Search

College students across the United States are engaging in protests, sit-ins, and walk-outs, but when do these political acts result in tangible institutional policy changes? This paper draws on qualitative data from interviews and focus groups with 502 participants across the United States to examine when and why college student political behaviors influence institutional changes on college campuses. Findings from this study suggest that higher education institutions present different political opportunity structures for students to engage in activism. These political opportunity structures provide policy windows at the institutional level to affect campus wide change. To the extent that these changes promote diversity, equity, and inclusion though also depends on these varying structures. In this paper, a typology of these structures is presented to explain when student activism shapes institutional change and for whom.

CONTEXT: Many American Indian nations, tribes, and bands are at an elevated risk for premature death from unintentional injury. Previous research has documented a relationship between alcohol-related injury and subsequent injury death among predominately urban samples. The presence or nature of such a relationship has not been documented among American Indians living in the northern plains. PURPOSE: The purpose of this study was to identify and characterize any association between prior injury and/or alcohol use contacts with the Indian Health Service (IHS) and subsequent alcohol-related injury death that may suggest opportunities for mitigation. METHODS: Death certificates of American Indians who died from injury (ICD-9-E 800-999) in a rural IHS area over 6 consecutive years were linked to IHS acute-care facility records and toxicology reports. Deaths and prior IHS contacts were stratified by alcohol use as a contributing factor. Of the 526 injury deaths involving American Indians in the IHS area studied, 411 (78%) were successfully linked to IHS records. One hundred fifty-two of these cases met the inclusion criteria, with an additional 98 cases identified as a comparison group. FINDINGS: No differences in alcohol use at time of death between groups with and without prior health care contact (for injury or alcohol) could be determined (81% vs 73%). A significant relationship was found between previous visits for acute or chronic alcohol use and subsequent alcohol-related fatalities (P =.01). CONCLUSIONS: Based on these findings, injury-prevention activities in the population studied should be initiated at the time of any health-system contact in which alcohol use is identified. Intervention strategies should be developed that convey the immediate risk of death from injury in these patients. [ABSTRACT FROM AUTHOR]

Objectives: The clinical and bacteriological efficacies and tolerability of grepafloxacin 400mg once daily for 10 days were compared with clarithromycin 500mg twice daily for 10 days in patients with acute bacterial exacerbations of chronic bronchitis (ABECB). Patients and Study Design: 379 patients with signs and symptoms of ABECB were enrolled in a randomised, double-blind clinical trial conducted at 15 outpatient centres in the USA. Eligible patients were randomly assigned to receive either grepafloxacin plus matched clarithromycin placebo (n = 192) or clarithromycin plus matched grepafloxacin placebo (n = 187). Results: The two treatment groups were equivalent with respect to clinical efficacy, and no statistically significant differences in the incidence of drug-related adverse events were seen between the two groups. A satisfactory clinical outcome was achieved in 88% (130 of 148) and 89% (134 of 150) of clinically evaluable patients treated with grepafloxacin or clarithromycin, respectively. The primary pathogens isolated from pretreatment sputum specimens were Haemophilus parainfluenzae, H. influenzae, Moraxella catarrhalis, Streptococcus pneumoniae and Staphylococcus aureus (31, 18, 6, 5 and 4% of isolates, respectively). Pathogens were eradicated or presumed to be eradicated in 88% (113 of 129) and 78% (97 of 125) of bacteriologically evaluable patients treated with grepafloxacin or clarithromycin, respectively. Both treatments were associated with a low incidence of drug-related adverse events. Conclusion: These results indicate that grepafloxacin 400mg once daily for 10 days is as well tolerated and as clinically effective as clarithromycin 500mg twice daily for 10 days in patients with ABECB. [ABSTRACT FROM AUTHOR]

Cardiopulmonary resuscitation (CPR) outcomes vary for patients with cancer. Here, we characterized cancer patients who underwent CPR in the emergency department (ED), their outcomes, and the effects of advanced care planning (ACP). The hospital databases and electronic medical records of cancer patients at a comprehensive cancer center who underwent CPR in the ED from 6 March 2016 to 31 December 2022 were reviewed for patient characteristics, return of spontaneous circulation (ROSC), conversion to do-not-resuscitate (DNR) status afterward, hospital and intensive care unit (ICU) length of stay, mortality, cost of hospitalization, and prior GOC discussions. CPR occurred in 0.05% of all ED visits. Of the 100 included patients, 67 patients achieved ROSC, with 15% surviving to hospital discharge. The median survival was 26 h, and the 30-day mortality rate was 89%. Patients with and without prior ACP had no significant differences in demographics, metastatic involvement, achievement of ROSC, or in-hospital mortality, but patients with ACP were more likely to change their code status to DNR and had shorter stays in the ICU or hospital. In conclusion, few cancer patients undergo CPR in the ED. Whether this results from an increase in terminally ill patients choosing DNR status requires further study. ACP was associated with increased conversion to DNR after resuscitation and decreased hospital or ICU stays without an increase in overall mortality.

