved by AUD104.86 (95% CI AUD38.52, AUD171.21) per scribed hour. Further study is recommended to determine if results are sustained or improved over a longer period. © 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Reducing Head CT Use for Children With Head Injuries in a Community Emergency Department.

PubMed

Jennings, Rebecca M; Burtner, Jennifer J; Pellicer, Joseph F; Nair, Deepthi K; Bradford, Miranda C; Shaffer, Michele; Uspal, Neil G; Tieder, Joel S

2017-04-01

Clinical decision rules have reduced use of computed tomography (CT) to evaluate minor pediatric head injury in pediatric emergency departments (EDs). CT use remains high in community EDs, where the majority of children seek medical care. We sought to reduce the rate of CT scans used to evaluate pediatric head injury from 29% to 20% in a community ED. We evaluated a quality improvement (QI) project in a community ED aimed at decreasing the use of head CT scans in children by implementing a validated head trauma prediction rule for traumatic brain injury. A multidisciplinary team identified key drivers of CT use and implemented decision aids to improve the use of prediction rules. The team identified and mitigated barriers. An affiliated children's hospital offered Maintenance of Certification credit and QI coaching to participants. We used statistical process control charts to evaluate the effect of the intervention on monthly CT scan rates and performed a Wald test of equivalence to compare preintervention and postintervention CT scan proportions. The baseline period (February 2013-July 2014) included 695 patients with a CT scan rate of 29.2% (95% confidence interval, 25.8%-32.6%). The postintervention period (August 2014-October 2015) included 651 patients with a CT scan rate of 17.4% (95% confidence interval, 14.5%-20.2%, P < .01). Barriers included targeting providers with variable pediatric experience and parental imaging expectations. We demonstrate that a Maintenance of Certification QI project sponsored by a children's hospital can facilitate evidence-based pediatric care and decrease the rate of unnecessary CT use in a community setting. Copyright © 2017 by the American Academy of Pediatrics.

Reducing eating disorder risk factors: A pilot effectiveness trial of a train-the-trainer approach to dissemination and implementation.

PubMed

Greif, Rebecca; Becker, Carolyn Black; Hildebrandt, Tom

2015-12-01

Impediments limit dissemination and implementation of evidence-based interventions (EBIs), including lack of sufficient training. One strategy to increase implementation of EBIs is the train-the-trainer (TTT) model. The Body Project is a peer-led body image program that reduces eating disorder (ED) risk factors. This study examined the effectiveness of a TTT model at reducing risk factors in Body Project participants. Specifically, this study examined whether a master trainer could train a novice trainer to train undergraduate peer leaders to administer the Body Project such that individuals who received the Body Project (i.e., participants) would evidence comparable outcomes to previous trials. We hypothesized that participants would evidence reductions in ED risk factors, with effect sizes similar to previous trials. Utilizing a TTT model, a master trainer trained a novice trainer to train undergraduate peer leaders to administer the Body Project to undergraduate women. Undergraduate women aged 18 years or older who received the Body Project intervention participated in the trial and completed measures at baseline, post-treatment, and five-month follow-up. Primary outcomes included body dissatisfaction, thin ideal internalization, negative affect, and ED pathology. Participants demonstrated significant reductions in thin ideal internalization, ED pathology and body dissatisfaction at post-treatment and 5-month follow-up. At 5 months, using three different strategies for managing missing data, effect sizes were larger or comparable to earlier trials for 3 out of 4 variables. Results support a TTT model for Body Project implementation and the importance of utilizing sensitivity analyses for longitudinal datasets with missing data. © 2015 Wiley Periodicals, Inc.

Junior doctor strike model of care: Reduced access block and predominant Fellow of the Australasian College for Emergency Medicine staffing improve emergency department performance.

PubMed

Thornton, Vanessa; Hazell, Wayne

2008-10-01

To describe the response and analyse ED performance during a 5-day junior doctor strike. Data were collected via the patient information management computer system. Key performance indicators included percentage seen within maximum waiting times per triage category (TC), ED length of stay, emergency medicine patients who did not wait to be seen, hospital bed occupancy and access block percentage. Comparisons were made for the same 5 days before the strike (BS), during the strike (S) and after the strike. Total doctor's shifts BS were 78.66 with 25% of these shifts being Fellow of the Australasian College for Emergency Medicine (FACEM) shifts. FACEM shifts were more common during the S period at 75% (P < 0.001). Total attendances (BS 631 vs S 596, P = 0.22) and TC percentages (P-values for TC 1, 2, 3, 4, 5, respectively, 1.0, 0.55, 0.88, 0.97, 0.46) in the BS, S and after-the-strike periods were not significantly different. Despite fewer total doctor shifts, the FACEM predominant model of care during the strike resulted in better percentages seen within the maximum waiting times for TC3 (66%), TC4 (78%) and TC5 (86%) (all P < 0.001). There was a reduction in patients who did not wait to be seen (28 BS vs 5 S, P < 0.001), ED length of stay (admissions: BS 451 min vs S 258 min, P < 0.001; discharges: BS 233 min vs S 144 min, P < 0.02) and referrals to inpatient services (P = 0.02). This occurred with reduced bed point occupancy of 66% and a consequent reduction in access block. FACEM staffing and reduced access block were significant factors in improved ED performance.

Short Duration Reduced Gravity Drop Tower Design and Development

NASA Astrophysics Data System (ADS)

Osborne, B.; Welch, C.

The industrial and commercial development of space-related activities is intimately linked to the ability to conduct reduced gravity research. Reduced gravity experimentation is important to many diverse fields of research in the understanding of fundamental and applied aspects of physical phenomena. Both terrestrial and extra-terrestrial experimental facilities are currently available to allow researchers access to reduced gravity environments. This paper discusses two drop tower designs, a 2.0 second facility built in Australia and a proposed 2.2 second facility in the United Kingdom. Both drop towers utilise a drag shield for isolating the falling experiment from the drag forces of the air during the test. The design and development of The University of Queensland's (Australia) 2.0 second drop tower, including its specifications and operational procedures is discussed first. Sensitive aspects of the design process are examined. Future plans are then presented for a new short duration (2.2 sec) ground-based reduced gravity drop tower. The new drop tower has been designed for Kingston University (United Kingdom) to support teaching and research in the field of reduced gravity physics. The design has been informed by the previous UQ drop tower design process and utilises a catapult mechanism to increase test time and also incorporates features to allow participants for a variety of backgrounds (from high school students through to university researchers) to learn and experiment in reduced gravity. Operational performance expectations for this new facility are also discussed.

Group-based education for patients with type 2 diabetes: a survey of Australian dietitians.

PubMed

Odgers-Jewell, Kate; Isenring, Elisabeth A; Thomas, Rae; Reidlinger, Dianne P

2017-09-01

Group-based education has the potential to substantially improve the outcomes of individuals with type 2 diabetes mellitus (T2DM) and reduce the enormous burden that chronic diseases place on healthcare systems worldwide. Despite this proven effectiveness, the utilisation of group services for the management of T2DM by Australian dietitians is surprisingly low. This study surveyed a sample of 263 Australian dietitians to explore the utilisation of group-based education for T2DM, as well as dietitians' preferences for practice and training. The results of this study indicate that Australian dietitians are currently under-utilising group-based education programs for the management of T2DM, with the primary reasons identified as a lack of training provided to dietitians in the area, limited access to facilities suitable for conducting group education, the perceived poor cost-effectiveness of these programs, and the lack of evidence-based practice guidelines for the group-based management of persons with T2DM. Additionally, the majority of preferences for further training were for either face-to-face or web-based formal training conducted over 3-6h. Clear, evidence-based practice guidelines and training resources for group education for the management of T2DM are needed in order to encourage better utilisation of group-based education by Australian dietitians.

