Search

Approximately 17,000 new spinal cord injuries occur each year in the United States, with motor vehicle collisions and falls being the most common causes. Even though 94% of patients survive the initial injury and corresponding hospitalization, their life expectancy is reduced secondary to the long-term complications that stem from their injury. Every patient should be approached in the same manner (i.e., as if they have a spinal cord injury) until proven otherwise to prevent additional injury. Important considerations that should take place in the emergency department include the patient's airway, the presence of shock, and the prevention of complications secondary to the primary injury. This article briefly summarizes the epidemiology and pathophysiology of spinal cord injuries and the therapies that may be recommended and initiated following a thorough assessment of the patient. [ABSTRACT FROM AUTHOR]

In addition to the fears associated with contracting COVID-19, the pandemic has forced families across the United States to quickly transition to new patterns of living. These transitions present new stressors, including health-related concerns, new demands placed on families by lockdowns and stay-at-home orders, and the possibility of losing a job or inability to pay bills. Such stressors have the potential to disrupt collaboration between coparents in addition to basic family functioning. Drawing upon a family systems perspective, the current study thus sought to examine links between COVID-19–related stressors and family cohesion through coparental functioning. A total of 1,003 parent/caregivers (97% from the United States; 82% Caucasian, 74% female; M = 40.9 years old, SD = 8.5; Mincome = $83,631, SDincome = $36,320) of school-age children completed an initial online survey from the end of March to the end of April of 2020. Of the initial sample, a total of 685 parents/caregivers completed weekly diaries for a month. Based on multilevel modeling, results suggested that, at the between-family level, coparental conflict mediated the impact of the stress of parenting/work demands and financial stress on family cohesion. At the within-family level, weekly spikes in health-related stress were associated with corresponding spikes in coparental conflict, which, in turn, were associated with drops in family cohesion. Results from the current study suggest that beyond the fears associated with contracting the COVID-19 virus, other key stressors associated with the emerging pandemic played a role in increasing coparental conflict, ultimately exacerbating family functioning. [ABSTRACT FROM AUTHOR]

Background Evidence on risk for adverse outcomes from coronavirus disease 2019 (COVID-19) among pregnant women is still emerging. We examined the association between COVID-19 at delivery and adverse pregnancy outcomes, maternal complications, and severe illness, and whether these associations differ by race/ethnicity, and describe discharge status by COVID-19 diagnosis and maternal complications. Methods Data from 703 hospitals in the Premier Healthcare Database during March–September 2020 were included. Adjusted risk ratios (aRRs) overall and stratified by race/ethnicity were estimated using Poisson regression with robust standard errors. Proportion not discharged home was calculated by maternal complications, stratified by COVID-19 diagnosis. Results Among 489 471 delivery hospitalizations, 6550 (1.3%) had a COVID-19 diagnosis. In adjusted models, COVID-19 was associated with increased risk for acute respiratory distress syndrome (aRR, 34.4), death (aRR, 17.0), sepsis (aRR, 13.6), mechanical ventilation (aRR, 12.7), shock (aRR, 5.1), intensive care unit admission (aRR, 3.6), acute renal failure (aRR, 3.5), thromboembolic disease (aRR, 2.7), adverse cardiac event/outcome (aRR, 2.2), and preterm labor with preterm delivery (aRR, 1.2). Risk for any maternal complications or for any severe illness did not significantly differ by race/ethnicity. Discharge status did not differ by COVID-19; however, among women with concurrent maternal complications, a greater proportion of those with (vs without) COVID-19 were not discharged home. Conclusions These findings emphasize the importance of implementing recommended prevention strategies to reduce risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and further inform counseling and clinical care for pregnant women during the COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

Background: Vasodilatory shock refractory to catecholamine vasopressors and arginine vasopressin is highly morbid and responsible for significant mortality. Synthetic angiotensin II is a potent vasoconstrictor that may be suitable for use in these patients.Research Question: What is the safety and effectiveness of angiotensin II and what variables are associated with a favorable hemodynamic response?Study Design and Methods: We performed a multicenter, retrospective study at five tertiary medical centers in the United States. The primary end point of hemodynamic responsiveness to angiotensin II was defined as attainment of mean arterial pressure (MAP) of ≥ 65 mm Hg with a stable or reduced total vasopressor dosage 3 h after drug initiation.Results: Of 270 included patients, 181 (67%) demonstrated hemodynamic responsiveness to angiotensin II. Responders showed a greater increase in MAP (+10.3 mm Hg vs +1.6 mm Hg, P < .001) and reduction in vasopressor dosage (-0.20 μg/kg/min vs +0.04 μg/kg/min; P < .001) compared with nonresponders at 3 h. Variables associated with favorable hemodynamic response included lower lactate concentration (OR 1.11; 95% CI, 1.05-1.17, P < .001) and receipt of vasopressin (OR, 6.05; 95% CI, 1.98-18.6; P = .002). In severity-adjusted multivariate analysis, hemodynamic responsiveness to angiotensin II was associated with reduced likelihood of 30-day mortality (hazard ratio, 0.50; 95% CI, 0.35-0.71; P < .001). Arrhythmias occurred in 28 patients (10%) and VTE was identified in 4 patients.Interpretation: In postmarketing use for vasopressor-refractory shock, 67% of angiotensin II recipients demonstrated a favorable hemodynamic response. Patients with lower lactate concentrations and those receiving vasopressin were more likely to respond to angiotensin II. Patients who responded to angiotensin II experienced reduced mortality. [ABSTRACT FROM AUTHOR]