Objectives: To examine whether severe Gulf War illness (SGWI) case status was associated with longitudinal multimorbidity patterns. Methods: Participants were users of the Veteran Health Administration Health Care System drawn from the Gulf War Era Cohort and Biorepository ( n = 840). Longitudinal measures of multimorbidity were constructed using (1) electronic health records (Charlson Comorbidity Index; Elixhauser; and Veterans Affairs Frailty Index) from 10/1/1999 to 6/30/2023 and (2) self-reported medical conditions (Deficit Accumulation Index) since the war until the survey date. Accelerated failure time models examined SGWI case status as a predictor of time until threshold level of multimorbidity was reached, adjusted for age and sociodemographic and military characteristics. Results: Models, adjusted for covariates, revealed that (1) relative to the SWGI- group, the SGWI+ group was associated with an accelerated time for reaching each threshold and (2) the relationship between SGWI and each threshold was not moderated by age. Discussion: Findings suggest that veterans with SGWI experienced accelerated aging., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Gulf War illness (GWI) is a chronic multisymptom disorder of unknown etiology that is believed to be caused by neurotoxicant exposure experienced during deployment to the Gulf War. Posttraumatic stress disorder (PTSD) covaries with GWI and is believed to play a role in GWI symptoms. The present study examined the association between self-reported military exposures and GWI, stratified by PTSD status, in veterans from the Gulf War Era Cohort and Biorepository who were deployed to the Persian Gulf during the war. Participants self-reported current GWI and PTSD symptoms as well as military exposures (e.g., pyridostigmine [PB] pills, pesticides/insecticides, combat, chemical attacks, and oil well fires) experienced during the Gulf War. Deployed veterans' (N = 921) GWI status was ascertained using the Centers for Disease Control and Prevention definition. Individuals who met the GWI criteria were stratified by PTSD status, yielding three groups: GWI-, GWI+/PTSD-, and GWI+/PTSD+. Multivariable logistic regression, adjusted for covariates, was used to examine associations between GWI/PTSD groups and military exposures. Apart from insect bait use, the GWI+/PTSD+ group had higher odds of reporting military exposures than the GWI+/PTSD- group, adjusted odds ratio (aOR) = 2.15, 95% CI [1.30, 3.56]-aOR = 6.91, 95% CI [3.39, 14.08]. Except for PB pills, the GWI+/PTSD- group had a higher likelihood of reporting military exposures than the GWI- group, aOR = 2.03, 95% CI [1.26, 3.26]-aOR = 4.01, 95% CI [1.57, 10.25]. These findings are consistent with roles for both PTSD and military exposures in the etiology of GWI., (© 2023 International Society for Traumatic Stress Studies.)

Background and Aims: Colorectal cancer (CRC) polygenic risk scores (PRS) may help personalize CRC prevention strategies. We investigated whether an existing PRS was associated with advanced neoplasia (AN) in a population undergoing screening and follow-up colonoscopy., Methods: We evaluated 10-year outcomes in the Cooperative Studies Program #380 screening colonoscopy cohort, which includes a biorepository of selected individuals with baseline AN (defined as CRC or adenoma ≥10 mm or villous histology, or high-grade dysplasia) and matched individuals without AN. A PRS was constructed from 136 prespecified CRC-risk single nucleotide polymorphisms. Multivariate logistic regression was used to evaluate the PRS for associations with AN prevalence at baseline screening colonoscopy or incident AN in participants with at least one follow-up colonoscopy., Results: The PRS was associated with AN risk at baseline screening colonoscopy ( P  = .004). Participants in the lowest PRS quintile had more than a 70% decreased risk of AN at baseline (odds ratio 0.29, 95% confidence interval 0.14-0.58; P < .001) compared to participants with a PRS in the middle quintile. Using a PRS cut-off of more than the first quintile to indicate need for colonoscopy as primary screening, the sensitivity for detecting AN at baseline is 91.8%. We did not observe a relationship between the PRS and incident AN during follow-up ( P  = .28)., Conclusion: A PRS could identify individuals at low risk for prevalent AN. Ongoing work will determine whether this PRS can identify a subset of individuals at sufficiently low risk who could safely delay or be reassured about noninvasive screening. Otherwise, more research is needed to augment these genetic tools to predict incident AN during long-term follow-up.