Applications of bauxite residue: A mini-review.

PubMed

Verma, Ajay S; Suri, Narendra M; Kant, Suman

2017-10-01

Bauxite residue is the waste generated during alumina production by Bayer's process. The amount of bauxite residue (40-50 wt%) generated depends on the quality of bauxite ore used for the processing. High alkalinity and high caustic content in bauxite residue causes environmental risk for fertile soil and ground water contamination. The caustic (NaOH) content in bauxite residue leads to human health risks, like dermal problems and irritation to eyes. Moreover, disposal of bauxite residue requires a large area; such problems can only be minimised by utilising bauxite residue effectively. For two decades, bauxite residue has been used as a binder in cement industries and filler/reinforcement for composite materials in the automobile industry. Valuable metals and oxides, like alumina (Al 2 O 3 ), titanium oxide (TiO 2 ) and iron oxide Fe 2 O 3 , were extracted from bauxite residue to reduce waste. Bauxite residue was utilised in construction and structure industries to make geopolymers. It was also used in the making of glass-ceramics and a coating material. Recently bauxite residue has been utilised to extract rare earth elements like scandium (Sc), yttrium (Y), lanthanum (La), cerium (Ce), neodymium (Nd) and dysprosium (Dy). In this review article, the mineralogical characteristics of bauxite residue are summarised and current progresses on utilisation of bauxite residue in different fields of science and engineering are presented in detail.

What do most erectile dysfunction guidelines have in common? No evidence-based discussion or recommendation of heart-healthy lifestyle changes and/or Panax ginseng

PubMed Central

Moyad, Mark A; Park, Kwangsung

2012-01-01

Sexual health or erectile dysfunction (ED) state of the art guidelines provide a thorough overview of conventional prescription or other notable extrinsic treatment options. Yet, over the past 10–15 years, a plethora of international researchers have established that individual and comprehensive lifestyle changes can prevent and potentially improve ED. We review the lifestyle evidence that should equate to grade A or level 1 evidence recommendations for ED. We also review the evidence for Panax ginseng, an over-the-counter (OTC) dietary supplement with a 35-year history of laboratory investigations, multiple positive randomized trials over approximately 15 years and several independent meta-analyses and systematic reviews. Perhaps it is time to at least discuss and even emphasize lifestyle and other non-conventional interventions in ED guidelines so that patients can explore a diversity of potentially synergistic choices with their physicians and can improve their quality and quantity of life. Ignoring the consistent, positive data on lifestyle modifications in ED guidelines, for example, is tantamount to ignoring diet and lifestyle changes to reduce the risk of or ameliorate cardiovascular diseases. PMID:23001440

Investigating the Role of Hypothalamic Tumor Involvement in Sleep and Cognitive Outcomes Among Children Treated for Craniopharyngioma

PubMed Central

Conklin, Heather M.; Scoggins, Matthew A.; Ashford, Jason M.; Merchant, Thomas E.; Mandrell, Belinda N.; Ogg, Robert J.; Curtis, Elizabeth; Wise, Merrill S.; Indelicato, Daniel J.; Crabtree, Valerie M.

2016-01-01

Objective: Despite excellent survival prognosis, children treated for craniopharyngioma experience significant morbidity. We examined the role of hypothalamic involvement (HI) in excessive daytime sleepiness (EDS) and attention regulation in children enrolled on a Phase II trial of limited surgery and proton therapy. Methods: Participants completed a sleep evaluation (N = 62) and a continuous performance test (CPT) during functional magnetic resonance imaging (fMRI; n = 29) prior to proton therapy. Results: EDS was identified in 76% of the patients and was significantly related to increased HI extent (p = .04). There was no relationship between CPT performance during fMRI and HI or EDS. Visual examination of group composite fMRI images revealed greater spatial extent of activation in frontal cortical regions in patients with EDS, consistent with a compensatory activation hypothesis. Conclusion: Routine screening for sleep problems during therapy is indicated for children with craniopharyngioma, to optimize the timing of interventions and reduce long-term morbidity. PMID:27189690

Active Dust Mitigation Technology for Thermal Radiators for Lunar Exploration

NASA Technical Reports Server (NTRS)

Calle, C. I.; Buhler, C. R.; Hogue, M. D.; Johansen, M. R.; Hopkins, J. W.; Holloway, N. M. H.; Connell, J. W.; Chen, A.; Irwin, S. A.; Case, S. O.;

Treatment of periodontal disease in a patient with Ehlers-Danlos syndrome. A case report and literature review.

PubMed

Perez, Luis A; Al-Shammari, Khalaf F; Giannobile, William V; Wang, Hom-Lay

2002-05-01

Ehlers-Danlos syndrome (EDS) designates a heterogeneous group of connective tissue disorders characterized by skin elasticity, tissue fragility, and chronic joint pain. Dental findings have been reported with some types of EDS. This case report describes the periodontal findings in a patient with a previously undiagnosed EDS type VIII. Diagnostic aids utilized included microbial testing, histological examination, gingival crevicular fluid (GCF) analysis for the levels of C-telopeptide pyridinoline cross-links (ICTP), and genetic counseling. Periodontal treatment consisted of mechanical debridement and adjunctive antibiotic therapy. Genetic counseling and clinical presentation confirmed the diagnosis of EDS type VIII. Periodontal treatment led to marked clinical improvements and GCF levels of the bone resorptive marker ICTP were significantly reduced. The patient and her siblings are currently pursuing appropriate medical care and genetic counseling. Periodontal involvement may lead to the diagnosis of an underlying systemic condition. Identification of suspected etiological factors of periodontal disease may prove critical for the general well-being of some patients.

Endothelial dysfunction: the early predictor of atherosclerosis.

PubMed

Mudau, Mashudu; Genis, Amanda; Lochner, Amanda; Strijdom, Hans

2012-05-01

Since the discovery in the 1980s that nitric oxide (NO) is in fact the elusive endothelium-derived relaxing factor, it has become evident that NO is not only a major cardiovascular signalling molecule, but that changes in its bioavailability are crucial in determining whether atherosclerosis will develop or not. Sustained high levels of harmful circulating stimuli associated with cardiovascular risk factors such as diabetes mellitus elicit responses in endothelial cells that appear sequentially, namely endothelial cell activation and endothelial dysfunction (ED). ED, characterised by reduced NO bioavailability, is now recognised by many as an early, reversible precursor of atherosclerosis. The pathogenesis of ED is multifactorial; however, oxidative stress appears to be the common underlying cellular mechanism in the ensuing loss of vaso-active, inflammatory, haemostatic and redox homeostasis in the body's vascular system. The role of ED as a pathophysiological link between early endothelial cell changes associated with cardiovascular risk factors and the development of ischaemic heart disease is of importance to basic scientists and clinicians alike.

Lifestyle modifications and erectile dysfunction: what can be expected?