Introduction: Remotely tele-mentored ultrasound (RTMUS) involves the real-time guidance of US-naïve providers as they perform point-of-care ultrasound (POCUS) by remotely located, US-proficient providers via telemedicine. The concordance between RTMUS and POCUS in the evaluation of critically ill patients has not been reported. This study sought to evaluate the concordance between RTMUS and POCUS for the cardiopulmonary evaluation of patients in acute respiratory insufficiency and/or shock. Methods: Ultrasound-naÏve nurses performed RTMUS on critically ill patients. Concordance between RTMUS and POCUS (performed by critical care fellows) in the evaluation of the heart and lungs was reported. The test characteristics of RTMUS were calculated using POCUS as a gold standard. Concordance between RTMUS and available transthoracic echocardiography (TTE) and computed tomography (CT) scans was also reported. Results: Twenty patients were enrolled. Concordance between RTMUS and POCUS was good (90%-100%) for left ventricle function, right ventricle (RV) dilatation/dysfunction, pericardial effusion, lung sliding, pulmonary interstitial syndrome, pleural effusion, and fair (80%) for lung consolidation. Concordance between RTMUS and TTE or CT was similar. RTMUS was highly specific (88%-100%) for all abnormalities evaluated and highly sensitive (89%-100%) for most abnormalities although sensitivity for the detection of RV dilatation/dysfunction (33%) and pulmonary interstitial syndrome (71%) was negatively impacted by false negatives. Conclusions: RTMUS may be a reasonable substitute for POCUS in the cardiopulmonary evaluation of patients with acute respiratory insufficiency and/or shock. These findings should be validated on a larger scale. [ABSTRACT FROM AUTHOR]

