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Background: The COVID-19 pandemic adversely affected children's mental health (MH) and changed patterns of MH emergency department (ED) utilization. Our objective was to assess how pediatric MH ED visits during the COVID-19 pandemic differed from expected prepandemic trends., Methods: We retrospectively studied MH ED visits by children 5 to <18 years old at nine U.S. hospitals participating in the Pediatric Emergency Care Applied Research Network Registry from 2017 to 2022. We described visit length by time period: prepandemic (January 2017-February 2020), early pandemic (March 2020-December 2020), midpandemic (2021), and late pandemic (2022). We estimated expected visit rates from prepandemic data using multivariable Poisson regression models. We calculated rate ratios (RRs) of observed to expected visits per 30 days during each pandemic time period, overall and by sociodemographic and clinical characteristics., Results: We identified 175,979 pediatric MH ED visits. Visit length exceeded 12 h for 7.3% prepandemic, 8.4% early pandemic, 15.0% midpandemic, and 19.2% late pandemic visits. During the early pandemic, observed visits per 30 days decreased relative to expected rates (RR 0.80, 95% confidence interval [CI] 0.78-0.84), were similar to expected rates during the midpandemic (RR 1.01, 95% CI 0.96-1.07), and then decreased below expected rates during the late pandemic (RR 0.92, 95% CI 0.86-0.98). During the late pandemic, visit rates were higher than expected for females (RR 1.10, 95% CI 1.02-1.20) and for bipolar disorders (RR 1.83, 95% CI 1.38-2.75), schizophrenia spectrum disorders (RR 1.55, 95% CI 1.10-2.59), and substance-related and addictive disorders (RR 1.50, 95% CI 1.18-2.05)., Conclusions: During the late pandemic, pediatric MH ED visits decreased below expected rates; however, visits by females and for specific conditions remained elevated, indicating a need for increased attention to these groups. Prolonged ED visit lengths may reflect inadequate availability of MH services., (© 2024 The Authors. Academic Emergency Medicine published by Wiley Periodicals LLC on behalf of Society for Academic Emergency Medicine.)

Purpose: To present the potential mechanisms by which landiolol enhances a positive inotropic response in critically ill patients., Methods: Analysis of preclinical, animal, and clinical data to provide novel knowledge and translate research findings into potential clinical application., Results: The super-selective β1-antagonist landiolol may increase inotropy and may be associated with positive outcomes in critically ill patients with acute decompensated heart failure or sepsis., Conclusion: This review sheds light on the potential mechanisms by which landiolol enhances a positive inotropic response, potentially alleviating the long-held concern over possible negative hemodynamic effects in critically ill patients., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Aim: Paediatric emergency departments (ED) nationwide experience a shared burden of boarding mental health patients. Whilst boarding, some patients have a change in disposition from hospitalization to discharge home. This phenomenon raises concern because EDs often have scarce resources for mental health patients. We sought to understand which patient and clinical factors are associated with a change in disposition outcome., Methods: A nested age-sex-race frequency-matched case-control study was conducted including paediatric patients who presented to an urban PED for mental healthcare over a 36-month period. Control patients included patients admitted to an inpatient psychiatric facility, whilst case patients were those discharged home. Descriptive statistics and multivariable logistic regression analyses were performed to compare groups., Results: Case patients were more likely to receive intramuscular Haloperidol (OR 2.2 [CI 1.1-4.4]) for agitation and a psychiatric consult (OR 2.3 [1.4-3.9]) whilst boarding. Case patients were also more likely to present with behavioural concerns (OR 1.8 [CI 1.1-3.1]) and have additional complexities such as medical comorbidities (OR 1.8 [CI 1.1-2.9]) or suicidal ideation/attempt (OR 2.6 [CI 1.1-6.1]). Amongst the most common themes for disposition change was improved patient status (58.8%)., Conclusion: These findings suggest that boarding mental health patients have different disposition outcomes and thus may benefit from patient-specific treatment interventions. Given that patients' statuses may change during the boarding period prompting discharge to home, more focus should be directed to developing brief evidence-based practises that may be implemented in the ED and effectively bridge the gap to outpatient mental health services., (© 2021 The Authors. Early Intervention in Psychiatry published by John Wiley & Sons Australia, Ltd.)

Proper transitions of care for people with HIV (PWH) are necessary to ensure continuity of care, medication adherence and maintenance of successful clinical outcomes. Three transitions of care may lead to suboptimal outcomes if PWH are not correctly engaged: adolescent to adult, prison to society and the postpartum period. The management of these care transitions is a vital part of engagement in treatment. Evidence highlighting the gaps in care transitions provides a potential framework to optimize outcomes for PWH., Competing Interests: Disclosure and potential conflicts of interest: MM: Speaker for Merck, Advisory board for Viiv and Theratechnologies. All other authors have no disclosures. The International Committee of Medical Journal Editors (ICMJE) Potential Conflicts of Interests form for the authors is available for download at: https://www.drugsincontext.com/wp-content/uploads/2021/10/dic.2021-8-11-COI.pdf, (Copyright © 2022 Murray M, Khaleq F, O’Donnell EP.)