PubMed Central

Maiorino, Maria Ida; Bellastella, Giuseppe; Esposito, Katherine

2015-01-01

Erectile dysfunction (ED) is a common medical disorder whose prevalence is increasing worldwide. Modifiable risk factors for ED include smoking, lack of physical activity, wrong diets, overweight or obesity, metabolic syndrome, and excessive alcohol consumption. Quite interestingly, all these metabolic conditions are strongly associated with a pro-inflammatory state that results in endothelial dysfunction by decreasing the availability of nitric oxide (NO), which is the driving force of the blood genital flow. Lifestyle and nutrition have been recognized as central factors influencing both vascular NO production, testosterone levels, and erectile function. Moreover, it has also been suggested that lifestyle habits that decrease low-grade clinical inflammation may have a role in the improvement of erectile function. In clinical trials, lifestyle modifications were effective in ameliorating ED or restoring absent ED in people with obesity or metabolic syndrome. Therefore, promotion of healthful lifestyles would yield great benefits in reducing the burden of sexual dysfunction. Efforts, in order to implement educative strategies for healthy lifestyle, should be addressed. PMID:25248655

Use of 16S rRNA-targeted oligonucleotide probes to investigate the distribution of sulphate-reducing bacteria in estuarine sediments.

PubMed

Purdy, K J.; Nedwell, D B.; Embley, T M.; Takii, S

2001-07-01

The distribution of sulphate-reducing bacteria (SRBs) in three anaerobic sediments, one predominantly freshwater and low sulphate and two predominantly marine and high sulphate, on the River Tama, Tokyo, Japan, was investigated using 16S rRNA-targeted oligonucleotide probes. Hybridisation results and sulphate reduction measurements indicated that SRBs are a minor part of the bacterial population in the freshwater sediments. Only Desulfobulbus and Desulfobacterium were detected, representing 1.6% of the general bacterial probe signal. In contrast, the SRB community detected at the two marine-dominated sites was larger and more diverse, representing 10-11.4% of the bacterial signal and with Desulfobacter, Desulfovibrio, Desulfobulbus and Desulfobacterium detected. In contrast to previous reports our results suggest that Desulfovibrio may not always be the most abundant SRB in anaerobic sediments. Acetate-utilising Desulfobacter were the dominant SRB in the marine-dominated sediments, and Desulfobulbus and Desulfobacterium were active in low-sulphate sediments, where they may utilise electron acceptors other than sulphate.

Utilisation of preharvest dropped apple peels as a flour substitute for a lower glycaemic index and higher fibre cake.

PubMed

Jun, Yujin; Bae, In Young; Lee, Suyong; Lee, Hyeon Gyu

2014-02-01

Fibre-enriched materials (FEMs) obtained from preharvest dropped apple peels were utilised as a source of dietary fibre in baked cakes and their effects on the textural/nutritional qualities and starch digestibility (glucose release behaviour, starch digestion fraction, predicted glycaemic index) of the cakes were evaluated. When FEMs were incorporated into the cake formulation (3 g and 6 g of dietary fibre per serving (100 g)), the volume of the cakes seemed to be reduced and their texture become harder. However, 3 g of FEMs did not degrade the cake qualities. The use of FEMs in cakes significantly reduced the levels of rapidly digestible starch and slowly digestible starch, while the levels of resistant starch increased. Additionally, the cake samples prepared with FEMs exhibited a lower predicted glycaemic index. This study may give rise to multi-functional bakery products with acceptable quality and low glycaemic index.

An observational study of emergency department utilization among enrollees of Minnesota Health Care Programs: financial and non-financial barriers have different associations

PubMed Central

2014-01-01

Background Emergency department (ED) use is costly, and especially frequent among publicly insured populations in the US, who also disproportionately encounter financial (cost/coverage-related) and non-financial/practical barriers to care. The present study examines the distinct associations financial and non-financial barriers to care have with patterns of ED use among a publicly insured population. Methods This observational study uses linked administrative-survey data for enrollees of Minnesota Health Care Programs to examine patterns in ED use—specifically, enrollee self-report of the ED as usual source of care, and past-year count of 0, 1, or 2+ ED visits from administrative data. Main independent variables included a count of seven enrollee-reported financial concerns about healthcare costs and coverage, and a count of seven enrollee-reported non-financial, practical barriers to access (e.g., limited office hours, problems with childcare). Covariates included health, health care, and demographic measures. Results In multivariate regression models, only financial concerns were positively associated with reporting ED as usual source of care, but only non-financial barriers were significantly associated with greater ED visits. Regression-adjusted values indicated notable differences in ED visits by number of non-financial barriers: zero non-financial barriers meant an adjusted 78% chance of having zero ED visits (95% C.I.: 70.5%-85.5%), 15.9% chance of 1(95% C.I.: 10.4%-21.3%), and 6.2% chance (95% C.I.: 3.5%-8.8%) of 2+ visits, whereas having all seven non-financial barriers meant a 48.2% adjusted chance of zero visits (95% C.I.: 30.9%-65.6%), 31.8% chance of 1 visit (95% C.I.: 24.2%-39.5%), and 20% chance (95% C.I.: 8.4%-31.6%) of 2+ visits. Conclusions Financial barriers were associated with identifying the ED as one’s usual source of care but non-financial barriers were associated with actual ED visits. Outreach/literacy efforts may help reduce reliance on/perception of ED as usual source of care, whereas improved targeting/availability of covered services may help curb frequent actual visits, among publicly insured individuals. PMID:24507761

An internet-based communication network for information transfer during patient transitions from skilled nursing facility to the emergency department.

PubMed

Hustey, Fredric M; Palmer, Robert M

2010-06-01

To determine whether the implementation of an Internet-based communication system improves the amount of essential information conveyed between a skilled nursing facility (SNF) and the emergency department (ED) during patient care transitions. Interventional; before and after. ED of an urban teaching hospital with approximately 55,000 visits per year and a 55-bed subacute free-standing rehabilitation facility (the SNF). All patients transferred from the SNF to the ED over 16 months. An Internet-based communication network with SNF-ED transfer form for communication during patient care transitions. Nine elements of patient information assessed before and after intervention through chart review. changes in efficiency of information transfer and staff satisfaction. Two hundred thirty-four of 237 preintervention and all 276 postintervention care transitions were reviewed. The Internet communication network was used in 78 (26%) of all care transitions, peaking at 40% by the end of the study. There was more critical patient information (1.85 vs 4.29 of 9 elements; P<.001) contained within fewer pages of transfer documents (24.47 vs 5.15; P<.001) after the intervention. Staff satisfaction with communication was higher among ED physicians after the intervention. The use of an Internet-based system increased the amount of information communicated during SNF-ED care transitions and significantly reduced the number of pages in which this information was contained.

Endothelial Dysfunction in Rheumatoid Arthritis: Mechanistic Insights and Correlation with Circulating Markers of Systemic Inflammation.