Protein-energy malnutrition (PEM), resulting from depleted energy and nutrient stores, compromises the body's defense systems and may exacerbate sepsis and its impact. However, population-based studies examining the association of PEM on the prevalence and health-care burden of sepsis are lacking. To investigate the relationship between PEM and sepsis, influence of PEM on clinical outcomes of sepsis, and impact of PEM on trends in sepsis mortality. The primary study is a retrospective cohort analysis of the 2012-2014 National Inpatient Sample (NIS) patient discharge records. Secondary analyses are cross-sectional study on the 2014 NIS and trend analysis on 2007-2014 NIS. The primary study included adult inpatient hospitalizations for sepsis in the United States. Mortality, complicated sepsis, and 10 other metrics of clinical outcomes and health care utilization. First, patients with sepsis (2014 NIS) were stratified into two groups: uncomplicated (without shock) and complicated (with shock). The adjusted odds ratio of having sepsis (total, uncomplicated, and complicated) was estimated with PEM as predictor using logistic regressions (binomial and multinomial). Second, among patients with sepsis (2012-2014 NIS), PEM cases were matched to cases without PEM (no-PEM) using a greedy-algorithm based propensity-matching methodology (1:1), and the outcomes were measured with conditional regression models. Finally, the trend in mortality from sepsis was calculated, stratified by PEM status, as an effect modifier, using Poisson models (2007-2014 NIS). All models accounted for the complex sampling methodology (SAS 9.4). In 2014, PEM was associated with higher odds for sepsis (3.97 [3.89 to 4.05], P <0.0001) and complicated vs uncomplicated sepsis (1.74 [1.67 to 1.81], P <0.0001). From 2012-2014, about 18% (167,133 of 908,552) of hospitalizations for sepsis had coexisting PEM. After propensity matching, PEM was associated with higher mortality (adjusted odds ratio: 1.35 [1.32 to 1.37], P <0.0001), cost ($160,724 [159,517 to 161,940] vs $86,650 [85,931 to 87,375], P <0.0001), length of stay (14.8 [14.9 to 14.8] vs 8.5 [8.5 to 8.6] days, P <0.0001), adverse events, and resource utilization. Although mortality in sepsis has been trending down from 2007-2014 (−1.19% per year, P trend<0.0001), the decrease was less pronounced among those with PEM vs no-PEM (−0.86% per year vs −1.29% per year, P <0.0001). PEM is a risk factor for sepsis and associated with poorer outcomes among patients with sepsis. A concerted effort involving all health care workers in the prevention, identification, and treatment of PEM in community-dwelling people before hospitalization might mitigate against these devastating outcomes. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To determine whether burden of multiple chronic conditions (MCCs) influences the risk of receiving inappropriate vs appropriate device therapies. DESIGN: Retrospective cohort study. SETTING: Seven US healthcare delivery systems. PARTICIPANTS: Adults with left ventricular systolic dysfunction receiving an implantable cardioverter‐defibrillator (ICD) for primary prevention. MEASUREMENTS: Data on 24 comorbid conditions were captured from electronic health records and categorized into quartiles of comorbidity burden (0‐3, 4‐5, 6‐7 and 8‐16). Incidence of ICD therapies (shock and antitachycardia pacing [ATP] therapies), including appropriateness, was collected for 3 years after implantation. Outcomes included time to first ICD therapy, total ICD therapy burden, and risk of inappropriate vs appropriate ICD therapy. RESULTS: Among 2235 patients (mean age = 69 ± 11 years, 75% men), the median number of comorbidities was 6 (interquartile range = 4‐8), with 98% having at least two comorbidities. During a mean 2.2 years of follow‐up, 18.3% of patients experienced at least one appropriate therapy and 9.9% experienced at least one inappropriate therapy. Higher comorbidity burden was associated with an increased risk of first inappropriate therapy (adjusted hazard ratio [HR] = 1.94 [95% confidence interval {CI} = 1.14‐3.31] for 4‐5 comorbidities; HR = 2.25 [95% CI = 1.25‐4.05] for 6‐7 comorbidities; and HR = 2.91 [95% CI = 1.54‐5.50] for 8‐16 comorbidities). Participants with 8‐16 comorbidities had a higher total burden of ICD therapy (adjusted relative risk [RR] = 2.12 [95% CI = 1.43‐3.16]), a higher burden of inappropriate therapy (RR = 3.39 [95% CI = 1.67‐6.86]), and a higher risk of receiving inappropriate vs appropriate therapy (RR = 1.74 [95% CI = 1.07‐2.82]). Comorbidity burden was not significantly associated with receipt of appropriate ICD therapies. Patterns were similar when separately examining shock or ATP therapies. CONCLUSIONS: In primary prevention ICD recipients, MCC burden was independently associated with an increased risk of inappropriate but not appropriate device therapies. Comorbidity burden should be considered when engaging patients in shared decision making about ICD implantation. [ABSTRACT FROM AUTHOR]

Background: Although significant research has been conducted on combat casualties receiving blood products, there is limited data for the subpopulation presenting in shock. The purpose of this study was to evaluate combat casualties arriving to a role 3 facility with an initial systolic blood pressure (SBP) ≤ 90 in order to identify clinical characteristics and associations between presentation, transfusion therapy, and mortality outcomes.Methods: The Department of Defense Trauma Registry was queried from 2001 to 2010 for trauma-related casualties who arrived at a role 3 combat surgical facility with a SBP ≤ 90. Transfers from role 2 facilities were excluded. Data captured included demographics, admission vital signs, laboratory values, blood products, and mortality. Relationships between admission physiology, blood product utilization, and mortality were developed. Independent associations between variables were determined by logistic regression analysis.Results: 1,703 patients were identified who met our inclusion criteria and composite mortality was 23%. Mortality in those receiving a balanced transfusion ratio was 18% versus 27% (p < 0.0001). Hypotensive casualties who survived were significantly more likely to have a higher presenting Glasgow Coma Score (GCS), temperature, SBP, shock index, and pH. In addition, this group was also more likely to have a lower international normalized ratio, pCO2, and base deficit (p < 0.001). Age, heart rate, and pulse pressure were not significantly different between groups. Independent predictors of mortality included Injury Severity Score, presentation GCS, and initial pH value (p < 0.0001). In contrast, independent predictors of survival included those with above-knee amputation and a balanced transfusion (p < 0.0001).Conclusions: Combat casualties hypotensive on arrival to surgical facilities have a significant expected mortality. Those receiving balanced transfusions demonstrated improved survival. Of the five independent risk factors, pH, GCS, and the presence of above-knee amputation are typically available during initial evaluation. These factors may be helpful in determining resource allocation and mortality risk, especially in triage or mass casualty settings. [ABSTRACT FROM AUTHOR]

