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With increasing knowledge of the risks associated with receiving blood transfusions, a new paradigm of bloodless medicine is needed. Principles of bloodless medicine include careful monitoring for obvious and hidden anemias, rapid intervention, minimizing blood losses from laboratory testing and procedures, and careful management of bleeding diatheses. As evidence is revealed and refined, standard treatment of anemia in the intensive care unit will include erythropoietin-stimulating agents, iron, folate, and vitamin B12, which will reduce risks associated with blood transfusions.

Negative symptoms at the end of life are distressing for both the patient and family. Effective management of both physical and psychological symptoms improves quality of life and well-being, but intervention strategies are not always effective or feasible and often are exclusively pharmacologic. De

Older adults with chronic obstructive pulmonary disease (COPD) are at known risk for deconditioning and functional decline during hospitalization. The purpose of this study was to examine correlations between in-hospital mobility activities and functional status indicators in hospitalized older adults with COPD. A predictive correlational, secondary analysis design using multivariate analyses assessed the relationship between mobility events and functional status indicators in patients with COPD ( n = 111) and non-COPD ( n = 190) diagnoses. Ambulation to the bathroom, ambulation outside the room, and number of days to first out-of-bed activity predicted discharge to home versus extended care facility (ECF; p ≤ .05); days to first out-of-bed activity and out-of-room ambulation predicted reduced length of stay (LOS; p ≤ .05); no variables predicted 30-day readmission. COPD patients experienced more nonweight-bearing activity and longer lengths of stay than non-COPD patients. Specific early weight-bearing activities were associated with positive functional status-related outcomes in hospitalized COPD patients.

This article explores anemia without an obvious cause from two perspectives: a patient and the evidence. Although evidence is required to drive favorable patient outcomes, the focus on evidence often hides the patient experience during diagnosis and treatment. Knowledge of experience with evidence can provide a deeper perspective for clinical decision making and meet nursing's ethical mandate to relieve suffering. Although one patient experience does not reflect every patient experience, this patient's experience demonstrates how difficult and dark anemia can be.

This single subject design study (ABAB) investigated the effects of using iPads in a classwide academic intervention to increase independent task completion and basic math skills of seven students diagnosed with autism spectrum disorders (ASD) enrolled in a special education school. The study also examined the advantages of and challenges to using iPads for classroom instruction. Traditional basic math instruction was used for the baseline phase, while a basic math skill app on an iPad was used for the intervention phase. Math probes were completed and the results recorded for four to five sessions for each of the four weeks of the study. Data on level of teacher prompting and presence of noncompliant behaviors were collected during every phase. Descriptive and visual analysis techniques were used to analyze the data. Findings expand current knowledge of the use of single subject design to document the effect of evidence-based practices in special education. Results were mixed for math skill development, but indicated an increase in independent task completion as demonstrated by a decrease in noncompliant behaviors and teacher prompt levels. Findings suggest iPads can be an effective instructional tool to enhance learning and independence. Contributions, limitations, and future research are presented.

IMPORTANCE: Retention in addiction treatment is associated with reduced mortality for individuals with opioid use disorder (OUD). Although clinical trials support use of OUD medications among youths (adolescents and young adults), data on timely receipt of buprenorphine hydrochloride, naltrexone hydrochloride, and methadone hydrochloride and its association with retention in care in real-world treatment settings are lacking. OBJECTIVES: To identify the proportion of youths who received treatment for addiction after diagnosis and to determine whether timely receipt of OUD medications is associated with retention in care. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used enrollment data and complete health insurance claims of 2.4 million youths aged 13 to 22 years from 11 states enrolled in Medicaid from January 1, 2014, to December 31, 2015. Data analysis was performed from August 1, 2017, to March 15, 2018. EXPOSURES: Receipt of OUD medication (buprenorphine, naltrexone, or methadone) within 3 months of diagnosis of OUD compared with receipt of behavioral health services alone. MAIN OUTCOMES AND MEASURES: Retention in care, with attrition defined as 60 days or more without any treatment-related claims. RESULTS: Among 4837 youths diagnosed with OUD, 2752 (56.9%) were female and 3677 (76.0%) were non-Hispanic white. Median age was 20 years (interquartile range [IQR], 19-21 years). Overall, 3654 youths (75.5%) received any treatment within 3 months of diagnosis of OUD. Most youths received only behavioral health services (2515 [52.0%]), with fewer receiving OUD medications (1139 [23.5%]). Only 34 of 728 adolescents younger than 18 years (4.7%; 95% CI, 3.1%-6.2%) and 1105 of 4109 young adults age 18 years or older (26.9%; 95% CI, 25.5%-28.2%) received timely OUD medications. Median retention in care among youths who received timely buprenorphine was 123 days (IQR, 33-434 days); naltrexone, 150 days (IQR, 50-670 days); and methadone, 324 days (IQR, 115-670 days) compared with 67 days (IQR, 14-206 days) among youths who received only behavioral health services. Timely receipt of buprenorphine (adjusted hazard ratio, 0.58; 95% CI, 0.52-0.64), naltrexone (adjusted hazard ratio, 0.54; 95% CI, 0.43-0.69), and methadone (adjusted hazard ratio, 0.32; 95% CI, 0.22-0.47) were each independently associated with lower attrition from treatment compared with receipt of behavioral health services alone. CONCLUSIONS AND RELEVANCE: Timely receipt of buprenorphine, naltrexone, or methadone was associated with greater retention in care among youths with OUD compared with behavioral treatment only. Strategies to address the underuse of evidence-based medications for youths with OUD are urgently needed.

Few residency curricular interventions have focused on improving well-being and promoting humanism. We describe the implementation of a novel curriculum based on small-group reflection rounds—the Emergency Medicine Reflection Rounds (EMRR)—at a 4-year US emergency medicine (EM) residency. During the inaugural year (2010–2011), nine residents volunteered to take part in 1-hour monthly sessions with faculty facilitators. Residents were provided with a confidential environment to discuss difficult ethical and interpersonal encounters from their clinical experiences. Ongoing feedback from participants was solicited, culminating with a four-question survey in which all respondents remarked that the EMRR contributed to improving their own well-being and agreed that it provided an important forum for residents to discuss difficult issues in a safe environment. In this article, we describe our innovation as an example of a wellness initiative that has promoted reflective practice and fostered cooperative learning around the communication, professional, and ethical challenges inherent in EM practice. Our EMRR model may be useful to other EM residences looking to supplement their wellness curriculum.

Commentary on: McNicol ED, Ferguson MC, Haroutounian S, et al. Single dose intravenous paracetamol or intravenous propacetamol for postoperative pain. Cochrane Database Syst Rev 2016:CD007126. Despite progress in uncovering the complex mechanisms responsible for acute …