PubMed

Totoson, Perle; Maguin-Gaté, Katy; Nappey, Maude; Wendling, Daniel; Demougeot, Céline

2016-01-01

To determine mechanisms involved in endothelial dysfunction (ED) during the course of arthritis and to investigate the link between cytokines, chemokines and osteoprotegerin. Experiments were conducted on aortic rings at day 4 (preclinical), day 11 (onset of disease), day 33 (acute disease) and day 90 (chronic disease) after adjuvant-induced arthritis (AIA) in Lewis rats. At day 4, the unique vascular abnormality was a reduced norepinephrine-induced constriction. At day 11, endothelial function assessed by the relaxation to acetylcholine was normal despite increased cyclo-oxygenase-2 activity (COX-2) and overproduction of superoxide anions that was compensated by increased nitric oxide synthase (NOS) activity. At day 33, ED apparition coincides with the normalization of NOS activity. At day 90, ED was only observed in rats with a persisting imbalance between endothelial NOS and COX-2 pathways and higher plasma levels of IL-1β and TNFα. Plasma levels of IL-1β, TNFα and MIP-1α negatively correlated with Ach-induced relaxation throughout the course of AIA. Our data identified increased endothelial NOS activity as an important compensatory response that opposes the ED in the early arthritis. Thereafter, a cross-talk between endothelial COX-2/NOS pathways appears as an important element for the occurrence of ED. Our results encourage determining the clinical value of IL-1β, TNFα and MIP-1α as biomarkers of ED in RA.

Redesigned geriatric emergency care may have helped reduce admissions of older adults to intensive care units.

PubMed

Grudzen, Corita; Richardson, Lynne D; Baumlin, Kevin M; Winkel, Gary; Davila, Carine; Ng, Kristen; Hwang, Ula

2015-05-01

Charged with transforming geriatric emergency care by applying palliative care principles, a process improvement team at New York City's Mount Sinai Medical Center developed the GEDI WISE (Geriatric Emergency Department Innovations in Care through Workforce, Informatics, and Structural Enhancements) model. The model introduced workforce enhancements for emergency department (ED) and adjunct staff, including role redefinition, retraining, and education in palliative care principles. Existing ED triage nurses screened patients ages sixty-five and older to identify those at high risk of ED revisit and hospital readmission. Once fully trained, these nurses screened all but 6 percent of ED visitors meeting the screening criteria. Newly hired ED nurse practitioners identified high-risk patients suitable for and desiring palliative and hospice care, then expedited referrals. Between January 2011 and May 2013 the percentage of geriatric ED admissions to the intensive care unit fell significantly, from 2.3 percent to 0.9 percent, generating an estimated savings of more than $3 million to Medicare. The decline in these admissions cannot be confidently attributed to the GEDI WISE program because other geriatric care innovations were implemented during the study period. GEDI WISE programs are now running at Mount Sinai and two partner sites, and their potential to affect the quality and value of geriatric emergency care continues to be examined. Project HOPE—The People-to-People Health Foundation, Inc.

Autoinjectors Preferred for Intramuscular Epinephrine in Anaphylaxis and Allergic Reactions

PubMed Central

Campbell, Ronna L.; Bellolio, M. Fernanda; Motosue, Megan S.; Sunga, Kharmene L.; Lohse, Christine M.; Rudis, Maria I.

2016-01-01

Introduction Epinephrine is the treatment of choice for anaphylaxis. We surveyed emergency department (ED) healthcare providers regarding two methods of intramuscular (IM) epinephrine administration (autoinjector and manual injection) for the management of anaphylaxis and allergic reactions and identified provider perceptions and preferred method of medication delivery. Methods This observational study adhered to survey reporting guidelines. It was performed through a Web-based survey completed by healthcare providers at an academic ED. The primary outcomes were assessment of provider perceptions and identification of the preferred IM epinephrine administration method by ED healthcare providers. Results Of 217 ED healthcare providers invited to participate, 172 (79%) completed the survey. Overall, 82% of respondents preferred the autoinjector method of epinephrine administration. Providers rated the autoinjector method more favorably for time required for training, ease of use, convenience, satisfaction with weight-based dosing, risk of dosing errors, and speed of administration (p<0.001 for all comparisons). However, manual injection use was rated more favorably for risk of provider self-injury and patient cost (p<0.001 for both comparisons). Three participants (2%) reported a finger stick injury from an epinephrine autoinjector. Conclusion ED healthcare providers preferred the autoinjector method of IM epinephrine administration for the management of anaphylaxis or allergic reactions. Epinephrine autoinjector use may reduce barriers to epinephrine administration for the management of anaphylaxis in the ED. PMID:27833688

Effectiveness of Implementing Evidence-based Interventions to Reduce C-spine Image Ordering in the Emergency Department: A Systematic Review.

PubMed

Desai, Shashwat; Liu, Chaocheng; Kirkland, Scott W; Krebs, Lynette D; Keto-Lambert, Diana; Rowe, Brian H

2018-06-01

Appropriate use of imaging for adult patients with cervical spine (C-spine) injuries in the emergency department (ED) is a longstanding issue. Guidance for C-spine ordering exists; however, the effectiveness of the decision support implementation in the ED is not well studied. This systematic review examines the implementation and effectiveness of evidence-based interventions aimed at reducing C-spine imaging in adults presenting to the ED with neck trauma. Six electronic databases and the gray literature were searched. Comparative intervention studies were eligible for inclusion. Two independent reviewers screened for study eligibility, study quality, and extracted data. The change in imaging was reported using individual odds ratios (ORs) with 95% confidence intervals (CIs) using random effects. A total of 990 unique citations were screened for relevance of which six before-after studies and one randomized controlled trial were included. None of the studies were assessed as high quality. Interventions consisted primarily of locally developed guidelines or established clinical decision rules such as the NEXUS or the Canadian C-spine rule. Overall, implementation of interventions aimed at reducing C-spine image ordering resulted in a statistically significant reduction in imaging (OR = 0.69, 95% CI = 0.51-0.93); however, heterogeneity was high (I 2  = 82%). Subgroup analysis revealed no differences between studies that specified enrolling alert and stable patients compared to unspecified trauma (p = 0.81) or between studies employing multifaceted versus nonmultifaceted interventions (p = 0.66). While studies generally provided details on implementation strategies (e.g., teaching sessions, pocket cards, posters, computerized decision support) the effectiveness of these implementation strategies were frequently not reported. There is moderate evidence regarding the effectiveness of interventions to reduce C-spine image ordering in adult patients seen in the ED with neck trauma. Given the national and international focus on improving appropriateness and reducing unnecessary C-spine imaging through campaigns such as Choosing Wisely, additional interventional research in this field is warranted. © 2017 by the Society for Academic Emergency Medicine.

Elevated Steady State WBC and Platelet Counts Are Associated with Frequent Emergency Room Use in Adults with Sickle Cell Anemia

PubMed Central

Danda, Neeraja; Etzion, Zipora

2015-01-01

Introduction Sickle cell anemia has many sequelae that result in emergency department (ED) use, but a minority of patients with sickle cell disease are frequent utilizers and make up the majority of ED visits. If patients who are likely to be frequent ED can be identified in steady state, they can be treated with disease modifying agents in an attempt to reduce ED use frequency. We sought to identify steady state markers for frequent ED use. Methods We identified all patients with SS/Sβ0 seen at our facilities in 2012. Health care utilization over the entire year was calculated and ED visit numbers categorized as either 0–1, 2–5, or 6 or more visits a year. Steady state and acutely active laboratory parameters were collected and analyzed using analysis of variance models and odds ratios. Results 432 adult sickle cell patients were identified, ages 18–87, 54% female, and 38% had been prescribed hydroxyurea. Of the 432 patients,192 had 0–1 visits in the year, 144 had 2–5 visits in the year, and 96 had >6 visits for a total of 2259 visits. Those who had >6 visits accounted for 1750 (77%) of the total visits for the year. When steady state laboratory markers were examined, each additional 50x109/L platelets was associated with 22% greater risk (p < .001); each 1x109/L of WBC was associated with 11% greater risk (p = .003), and each 1g/dL Hb was associated with 23% lower risk (p = .007) of >6 ED visits/year. We did not observe a relationship between baseline HbF, LDH or reticulocyte count with >6 ED visits. Conclusion Patients with elevated white blood cell counts, elevated platelet counts, and low hemoglobin levels exhibited higher risk for frequent ED utilization and could be candidates for early and aggressive therapy with disease modifying agents. PMID:26248283

Effect of a pager notification system on Australasian Triage Scale category 2 patients in a paediatric emergency department.