Objective: To determine reference ranges for patient vital signs during the immediate postpartum period.Methods: A retrospective chart review collected data on the variables of interest for all women with 0-24-hour postpartum data available at two hospitals in the USA, between July 1, 2012, and January 31, 2015. Patients were excluded if they had received antihypertensives, uterotonics, or blood products. Regression lines, with 95% prediction intervals, were constructed for shock index, systolic blood pressure, heart rate, pulse pressure, and rate over pressure evaluation (ROPE) values.Results: There were 8874 patients and 87 336 data measurements included in the analysis. During the 24 hours following delivery, an increase in ROPE values, and decreases in pulse pressure, heart rate, and systolic blood pressure were recorded for all patients; an increase in shock index was observed among patients who had cesarean deliveries. Anomalous values for the shock index (>1.0), and reference ranges for pulse pressure (21.09-69.32 mm Hg), ROPE (1.01-3.22 bpm/mm Hg), heart rate (51-112 bpm), and SBP (81-137 mm Hg) were generated.Conclusion: Specific reference ranges for patients during the postpartum period could be used in future studies to determine the parameters, or combinations of parameters, that perform best as early markers of hemodynamic compromise in women experiencing early postpartum hemorrhage. [ABSTRACT FROM AUTHOR]

Introduction: Resuscitation from burn shock using fresh frozen plasma (FFP) has been described. Critics of FFP resuscitation cite the development of transfusion related acute lung injury (TRALI) as a deterrent to its use. This study examines the occurrence of TRALI with FFP resuscitation of critically ill burned patients.Methods: A retrospective chart review was conducted of severely burned patients who received FFP resuscitation. Data points included age, TBSA, TBSA full thickness, presence of alternate etiologies of acute lung injury, total FFP administered, and signs and symptoms of TRALI as defined per the Canadian Blood Services Consensus Conference.Results: Eighty-three patients met the definition of severe burn and received FFP resuscitation. Of those, 65 met exclusion criteria. Eighteen patients were left for analysis with only one found to have signs and symptoms of TRALI. That patient suffered a 53.5% TBSA burn, received a total of 6228ml FFP, had no competing etiologies of ALI, and was diagnosed with TRALI within 6h of completing the FFP transfusion.Conclusion: The possible occurrence of TRALI in burn patients receiving FFP resuscitation should be weighed against the reported benefits of such a resuscitation strategy. [ABSTRACT FROM AUTHOR]

Study Objective: Some helicopter emergency medical services (HEMS) maintain an independent supply of blood for use during transport, although practice is variable and not well described. We aimed to characterize the blood-carrying practices by HEMS programs across the United States. Methods: Online surveys were sent to the leadership of the 261 HEMS programs nationwide listed in the 2011 Atlas and Database of Air Medical Services (ADAMS) database. We examined blood-carrying practices in aggregate, including typical transport time, proportion of scene transports, and local population density. A GIS (Geographic Information System) and multivariable logistic regression models were used to estimate the impact of characteristics of local practice on each program's decision to carry blood. Results: A total of 235 (91%) programs responded to the survey, representing 857 of the 929 (92.2%) HEMS rotor wing aircraft nationwide. Fifty-nine (25.3%) programs independently carried blood. A higher proportion of interfacility transports (OR 1.023; 95% CI 1.010–1.036) and decreased local population density (OR 1.006; 95% CI 1.001–1.011) were associated with increased odds of carrying blood. Transport time (OR 1.006; 95% CI 0.991–1.020) and number of transports (OR 1.000; CI 1.000–1.000) were not associated with a program's blood carrying practices. There was no effect of local practices on a program's decision to carry blood (OR 1.002; 95% CI 0.980–1.026). Conclusion: There is great variability in the utilization of blood by HEMS programs in the United States. Programs that serve more rural areas and programs with a larger percentage of interfacility transports are more likely to independently carry blood. [ABSTRACT FROM AUTHOR]

The article focuses on the use of corticosteroids in the treatment of community-acquired pneumonia (CAP). It references a Cochrane systematic review of patients hospitalized with CAP which identified hyperglycemia as the only adverse event associated with corticosteroids. The benefits of corticosteroids to patients with pneumonia and a history of chronic obstructive pulmonary disease (COPD) are discussed.