Abstract: In the absence of trauma, sudden unilateral painless visual loss is an uncommon condition in the pediatric population requiring emergent medical evaluation. In the acute care setting, clinicians face the challenge of accurately assessing the patient and determining the initial diagnostic workup. A careful history alone helps guide diagnosis with sudden visual loss that is unilateral and persistent. Several neuro-ophthalmological conditions that present with these characteristics include retinal artery or vein occlusion, diseases affecting the cavernous sinus or orbital apex region, and optic neuropathy. Simple eye examination techniques have crucial diagnostic value in helping localize the disease process, determining the level of urgency, and need for timely intervention. Here we present an adolescent patient with nontraumatic, acute unilateral visual loss who had concerning ophthalmological examination findings and was subsequently diagnosed with optic neuropathy secondary to allergic fungal sinusitis., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The objective of this study was to examine the effects of metoprolol versus diltiazem in the acute management of atrial fibrillation (AF) with rapid ventricular response (RVR) in patients with heart failure with reduced ejection fraction (HFrEF)., Methods: This retrospective cohort study of patients with HFrEF in AF with RVR receiving either intravenous push (IVP) doses of metoprolol or diltiazem was conducted between January 2012 and September 2016. The primary outcome was successful rate control within 30 min of medication administration, defined as a heart rate (HR) < 100 beats per minute or a HR reduction ≥ 20%. Secondary outcomes included rate control at 60 min, maximum median change in HR, and incidence of hypotension, bradycardia, or conversion to normal sinus rhythm within 30 min. Signs of worsening heart failure were also evaluated., Results: Of the 48 patients included, 14 received metoprolol and 34 received diltiazem. The primary outcome, successful rate control within 30 min, occurred in 62% of the metoprolol group and 50% of the diltiazem group (p = 0.49). There was no difference in HR control at predefined time points or incidence of hypotension, bradycardia, or conversion. Although baseline HR varied between groups, maximum median change in HR did not differ. Signs of worsening heart failure were similar between groups., Conclusions: For the acute management of AF with RVR in patients with HFrEF, IVP diltiazem achieved similar rate control with no increase in adverse events when compared to IVP metoprolol., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: Centhaquin citrate is a novel agent that is being developed for use in the resuscitation of patients with haemorrhagic shock. While pharmacokinetics have been described in small animal models, the pharmacokinetic parameters of centhaquin citrate in large mammals have yet to be described., Methods: Four healthy Beagle dogs (two males and two females) were given an intravenous bolus of 1.0 mg/kg centhaquin citrate. Plasma concentrations were measured at baseline and at ten time points within 24 h after administration. Multiple compartmental models were built and compared. The nonparametric adaptive grid function within the Pmetrics package for R was used for parameter estimation. Predicted concentrations were calculated using population mean and individual Bayesian posterior parameters., Key Findings: Centhaquin citrate pharmacokinetic parameters were best described using a two-compartment model. Median (IQR) values for Ke , Vc , Vp , Kcp and Kpc were 4.9 (4.4-5.2) h(-1) , 328.4 (304.0-331.9) l, 1000.6 (912.3-1042.4) l, 10.6 (10.3-11.1) h(-1) and 3.2 (2.9-3.7) h(-1) , respectively., Conclusions: Pharmacokinetic parameters of centhaquin citrate in a large mammal have been described. A large volume of distribution and rapid elimination were observed, consistent with previous work in rats., (© 2016 Royal Pharmaceutical Society.)

Background: Obese patients display differences in vancomycin drug disposition, which may complicate attainment of appropriate serum vancomycin concentrations (SVCs). This study was conducted to determine if obesity leads to trough SVCs above the therapeutic range., Methods: This retrospective cohort study sought to determine the rate and predictors of high (i.e. >20 mg/L) serum trough levels according to level of obesity., Results: Increasing BMI predicted SVCs > 20 mg/L after controlling for dose, age, and serum creatinine. Obese patients had significantly higher mean trough SVCs compared to non-obese patients (16.5 mg/L vs 12.1 mg/L, p = 0.004) and a significantly higher proportion of obese patients had trough SVCs > 20 mg/L (18.9% vs 4.2%, p = 0.03)., Conclusion: Increasing obesity predicted higher probabilities of SVCs > 20 mg/L. Development of alternative dosing and management strategies for vancomycin may be necessary to account for pharmacokinetic changes associated with obesity., (Copyright © 2015 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