PubMed

Cheng, Daryl R; McCartney, Laura E; West, Adam; Craig, Simon S

2016-08-01

Australasian EDs have introduced innovative processes to ensure safe and timely management of patients. Our ED introduced a dedicated pager system to provide rapid assessment of Australasian Triage Scale (ATS) category 2 patients in an attempt to expedite ED care. The present paper aims to evaluate the impact of this initiative on time to clinician, ED length of stay (LOS) and clinical outcomes in a tertiary paediatric ED. Retrospective structured chart review on patients presenting in a 2 month period before the intervention (August-September 2009) and the same time 1 year later. Patients were grouped into common ATS category 2 presentations and analysed in these subcategories. Clinical indicators of appropriate and timely performance were selected from best practice performance guidelines. 779 ATS category 2 patients were seen during the two periods: 370 pre-intervention and 409 post-intervention. The overall percentage of ATS category 2 patients seen within the target time increased by 22.3%, although there was no significant change in ED LOS. The median time for patients from triage to being seen by an ED clinician improved from 10 to 6 min (P < 0.01). However, we were unable to demonstrate an impact of the pager system on various clinical quality indicators. The rapid assessment pager system proved beneficial in reducing triage to clinician times for ATS category 2 patients but showed no improvement in overall ED LOS or disease-specific clinical quality indicators. Further research is needed to determine the influence of other components of ED functioning on clinical outcomes, as well as the overall clinical impact a pager system has on other measures of quality such as patient satisfaction and other subgroups of patients. © 2016 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

A review of current methods using bacteriophages in live animals, food and animal products intended for human consumption.

PubMed

Cooper, Ian R

2016-11-01

Bacteriophages are utilised in the food industry as biocontrol agents to reduce the load of bacteria, and thus reduce potential for human infection. This review focuses on current methods using bacteriophages within the food chain. Limitations of research will be discussed, and the potential for future food-based bacteriophage research. Copyright © 2016 Elsevier B.V. All rights reserved.

Work Values System Development during Adolescence

ERIC Educational Resources Information Center

Porfeli, Erik J.

2007-01-01

Work values stability, change, and development can be appreciably reduced to a living system model [Ford, D. H. (1994). "Humans as self-constructing living systems: A developmental perspective on behavior and personality" (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum Associates]. This theoretical model includes discrepancy-reducing and…

Reducing Non-Attendance Rates for Assessment at an Eating Disorders Service: A Quality Improvement Initiative.

PubMed

Jenkins, Paul E

2017-10-01

Rates of non-attendance at initial appointments within community eating disorder (ED) services are frequently high, although this has received relatively little research attention and no reports of interventions designed to address this. The current report describes outcomes following a change of procedure introducing a 'partial booking' system. Attendance rates at first appointments (N = 1260) were audited following introduction of a system designed to reduce non-attendance in January 2013 within a UK ED service. Rates were compared following implementation of the new system, using a historical control group for comparison, and showed a decline from 20.4 to 15.1%, a medium-sized effect. Use of a system asking patients to book an appointment reduced non-attendance at initial appointments and may be of use to similar services experiencing high non-attendance rates. Opt-in initiatives can reduce burden resulting from long waiting times and can be easily adapted to individual services.

In Defense of Freedom: Protection of Human Rights at Home and Abroad

DTIC Science & Technology

2010-10-01

ed. The World of Child Labor: An Historical and Regional Survey. Armonk: M.E. Sharpe, 2009. (HD 6231 .W67 2009) Hollenbach, David, ed. Driven from...no. 2 (Summer 2007 ): 163-74 Horowitz, Andrew W. and Julie R. Trivitt. "Does Child Labor Reduce Youth Crime?" Kyklos 60, no. 4 (November 2007...Parreńas. "Screening Sexual Slavery? Southeast Asian Gonzo Porn and US Anti-Trafficking Law." Sexualities 13, no. 2 (April 2010 ): 161-70 Siraj, Mazhar

Sustainable Benefits of a Community Hospital-Based Paediatric Asthma Clinic.

PubMed

Kuzik, Brian A; Chen, Chee P; Hansen, Miriam J; Montgomery, Paula L

2017-01-01

In 2011, we reported that our paediatric asthma clinic (PAC) appeared to significantly reduce the burden of paediatric asthma in our community. Supported by these results, the PAC underwent a gradual threefold expansion while maintaining the same model of care. We now report on the outcome of that expansion and demonstrate that our PAC continues to significantly reduce the burden of paediatric asthma in our community. As previously, newly enrolled PAC patients continue to show a 12-month reduction in asthma-related emergency department (ED) visits and admissions exceeding 60% and 80%, respectively. This consistent short-term benefit, coupled with clinic expansion, has contributed to a significant improvement in our rate of paediatric asthma-related ED visits or hospitalizations when compared to other Ontario hospitals.

Intervention to prevent further falls in older people who call an ambulance as a result of a fall: a protocol for the iPREFER randomised controlled trial.

PubMed

Mikolaizak, A Stefanie; Simpson, Paul M; Tiedemann, Anne; Lord, Stephen R; Caplan, Gideon A; Bendall, Jason C; Howard, Kirsten; Close, Jacqueline C T

2013-09-27

An increasing number of falls result in an emergency call and the subsequent dispatch of paramedics. In the absence of physical injury, abnormal physiological parameters or change in usual functional status, it could be argued that routine conveyance by ambulance to the Emergency Department (ED) is not the most effective or efficient use of resources. Further, it is likely that non-conveyed older fallers have the potential to benefit from timely access to fall risk assessment and intervention. The aim of this randomised controlled trial is to evaluate the effect of a timely and tailored falls assessment and management intervention on the number of subsequent falls and fall-related injuries for non-conveyed older fallers. Community dwelling people aged 65 years or older who are not conveyed to the ED following a fall will be eligible to be visited at home by a research physiotherapist. Consenting participants will receive individualised intervention strategies based on risk factors identified at baseline. All pre-test measures will be assessed prior to randomisation. Post-test measures will be undertaken by a researcher blinded to group allocation 6 months post-baseline. Participants in the intervention group will receive individualised pro-active fall prevention strategies from the clinical researcher to ensure that risk factors are addressed adequately and interventions carried out. The primary outcome measure will be the number of falls recorded by a falls diary over a 12 month period. Secondary outcome measures assessed six months after baseline will include the subsequent use of medical and emergency services and uptake of recommendations. Data will be analysed using the intention-to-treat principle. As there is currently little evidence regarding the effectiveness or feasibility of alternate models of care following ambulance non-conveyance of older fallers, there is a need to explore assessment and intervention programs to help reduce subsequent falls, related injuries and subsequent use of health care services. By linking existing services rather than setting up new services, this pragmatic trial aims to utilise the health care system in an efficient and timely manner. Australian New Zealand Clinical Trials Registry: ACTRN 12611000503921.