The approval of synthetic human angiotensin II (Giapreza, LaJolla Pharmaceuticals) by the FDA in December 2017 provides clinicians with a new tool in the treatment of distributive shock. Angiotensin II (ATII) was approved based on the results of the ATHOS-3 trial. In this trial, patients who received angiotensin II were more likely to achieve a mean arterial pressure of 75 mmHg or an increase in mean arterial pressure of 10 mmHg above that seen in patients who received a placebo. However, the results of ATHOS-3 also highlighted important concerns about thrombotic and infectious complications associated with ATII. Given that the cost of medication acquisition is approximately $1,500 per vial, practitioners must also decide how to implement ATII into practice in the most cost-effective manner. This commentary examines the current controversies surrounding both the safety and efficacy of ATII. [ABSTRACT FROM AUTHOR]

Background: We aimed to investigate mortality trends in hospitalized patients with septic shock in the US. To achieve this objective, we tested hypothesis that mortality decreased in patients identified by the code of septic shock while mortality did not change in those with septic shock identified by vasopressor use.Methods: We conducted a serial cross-sectional analysis using Nationwide Inpatient Sample database from 2005 through 2011. First, we identified all adult patients aged ≥18 years hospitalized for septic shock by the following criteria: 1) primary ICD-9 diagnosis of infection plus procedure code for vasopressor use, 2) primary ICD-9 diagnosis of infection plus septic shock in non-primary field, and 3) primary ICD-9 diagnosis of septic shock. Second, we stratified all identified patients by record of vasopressor use. The outcome of interest was year-to-year changes in the in-hospital all-cause mortality.Results: From 2005 to 2011, we identified 109,812 weighted hospitalizations with septic shock. Overall, there was a significant downward trend in in-hospital mortality (from 46 % in 2005 to 42 % in 2011; P trend  = 0.003); the adjusted mortality also decreased significantly (OR for comparison of 2005 with 2011, 0.98; 95 % CI, 0.96-1.00; P < 0.001). In stratified analysis, the mortality trend was not significant in the subgroup with vasopressor use (from 42 % in 2005 to 40 % in 2011; P trend =0.57); similarly, the adjusted mortality did not change significantly (OR, 1.01; 95 % CI, 0.97-1.05; P =0.62). By contrast, there was a downward trend in mortality in the subgroup without vasopressor use (from 47 % in 2005 to 43 % in 2011; P trend =0.002); likewise, the adjusted mortality decreased significantly (OR, 0.97; 95 % CI, 0.95-0.99; P =0.002) CONCLUSIONS: From 2005 to 2011, we found a modest decrease in in-hospital mortality among patients identified with septic shock. However, in the subgroup with vasopressor use, we found no significant change in mortality. Our data challenge the conventional wisdom that mortality in this population has improved during the last decade. [ABSTRACT FROM AUTHOR]

Sepsis is a leading cause of morbidity and mortality for infants and children in the United States and is associated with peripheral and central nervous system dysfunction including encephalopathy and paresis. Sepsis-associated encephalopathy (SAE) may be underdiagnosed in children, but the exact incidence is not known because of variable criteria for its diagnosis, which require a high index of suspicion and exclusion of other confounding factors. Neuroimaging and cerebrospinal fluid analysis are often normal. Electroencephalography may correlate with the severity of encephalopathy. Intensive care unit--acquired weakness due to critical illness neuropathy or myopathy develops later, and resolution of weakness is gradual. Difficulty weaning from the ventilator is an early sign. Electroencephalography may be helpful in identifying SAE once other causes of encephalopathy have been ruled out. However, the lack of consensus on the definition of SAE and sparse pediatric data limit the specific evidence-based recommendations, which can be made for the assessment and treatment of this disorder in the emergency department. [ABSTRACT FROM AUTHOR]

The article presents a research on use of blood and blood products in traumatic brain injury resuscitation improve patient outcomes. It classifies classes of shock presented by American College of Surgeons Committee on Trauma on the basis of estimating characters including blood loss, blood volume and blood pressure. It mentions studies to control haemorrhage and coagulopathy of trauma to maintain blood volumes. It also presents tables and figures related to trauma resuscitation.

Background: Development of trauma systems is a demanding process. The United States and Germany both have sophisticated trauma systems. This manuscript is a summary of political, economic, and medical changes that have led to the development of both trauma systems and the current high-quality standards. Questions/purposes: We specifically asked three questions: (1) What tasks are involved in developing a modern trauma system? (2) What is the approach to achieve this task? (3) Do these systems work? Methods: We conducted a systematic review of relevant articles by searching electronic databases (PubMed, Embase, Cochrane library) using the following search terms: 'trauma system', 'polytrauma', 'trauma networks', and 'trauma registry'. Of 2573 retrieved manuscripts, the authors made a personal selection of studies. A personal study selection from our experiences was added when their contribution to the topic was judged important. Results: Worldwide, similar tasks concerning trauma care have to be addressed. In most societies, traffic accidents and firearm-related injuries contribute to a high number of trauma victims. The German approach has been to decrease the number of accidents through injury prevention and to provide better care by establishing an emergency medical system. For in-hospital treatment, clinical care has constantly improved and a close interaction with members from the American Association for the Surgery of Trauma and the Orthopaedic Trauma Association has helped a great deal to achieve these improvements. The German healthcare system was developed as a powerful healthcare tool covering patients from injury to rehabilitation. In addition, trauma and injury research has been strengthened to deal with various questions of trauma care. Conclusions: Organized injury prevention programs and systematized professional patient care can address the issues associated with the global burden of trauma. These trauma systems require constant monitoring and improvement. [ABSTRACT FROM AUTHOR]