Objective: To examine how fatigue and dissatisfaction with practicing medicine relate to US physicians' perceptions of their professional responsibilities in a time of upheaval in health care., Methods: From May 30, 2012, through September 1, 2012, we mailed an 8-page paper survey, including measures of perceived social responsibility, fatigue, and satisfaction, to a random sample of 3897 physicians selected from the American Medical Association Physician Masterfile. We performed bivariate tests and multivariable logistic regression to examine associations between key predictors (fatigue and satisfaction) and 3 dependent variables: obligations to care for the uninsured and underinsured, obligations to address policy issues, and agreement with cost-containment., Results: A total of 2556 physicians (65.6%) responded to the survey. Nearly half of physicians (1160 [45.4%]) reported high levels of fatigue, whereas most (1810 [70.8%]) expressed satisfaction with practicing medicine. Dissatisfaction in practicing medicine proved to be a significant predictor in how physicians perceive their professional responsibilities and in medical decision-making. Overall, physicians who rated themselves as very dissatisfied had a significantly reduced likelihood of favoring limiting reimbursement to expand basic coverage (odds ratio, 0.5; 95% CI, 0.3-0.7), recognizing an obligation to care for the uninsured (odds ratio, 0.5; 95% CI, 0.3-0.7), and addressing societal health policy issues (OR, 0.7; 95% CI, 0.5-0.9)., Conclusion: Although fatigue and satisfaction are strongly associated, only satisfaction appears to correlate with physicians' perceived social responsibilities. Physicians who are dissatisfied with their profession may be less inclined to address health policy issues, embrace charity care, or practice cost containment., (Copyright © 2015 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Background: In recent years, medical students have recognized and advocated for opportunities to explore various specialties earlier in their medical education. A brief literature review, however, reveals little consensus on the best approach to introduce students to different fields during their preclinical years., Aim: We present one of the first reports of a student-led effort to design and implement a preclinical specialty-specific elective., Methods: At Mayo Medical School, for two consecutive years the student president of the Pediatric Interest Group has created a peer-designed weeklong group elective ("selective") experience consisting of workshops, faculty and resident panel discussions, and clinical shadowing experiences based on a student needs assessment., Results: Each year, more than 25% of the first- and second-year medical student body participated. The majority of students who completed the selective agreed that this experience heightened their interests and expanded their knowledge about pediatrics., Conclusions: The pediatric group selective has provided students with important resources for their medical education and future careers. Students found the group selective beneficial to their learning experience and recommend continuing to offer it in the future.

Objectives: To compare the incidence of renal impairment in HIV-infected patients exposed versus unexposed to tenofovir and to characterize risk factors associated with renal impairment., Methods: We undertook a retrospective cohort and nested case-control study of 514 Northwestern University HIV Outpatient Study participants who received antiretroviral therapy (ART) between 1 August 2001 and 31 July 2007. Renal impairment was defined as meeting at least one of two validated criteria based on serum creatinine, calculated glomerular filtration rate and creatinine clearance. Multivariable analysis was performed to identify risk factors for renal impairment., Results: Renal impairment occurred in 14% (n = 72) of the cohort and was not correlated with exposure to tenofovir in univariate analyses. In multivariable analysis, more advanced age [odds ratio (OR) = 1.04, P = 0.02], diabetes (OR = 3.6, P < 0.01), decreased weight (OR = 0.97, P = 0.02) and endpoint CD4 ≤200 cells/mm(3) (OR = 2.5, P = 0.03) were positive predictors of renal impairment; tenofovir exposure (OR = 0.41, P = 0.01) was negatively correlated with renal impairment., Conclusions: Tenofovir-containing ART was associated with less renal impairment than ART without tenofovir in a patient cohort with a high incidence of renal impairment. Chronic co-morbid conditions known to be associated with renal impairment should be excluded prior to attributing renal impairment to tenofovir.

Appropriate early management of infectious emergencies is essential to preventing adverse outcomes. Clinicians in acute-care settings must be prepared to provide appropriate empiric antibiotics, as failure to do so has been associated with an increased risk of mortality. Empiric treatment of these infections requires knowledge of the disease state, most common pathogens, and patient-specific risk factors. Additionally, regional and institutional patterns of antibiotic resistance must be taken into consideration. At the same time, inappropriate use of broad-spectrum antibiotics should be avoided to prevent emergence of antimicrobial resistance. It is also essential that initial antibiotic therapy be de-escalated and redirected once the causative pathogen has been identified and antibiotic susceptibilities determined. Bacterial infection with pneumonia, meningitis and sepsis severe enough to warrant hospitalization are included in this review. The most common bacterial pathogens and empiric antibiotic recommendations for immunocompetent adults will be discussed. In addition, circumstances that may influence the selection of certain antibiotics are reviewed., (Copyright 2009 Prous Science, S.A.U. or its licensors. All rights reserved.)

Inbred mice vary in their susceptibility to develop macroscopic, chemically-induced, pulmonary neoplasias. It is not known, however, whether microscopic lesions appear in resistant strains but do not grow or if no early lesions arise at all. We show herein that resistant C57BL/6J (B6) and intermediately resistant BALB/cByJ (BALB) mice form very few urethane-induced early microadenomas (i.e. adenomas larger than hyperplasic foci, but detectable only by light microscopy). Additionally, while all urethane-induced microadenomas in sensitive A/J mice gave rise to adenomas, most microscopic tumors induced in BALB mice by 2-stage, 3-methylcholanthrene/butylated hydroxytoluene carcinogenesis spontaneously regressed. The formation of microscopic lesions is thus genetically dependent, but whether they continue to grow or regress depends on how they were induced.