Informing the Design and Evaluation of Superuser Care Management Initiatives: Accounting for Regression-to-the-Mean.

PubMed

Chakravarty, Sujoy; Cantor, Joel C

2016-09-01

Health care spending is concentrated among a small number of high-cost patients, and the popularity of initiatives to improve care and reduce cost among such "superusers" (SUs) is growing. However, SU costs decline naturally over time, even without intervention, a statistical phenomenon known as regression-to-the-mean (RTM). We assess the magnitude of RTM in hospital costs for cohorts of hospital SUs identified on the basis of high inpatient (IP) or emergency department (ED) utilization. We further examine how cost and RTM are associated with patient characteristics including behavioral health (BH) problems, multiple chronic conditions, and indicators of vulnerability. Using longitudinally linked all-payer hospital billing data, we selected patient cohorts with ≥2 IP stays (IP SUs) or ≥6 ED visits (ED SUs) during a 6-month baseline period, and additional subgroups defined by combinations of IP and ED superuse. A total of 289,060 NJ hospital IP and treat-and-release ED patients over 2009-2011. Hospital costs among IP and ED SUs declined 70% and 38%, respectively, over 8 quarters following the baseline period. The decrease occurs more quickly for IP SUs compared with ED SUs. Presence of BH problems was positively associated with costs among patients overall, but the relationship varied by SU cohort. Understanding patterns of RTM among SU populations is important for designing intervention strategies, as there is greater potential for savings among patients with more persistent costs (less RTM). Further, as many SU initiatives lack resources for rigorous evaluation, quantifying the extent of RTM is vital for interpreting program outcomes.

Exploring the association of urban or rural county status and environmental, nutrition- and lifestyle-related resources with the efficacy of SNAP-Ed (Supplemental Nutrition Assistance Program-Education) to improve food security.

PubMed

Rivera, Rebecca L; Dunne, Jennifer; Maulding, Melissa K; Wang, Qi; Savaiano, Dennis A; Nickols-Richardson, Sharon M; Eicher-Miller, Heather A

2018-04-01

To investigate the association of policy, systems and environmental factors with improvement in household food security among low-income Indiana households with children after a Supplemental Nutrition Assistance Program-Education (SNAP-Ed) direct nutrition education intervention. Household food security scores measured by the eighteen-item US Household Food Security Survey Module in a longitudinal randomized and controlled SNAP-Ed intervention study conducted from August 2013 to April 2015 were the response variable. Metrics to quantify environmental factors including classification of urban or rural county status; the number of SNAP-authorized stores, food pantries and recreational facilities; average fair market housing rental price; and natural amenity rank were collected from government websites and data sets covering the years 2012-2016 and used as covariates in mixed multiple linear regression modelling. Thirty-seven Indiana counties, USA, 2012-2016. SNAP-Ed eligible adults from households with children (n 328). None of the environmental factors investigated were significantly associated with changes in household food security in this exploratory study. SNAP-Ed improves food security regardless of urban or rural location or the environmental factors investigated. Expansion of SNAP-Ed in rural areas may support food access among the low-income population and reduce the prevalence of food insecurity in rural compared with urban areas. Further investigation into policy, systems and environmental factors of the Social Ecological Model are warranted to better understand their relationship with direct SNAP-Ed and their impact on diet-related behaviours and food security.

Characteristics features and factors influencing early death in Acute promyelocytic leukemia; Experience from United Arab Emirates (UAE).

PubMed

Hassan, Inaam Bashir; Zaabi, Mariam R Al; Alam, Arif; Hashim, Mohammed Jawad; Tallman, Martin S; Kristensen, Jorgen

2017-07-01

Although acute promyelocytic leukemia (APL) is a curable hematologic malignancy, early death (ED) remains a significant cause of treatment failure especially in developing countries. In a retrospective data analysis of 67 adult APL patients diagnosed in United Arab Emirates we report an ED rate of 11.9% which is comparable to that reported from more developed countries. We identified the following parameters at presentation as significant predictor of increased ED: Age >40 years (P = 0.015), fever (P = 0.030), WBC count >20 × 10 9 /L (P = 0.010), the breakpoints other than bcr1 (P = 0.043) and fibrinogen level <1.5 g/L (P = 0.025). Delay in ATRA administration beyond 24 h from admission and fibrinogen <150 mg/dL were also significant predictors of ED, but only among high-risk patients (P = 0.035 and P = 0.033, respectively). WBC count >10 × 10 9 /L and expression of HLA-DR (P = 0.018) or CD2 (P = 0.017) were significant predictors for differentiation syndrome (DS) which was found to be a predictor of ED (P = 0.002). Reducing the APL related ED rate in centers with limited resources is feasible provided early initiation of ATRA administration and early correction of coagulopathy in high-risk patients in addition to prompt treatment of DS. To our knowledge this is the first report from the Arabian Gulf describing ED in APL.

Feminist approaches to Anorexia Nervosa: a qualitative study of a treatment group.

PubMed

Holmes, Su; Drake, Sarah; Odgers, Kelsey; Wilson, Jon

2017-01-01

Eating disorders (EDs) are now often approached as biopsychosocial problems. But it has been suggested by scholars interested in sociocultural factors that all is not equal within this biospsychosocial framework, with the 'social' aspects of the equation relegated to secondary factors within ED treatment contexts. Although sociocultural influences are well-established as risk factors for EDs, the exploration of whether or how such perspectives are useful in treatment has been little explored. In responding to this context, this article seeks to discuss and evaluate a 10 week closed group intervention based on feminist approaches to EDs at a residential eating disorder clinic in the East of England. The data was collected via one-to-one qualitative interviews and then analysed using thematic discourse analysis. The participants suggested that the groups were helpful in enabling them to situate their problem within a broader cultural and group context, that they could operate as a form of 'protection' from ideologies regarding femininity, and that a focus on the societal contexts for EDs could potentially reduce feelings of self-blame. At the same time, the research pointed to the complexities of participants considering societal rather than individualised explanations for their problems, whilst it also confronted the implications of ambivalent responses toward feminism. Highly visible sociocultural factors in EDs - such as gender - may often be overlooked in ED clinical contexts. Although based on limited data, this research raises questions about the marginalisation of sociocultural factors in treatment, and the benefits and challenges including the latter may involve.

The financial impact of health information exchange on emergency department care.