ACADEMIC EMERGENCY MEDICINE 2012; 19:843-849 © 2012 by the Society for Academic Emergency Medicine Abstract Objectives: Drug overdose is a leading cause of cardiac arrest and is currently the second leading cause of overall injury-related fatality in the United States. Despite these statistics, the incidence of adverse cardiovascular events (ACVEs) in emergency department (ED) patients following acute drug overdose is unknown. With this study, we address the 2010 American Heart Association Emergency Cardiovascular Care update calling for research to characterize the incidence of in-hospital ACVE following drug overdose. Methods: This was a prospective cohort study at two tertiary care hospitals over 12 months. Consecutive adult ED patients with acute drug overdose were prospectively followed to hospital discharge. The main outcome was occurrence of in-hospital ACVE, defined as the occurrence of one or more of the following: myocardial injury, shock, ventricular dysrhythmia, and cardiac arrest. Results: There were 459 ED patients with suspected drug overdose, of whom 274 acute drug overdose qualified and were included for analysis (mean [±SE] age = 40.3 [±1.0] years; 63% male). Hospital course was complicated by ACVE in 16 patients (some had more than one): 12 myocardial injury, three shock, two dysrhythmia, and three cardiac arrest. The incidence of ACVE was 5.8% overall (95% confidence interval [CI] = 3.6% to 9.3%) and 10.7% (95% CI = 6.6% to 16.9%) among inpatient admissions, with all-cause mortality at 0.7% (95% CI = 0.2% to 2.6%). Conclusions: Based on this study of adult patients with acute drug overdose, ACVE may occur in up to 9.3% overall and up to 16.9% of hospital admissions. Implications for the evaluation and triage of ED patients with acute drug overdose require further study with regard to optimizing interventions to prevent adverse events. [ABSTRACT FROM AUTHOR]

Outbreaks of Bacillus anthracis in the US and Europe over the past 10 years have emphasized the health threat this lethal bacteria poses even for developed parts of the world. In contrast to cutaneous anthrax, inhalational disease in the US during the 2001 outbreaks and the newly identified injectional drug use form of disease in the UK and Germany have been associated with relatively high mortality rates. One notable aspect of these cases has been the difficulty in supporting patients once shock has developed. Anthrax bacilli produce several different components which likely contribute to this shock. Growing evidence indicates that both major anthrax toxins may produce substantial cardiovascular dysfunction. Lethal toxin (LT) can alter peripheral vascular function; it also has direct myocardial depressant effects. Edema toxin (ET) may have even more pronounced peripheral vascular effects than LT, including the ability to interfere with the actions of conventional vasopressors. Additionally, ET also appears capable of interfering with renal sodium and water retention. Importantly, the two toxins exert their actions via quite different mechanisms and therefore have the potential to worsen shock and outcome in an additive fashion. Finally, both toxins have the ability to inhibit host defense and microbial clearance, possibly contributing to the very high bacterial loads noted in patients dying with anthrax. This last point is clinically relevant since emerging data has begun to implicate other bacterial components such as anthrax cell wall in the shock and organ injury observed with infection. Taken together, accumulating evidence regarding the potential contribution of LT and ET to anthrax-associated shock supports efforts to develop adjunctive therapies that target both toxins in patients with progressive shock. [ABSTRACT FROM AUTHOR]

Abstract: Chronic anxiety may differ from cued fear and hence require other treatment strategies. In a human fear conditioning paradigm, chronic anxiety to the experimental context was experimentally induced by presenting unpredictable shocks. Two methods to reduce chronic anxiety were tested and compared. First, in parallel with the standard extinction procedure, participants were exposed to the anxiety-eliciting context in the absence of shocks (context-exposure group). Second, an alternative procedure was tested in which the previously unpredictable shocks were now signaled by a specific cue (signaled group). A control group continued to receive unsignaled shocks. Results indicated that chronic contextual anxiety, as measured by fear-potentiated startle and US-expectancy ratings, was equally reduced in the context-exposure group as in the signaled group compared with the control group. When applied to the treatment of, for example, panic disorder, these findings support the idea that exposure to the context in which the unpredictable panic attacks occurred and making unpredictable panic attacks predictable, are both valuable methods in order to reduce chronic anxiety. [Copyright &y& Elsevier]