PubMed

Frisse, Mark E; Johnson, Kevin B; Nian, Hui; Davison, Coda L; Gadd, Cynthia S; Unertl, Kim M; Turri, Pat A; Chen, Qingxia

2012-01-01

To examine the financial impact health information exchange (HIE) in emergency departments (EDs). We studied all ED encounters over a 13-month period in which HIE data were accessed in all major emergency departments Memphis, Tennessee. HIE access encounter records were matched with similar encounter records without HIE access. Outcomes studied were ED-originated hospital admissions, admissions for observation, laboratory testing, head CT, body CT, ankle radiographs, chest radiographs, and echocardiograms. Our estimates employed generalized estimating equations for logistic regression models adjusted for admission type, length of stay, and Charlson co-morbidity index. Marginal probabilities were used to calculate changes in outcome variables and their financial consequences. HIE data were accessed in approximately 6.8% of ED visits across 12 EDs studied. In 11 EDs directly accessing HIE data only through a secure Web browser, access was associated with a decrease in hospital admissions (adjusted odds ratio (OR)=0.27; p<0001). In a 12th ED relying more on print summaries, HIE access was associated with a decrease in hospital admissions (OR=0.48; p<0001) and statistically significant decreases in head CT use, body CT use, and laboratory test ordering. Applied only to the study population, HIE access was associated with an annual cost savings of $1.9 million. Net of annual operating costs, HIE access reduced overall costs by $1.07 million. Hospital admission reductions accounted for 97.6% of total cost reductions. Access to additional clinical data through HIE in emergency department settings is associated with net societal saving.

Automatic, Multiple Assessment Options in Undergraduate Meteorology Education

ERIC Educational Resources Information Center

Kahl, Jonathan D. W.

2017-01-01

Since 2008, automatic, multiple assessment options have been utilised in selected undergraduate meteorology courses at the University of Wisconsin--Milwaukee. Motivated by a desire to reduce stress among students, the assessment methodology includes examination-heavy and homework-heavy alternatives, differing by an adjustable 15% of the overall…

What makes emergency department patients reduce their alcohol consumption?--a computer-based intervention study in Sweden.

PubMed

Trinks, Anna; Festin, Karin; Bendtsen, Preben; Nilsen, Per

2013-01-01

This study investigates the effectiveness of a computerized emergency department intervention for alcohol consumption and identifies explanation factors associated with reduced alcohol consumption from risk to non-risk drinking. Patients aged 18-69 years registered at the ED triage answered alcohol-related questions on a touch-screen computer. Follow-up data were collected by means of a postal questionnaire that was mailed to the patients 6 months after their ED visit. There were four independent explanations for reduced alcohol consumption: being motivated to reduce alcohol consumption at baseline, influenced by just visiting the emergency department, considering the alcohol-related feedback information and impact from a health care provider. 339 patients could be followed up and of these were 97 categorized as risk drinkers at baseline and 45 became non-risk drinker 6 month later. Being motivated to reduce alcohol consumption at baseline, influenced by just visiting the emergency department, considering the alcohol-related feedback information and impact from a health care provider were predictors for change from risk to non-risk drinking 6 months later. Copyright © 2011 Elsevier Ltd. All rights reserved.

The impact of hypomagnesemia on erectile dysfunction in elderly, non-diabetic, stage 3 and 4 chronic kidney disease patients: a prospective cross-sectional study.

PubMed

Toprak, Omer; Sarı, Yasin; Koç, Akif; Sarı, Erhan; Kırık, Ali

2017-01-01

Erectile dysfunction (ED) is common in older men with chronic kidney disease. Magnesium is essential for metabolism of nitric oxide which helps in penile erection. There is little information available about the influence of serum magnesium on ED. The aim of the study was to assess the influence of hypomagnesemia on ED in elderly chronic kidney disease patients. A total of 372 patients aged 65-85 years, with an estimated glomerular filtration rate of 60-15 mL/min/1.73 m 2 , were divided into two groups according to serum magnesium levels: hypomagnesemia, n=180; and normomagnesemia, n=192. ED was assessed through the International Index of Erectile Function-5. Hypomagnesemia is defined as serum magnesium <1.8 mg/dL. The prevalence of ED was higher among hypomagnesemic subjects compared to that among normomagnesemics (93.3% vs 70.8%, P <0.001). Severe ED (62.8% vs 43.8%, P =0.037), mild-to-moderate ED (12.2% vs 5.2%, P =0.016), abdominal obesity (37.2% vs 22.9%, P =0.003), metabolic syndrome (38.4% vs 19.2%, P =0.026), proteinuria (0.83±0.68 vs 0.69±0.48 mg/dL, P =0.023), and C-reactive protein (6.1±4.9 vs 4.1±3.6 mg/L, P <0.001) were high; high-density lipoprotein cholesterol (48.8±14.0 vs 52.6±13.5 mg/dL, P =0.009), and albumin (4.02±0.53 vs 4.18±0.38 g/dL, P =0.001) were low in the hypomagnesemia group. Serum magnesium ≤1.85 mg/dL was the best cutoff point for prediction of ED. Hypomagnesemia (relative risk [RR] 2.27), age ≥70 (RR 1.74), proteinuria (RR 1.80), smoking (RR 21.12), C-reactive protein (RR 1.34), abdominal obesity (RR 3.92), and hypertension (RR 2.14) were predictors of ED. Our data support that ED is related to hypomagnesemia in elderly patients with moderately to severely reduced kidney function.

Lean thinking in emergency departments: concepts and tools for quality improvement.

PubMed

Bruno, Frances

2017-10-12

The lean approach is a viable framework for reducing costs and enhancing the quality of patient care in emergency departments (EDs). Reports on lean-inspired quality improvement initiatives are rapidly growing but there is little emphasis on the philosophy behind the processes, which is the essential ingredient in sustaining transformation. This article describes lean philosophy, also referred to as lean, lean thinking and lean healthcare, and its main concepts, to enrich the knowledge and vocabulary of nurses involved or interested in quality improvement in EDs. The article includes examples of lean strategies to illustrate their practical application in EDs. ©2012 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.

Improving Emergency Department radiology transportation time: a successful implementation of lean methodology.

PubMed

Hitti, Eveline A; El-Eid, Ghada R; Tamim, Hani; Saleh, Rana; Saliba, Miriam; Naffaa, Lena

2017-09-05

Emergency Department overcrowding has become a global problem and a growing safety and quality concern. Radiology and laboratory turnaround time, ED boarding and increased ED visits are some of the factors that contribute to ED overcrowding. Lean methods have been used in the ED to address multiple flow challenges from improving door-to-doctor time to reducing length of stay. The objective of this study is to determine the effectiveness of using Lean management methods on improving Emergency Department transportation times for plain radiography. We performed a before and after study at an academic urban Emergency Department with 49,000 annual visits after implementing a Lean driven intervention. The primary outcome was mean radiology transportation turnaround time (TAT). Secondary outcomes included overall study turnaround time from order processing to preliminary report time as well as ED length of stay. All ED patients undergoing plain radiography 6 months pre-intervention were compared to all ED patients undergoing plain radiography 6 months post-intervention after a 1 month washout period. Post intervention there was a statistically significant decrease in the mean transportation TAT (mean ± SD: 9.87 min ± 15.05 versus 22.89 min ± 22.05, respectively, p-value <0.0001). In addition, it was found that 71.6% of patients in the post-intervention had transportation TAT ≤ 10 min, as compared to 32.3% in the pre-intervention period, p-value <0.0001, with narrower interquartile ranges in the post-intervention period. Similarly, the "study processing to preliminary report time" and the length of stay were lower in the post-intervention as compared to the pre-intervention, (52.50 min ± 35.43 versus 54.04 min ± 34.72, p-value = 0.02 and 3.65 h ± 5.17 versus 4.57 h ± 10.43, p < 0.0001, respectively), in spite of an increase in the time it took to elease a preliminary report in the post-intervention period. Using Lean change management techniques can be effective in reducing transportation time to plain radiography in the Emergency Department as well as improving process reliability.