Background: Descriptions of dengue immunopathogenesis have largely relied on data from South-east Asia and America, while India is poorly represented. This study characterizes dengue cases from Pune, Western India, with respect to clinical profile and pro-inflammatory cytokines. Methodology/Principal Findings: In 2005, 372 clinically suspected dengue cases were tested by MAC-ELISA and RT-PCR for dengue virus (DENV) aetiology. The clinical profile was recorded at the hospital. Circulating levels of IFN-γ, TNF-α, IL-6, and IL-8 were assessed by ELISA and secondary infections were defined by IgM to IgG ratio. Statistical analysis was carried out using the SPSS 11.0 version. Of the 372 individuals, 221 were confirmed to be dengue cases. Three serotypes, DENV-1, 2 and 3 were co-circulating and one case of dual infection was identified. Of 221 cases, 159 presented with Dengue fever (DF) and 62 with Dengue hemorrhagic fever (DHF) of which six had severe DHF and one died of shock. There was a strong association of rash, abdominal pain and conjunctival congestion with DHF. Levels of IFN-γ were higher in DF whereas IL-6 and IL-8 were higher in DHF cases (p<0.05). The mean levels of the three cytokines were higher in secondary compared to primary infections. Levels of IFN-γ and IL-8 were higher in early samples collected 2-5 days after onset than late samples collected 6-15 days after onset. IFN-γ showed significant decreasing time trend (p = 0.005) and IL-8 levels showed increasing trend towards significance in DHF cases (interaction p = 0.059). There was a significant association of IL-8 levels with thrombocytopenia and both IFN-γ and IL-8 were positively associated with alanine transaminase levels. Conclusions/Significance: Rash, abdominal pain and conjunctival congestion could be prognostic symptoms for DHF. High levels of IL-6 and IL-8 were shown to associate with DHF. The time trend of IFN-γ and IL-8 levels had greater significance than absolute values in DHF pathogenesis. [ABSTRACT FROM AUTHOR]

Background: Selection of patients for diagnostic tests for acute pulmonary embolism requires recognition of the possibility of pulmonary embolism on the basis of the clinical characteristics. Patients in the Prospective Investigation of Pulmonary Embolism Diagnosis II had a broad spectrum of severity, which permits an evaluation of the subtle characteristics of mild pulmonary embolism and the characteristics of severe pulmonary embolism.Methods: Data are from the national collaborative study, Prospective Investigation of Pulmonary Embolism Diagnosis II.Results: There may be dyspnea only on exertion. The onset of dyspnea is usually, but not always, rapid. Orthopnea may occur. In patients with pulmonary embolism in the main or lobar pulmonary arteries, dyspnea or tachypnea occurred in 92%, but the largest pulmonary embolism was in the segmental pulmonary arteries in only 65%. In general, signs and symptoms were similar in elderly and younger patients, but dyspnea or tachypnea was less frequent in elderly patients with no previous cardiopulmonary disease. Dyspnea may be absent even in patients with circulatory collapse. Patients with a low-probability objective clinical assessment sometimes had pulmonary embolism, even in proximal vessels.Conclusion: Symptoms may be mild, and generally recognized symptoms may be absent, particularly in patients with pulmonary embolism only in the segmental pulmonary branches, but they may be absent even with severe pulmonary embolism. A high or intermediate-probability objective clinical assessment suggests the need for diagnostic studies, but a low-probability objective clinical assessment does not exclude the diagnosis. Maintenance of a high level of suspicion is critical. [ABSTRACT FROM AUTHOR]

This article presents the author's comment on rhetoric of Trauma in September 11, 2001. As individuals of an earlier generation recall where they were and what they were doing when they learned that JFK had been shot, so one may recall one's own where's and what's of September 11, 2001. Psychologists inform that talking or writing about trauma is of healthy use to survivors. In a recent article that explores "trauma" as an evolving concept, Irene Kacandes finds that only within the last 100 years has the term referred to psychic wounding, and then has done so haphazardly, for "trauma" can refer both to the conditions that wound a psyche and the resulting injured state of mind.' The actual labor of crafting a story is especially therapeutic.

Presents commentaries on several studies related to pediatrics. Physiological effects of midazolam-fentanyl sedation; Use of sucrose as analgesic for newborn infants; Information on hypovolemic shock as consequence of punishment.

The article presents perspective on riots. The author states that during the 1960s, riots in Afro-American ghettos swept across urban areas of the United States in seemingly epidemic fashion. Though the arson, looting and violence of recent ghetto disturbances were alarming and perplexing to most people, riots are certainly not unique events in the social experience of the United States nor, for that matter, in the experience of other nations. But in view of the destructiveness and extensiveness of recent riots, it is not surprising that the nation reacted with shock and bewilderment. Some public officials, among others, have declared that the riots were "senseless" outbursts of violence devoid of message and further meaning, politically or, psychologically. A scientific view denies that social events are acausal and adds that neither has it been true historically that riots were meaningless outbursts. On the contrary, riots were frequently used in times past as a means of achieving desired goals when more legitimate means were unavailable or had met with failure

Background: While research has demonstrated increasing risk for severe maternal morbidity in the United States, risk at lower volume hospitals remains poorly characterized. More than half of all obstetric units in the United States perform <1000 deliveries per year and improving care at these hospitals may be critical to reducing risk nationwide.Objective: We sought to characterize maternal risk profiles and severe maternal morbidity at low-volume hospitals in the United States.Study Design: We used data from the Nationwide Inpatient Sample to evaluate trends in severe maternal morbidity and comorbid risk during delivery hospitalizations in the United States from 1998 through 2011. Comorbid maternal risk was estimated using a comorbidity index validated for obstetric patients. Severe maternal morbidity was defined as the presence of any 1 of 15 diagnoses representative of acute organ injury and critical illness.Results: A total of 2,300,279 deliveries occurred at hospitals with annual delivery volume <1000, representing 20% of delivery hospitalizations overall. There were 7849 cases (0.34%) of severe morbidity in low-volume hospitals and this risk increased over the course of the study from 0.25% in 1998 through 1999 to 0.49% in 2010 through 2011 (P < .01). The risk in hospitals with ≥1000 deliveries increased from 0.35-0.62% during the same time periods. The proportion of patients with the lowest comorbidity decreased, while the proportion of patients with highest comorbidity increased the most. The risk of severe morbidity increased across all women including those with low comorbidity scores. Risk for severe morbidity associated with obstetric hemorrhage, infection, hypertensive diseases of pregnancy, and medical conditions all increased during the study period.Conclusion: Our findings demonstrate increasing maternal risk at hospitals performing <1000 deliveries per year broadly distributed over the patient population. Rates of morbidity in centers with ≥1000 deliveries have also increased. These findings suggest that maternal safety improvements are necessary at all centers regardless of volume. [ABSTRACT FROM AUTHOR]

Background: In the setting of persistently high risk for maternal death and severe obstetric morbidity, little is known about the relationship between hospital delivery volume and maternal outcomes.Objective: The objectives of this analysis were (1) to determine maternal risk for severe morbidity during delivery hospitalizations by hospital delivery volume in the United States and (2) to characterize, by hospital volume, the risk for death in the setting of severe obstetric morbidity, a concept known as failure to rescue.Study Design: This cohort study evaluated 50,433,539 delivery hospitalizations across the United States from 1998-2010. The main outcome measures were (1) severe morbidity that was defined as a composite of any 1 of 15 diagnoses that are representative of acute organ injury and critical illness and (2) failure to rescue that was defined as death in the setting of severe morbidity.Results: The prevalence of severe morbidity rose from 471.2-751.5 cases per 100,000 deliveries from 1998-2010, which was an increase of 59.5%. Failure to rescue was highest in 1998 (1.5%), decreased to 0.6% in 2007, and rose to 0.9% in 2010. In models that were adjusted for comorbid risk and hospital factors, both low and high annualized delivery volume were associated with increased risk for failure to rescue and severe morbidity. However, the relative importance of hospital volume for both outcomes compared with other factors was relatively small.Conclusion: Although low-and high-delivery volume are associated with increased risk for both failure to rescue and severe maternal morbidity, other factors, in particular characteristics of individual centers, may be more important in the determination of outcomes. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 60-year-old man with ischemic cardiomyopathy who was admitted to the hospital's cardiac care unit with cardiogenic shock. During the patient's stay in the cardiac unit, he experienced multiple paced wide-complex tachycardia accompanied by hemodynamic deterioration. The article discusses the tachycardia and the mechanism of change in its cycle length.

The article discusses the findings of a research about in-hospital cardiac arrests in the U.S. and Canada. The research found that most in-hospital cardiac arrests are caused by progressive respiratory failure and shock, not by sudden arrhythmia. The research also found that adult and pediatric cardiac arrests are more similar than clinicians realize.