Utilisation of rheumatology care services in Germany: the case of physical therapy and self-help groups.

PubMed

Thieme, Holm; Borgetto, Bernhard

2012-01-01

Physical Therapy (PT) and self-help groups (SHG) are important components of health care in rheumatic diseases. The utilisation of PT and SHG by patients with rheumatic diseases may be influenced by several factors. The aim of this study is to summarize the evidence on PT and SHG utilisation of patients with rheumatic diseases in Germany. We systematically searched the MEDLINE-database for studies that evaluated the utilisation and factors that possibly influence the utilisation of PT and SHG. Eight studies were found for PT-utilisation and one for SHG-utilisation. Between 25 and 59 percent of patients with rheumatic diseases received PT services. Several individual and contextual factors that may influence the utilisation could be identified. In conclusion, evidence exists for wide variations in the utilisation of PT services and an underuse of such services among patients with rheumatic diseases in Germany. By contrast, little evidence exists on the utilisation of SHG.

Healthcare Resource Utilisation Associated with Herpes Zoster in a Prospective Cohort of Older Australian Adults.

PubMed

Karki, Surendra; Newall, Anthony T; MacIntyre, C Raina; Heywood, Anita E; McIntyre, Peter; Banks, Emily; Liu, Bette

2016-01-01

Herpes zoster (HZ) is a common condition that increases in incidence with older age but vaccines are available to prevent the disease. However, there are limited data estimating the health system burden attributable to herpes zoster by age. In this study, we quantified excess healthcare resource usage associated with HZ during the acute/sub-acute period of disease (21days before to 90 days after onset) in 5952 cases and an equal number of controls matched on age, sex, and prior healthcare resource usage. Estimates were adjusted for potential confounders in multivariable regression models. Using population-based estimates of HZ incidence, we calculated the age-specific excess number of health service usage events attributable to HZ in the population. Per HZ case, there was an average of 0.06 (95% CI 0.04-0.08) excess hospitalisations, 1.61 (95% CI 1.51-1.69) excess general practitioner visits, 1.96 (95% CI 1.86-2.15) excess prescriptions filled and 0.11 (95% CI 0.09-0.13) excess emergency department visits. The average number of healthcare resource use events, and the estimated excess per 100,000 population increased with increasing age but were similar for men and women, except for higher rates of hospitalisation in men. The excess annual HZ associated burden of hospitalisations was highest in adults ≥80 years (N = 2244, 95%CI 1719-2767); GP visits was highest in those 60-69 years (N = 50567, 95%CI 39958-61105), prescriptions and ED visits were highest in 70-79 years (N = 50524, 95%CI 40634-60471 and N = 2891, 95%CI 2319-3449 respectively). This study provides important data to establish the healthcare utilisation associated with HZ against which detailed cost-effectiveness analyses of HZ immunisation in older adults can be conducted.

Benign Headache Management in the Emergency Department.

PubMed

Long, Brit J; Koyfman, Alex

2018-04-01

Headache is a common complaint managed in the emergency department (ED), with emergency physicians focusing on evaluation for life-threatening conditions while treating pain and nausea. This review evaluates the treatment of benign, primary headaches in the ED, with recommendations provided based on the literature. Headaches are a major cause of disability in the United States and a common condition managed in the ED. The primary objectives of emergency evaluation of these patients include evaluation for a life-threatening, secondary cause of headache, with treatment of primary headaches. Close evaluation for a secondary cause of headache include consideration of red flags and focused neurologic examination. The diagnosis of primary headaches is clinical. Literature has evaluated medication efficacy in headache treatment, with antidopaminergic medications demonstrating high rates of efficacy when used in combination with nonsteroidal inflammatory drugs or acetaminophen. Dexamethasone can be used for the reduction of headache recurrence. If dehydration is present, intravenous fluids should be provided. Diphenhydramine is not recommended for analgesia but may reduce akathisia associated with prochlorperazine. Ketamine, propofol, and nerve blocks demonstrate promise. Triptan agents are also efficacious, provided absence of contraindications. Most patients are appropriate for discharge with pain improvement. A variety of medications is available for the treatment of primary headaches in the ED. Antidopaminergic agents demonstrate the highest efficacy and should be provided with acetaminophen and nonsteroidal inflammatory drugs. Dexamethasone may reduce headache recurrence. Other treatments include ketamine, propofol, and nerve blocks. Published by Elsevier Inc.

Simulating the behavior of patients who leave a public hospital emergency department without being seen by a physician: a cellular automaton and agent-based framework.

PubMed

Yousefi, Milad; Yousefi, Moslem; Fogliatto, F S; Ferreira, R P M; Kim, J H

2018-01-11

The objective of this study was to develop an agent based modeling (ABM) framework to simulate the behavior of patients who leave a public hospital emergency department (ED) without being seen (LWBS). In doing so, the study complements computer modeling and cellular automata (CA) techniques to simulate the behavior of patients in an ED. After verifying and validating the model by comparing it with data from a real case study, the significance of four preventive policies including increasing number of triage nurses, fast-track treatment, increasing the waiting room capacity and reducing treatment time were investigated by utilizing ordinary least squares regression. After applying the preventing policies in ED, an average of 42.14% reduction in the number of patients who leave without being seen and 6.05% reduction in the average length of stay (LOS) of patients was reported. This study is the first to apply CA in an ED simulation. Comparing the average LOS before and after applying CA with actual times from emergency department information system showed an 11% improvement. The simulation results indicated that the most effective approach to reduce the rate of LWBS is applying fast-track treatment. The ABM approach represents a flexible tool that can be constructed to reflect any given environment. It is also a support system for decision-makers to assess the relative impact of control strategies.

Optimizing financial effects of HIE: a multi-party linear programming approach.

PubMed

Sridhar, Srikrishna; Brennan, Patricia Flatley; Wright, Stephen J; Robinson, Stephen M

2012-01-01

To describe an analytical framework for quantifying the societal savings and financial consequences of a health information exchange (HIE), and to demonstrate its use in designing pricing policies for sustainable HIEs. We developed a linear programming model to (1) quantify the financial worth of HIE information to each of its participating institutions and (2) evaluate three HIE pricing policies: fixed-rate annual, charge per visit, and charge per look-up. We considered three desired outcomes of HIE-related emergency care (modeled as parameters): preventing unrequired hospitalizations, reducing duplicate tests, and avoiding emergency department (ED) visits. We applied this framework to 4639 ED encounters over a 12-month period in three large EDs in Milwaukee, Wisconsin, using Medicare/Medicaid claims data, public reports of hospital admissions, published payer mix data, and use data from a not-for-profit regional HIE. For this HIE, data accesses produced net financial gains for all providers and payers. Gains, due to HIE, were more significant for providers with more health maintenance organizations patients. Reducing unrequired hospitalizations and avoiding repeat ED visits were responsible for more than 70% of the savings. The results showed that fixed annual subscriptions can sustain this HIE, while ensuring financial gains to all participants. Sensitivity analysis revealed that the results were robust to uncertainties in modeling parameters. Our specific HIE pricing recommendations depend on the unique characteristics of this study population. However, our main contribution is the modeling approach, which is broadly applicable to other populations.