Immune checkpoint inhibitor monoclonal antibodies allow the host's immune system to attack tumors, which has revolutionized cancer care over the last decade. As the use of immune checkpoint inhibitors has expanded, so have autoimmune-like complications known as immune-related adverse events. These include the infrequent but increasingly more common, potentially deadly neurological immune related adverse events. When feeling acutely ill, patients will often seek care not from their oncologist but from their family physician, clinics, emergency, and urgent care sites, or other available providers. Thus, while assessing acutely ill cancer patients who are experiencing neurological symptoms, non-oncologists should be prepared to recognize, diagnose, and treat neurological immune related adverse events in addition to more familiar conditions. This narrative review is designed to update acute care clinicians on current knowledge and to present a symptom-based framework for evaluating and treating neurological immune related adverse events based on the leading immunotoxicity organizations' latest recommendations., Competing Interests: The authors declare the following conflict of interests: S.-C. Yeung reports grants from Bausch Health Companies, Inc., Assertio Therapeutics, Inc. (previously Depomed, Inc.), and Bristol-Myer Squibb, and expert panel member at Celgene, Inc. outside the submitted work. DN Lipe is employed by IQVIA Biotech. No potential conflicts of interest were disclosed by the other authors., (© 2023 The Authors. Published by Elsevier Ltd.)

Background: Delirium, poor performance status, and dyspnea predict short survival in the palliative care setting., Objective: Our goal was to determine whether these three conditions, which we refer to as a "triple threat," also predict mortality among patients with advanced cancers in the emergency department (ED)., Methods: The study sample included 243 randomly selected, clinically stable patients with advanced cancer who presented to our ED. The analysis included patients who had delirium (Memorial Delirium Assessment Scale score ≥ 7), poor performance status (Eastern Cooperative Oncology Group performance status score of 3 or 4), or dyspnea as a presenting symptom. We obtained survival data from medical records. We calculated predicted probability of dying within 30 days and association with number of symptoms after the ED visit using logistic regression analysis., Results: Twenty-eight patients died within 30 days after presenting to the ED. Death within 30 days occurred in 36% (16 of 44) of patients with delirium, 28% (17 of 61) of patients with poor performance status, and 14% (7 of 50) of patients with dyspnea, with a predicted probability of 30-day mortality of 0.38 (95% confidence interval [CI] 0.25-0.53), 0.28 (95% CI 0.18-0.40), and 0.15 (95% CI 0.07-0.29), respectively. The predicted probability of death within 30 days for patients with two or three of the conditions was 0.49 (95% CI 0.34-0.66) vs. 0.05 (95% CI 0.02-0.09) for patients with none or one of the conditions., Conclusions: Patients with advanced cancers who present to the ED and have at least two triple threat conditions have a high probability of death within 30 days., (Published by Elsevier Inc.)

This study examines how health-related quality of life (HRQOL) and related indices vary by Gulf War illness (GWI) case status. The study population included veterans from the Gulf War Era Cohort and Biorepository (n = 1116). Outcomes were physical and mental health from the Veterans RAND 12 and depression, post-traumatic stress (PTSD), sleep disturbance, and pain. Kansas (KS) and Centers for Disease Control and Prevention (CDC) GWI definitions were used. Kansas GWI derived subtypes included GWI (met symptom criteria; no exclusionary conditions (KS GWI: Sym+/Dx−)) and those without GWI: KS noncase (1): Sym+/Dx+, KS noncase (2): Sym−/Dx+, and noncase (3): Sym−/Dx−. CDC-derived subtypes included CDC GWI severe, CDC GWI mild-to-moderate and CDC noncases. Case status and outcomes were examined using multivariable regression adjusted for sociodemographic and military-related characteristics. Logistic regression analysis was used to examine associations between GWI case status and binary measures for depression, PTSD, and severe pain. The KS GWI: Sym+/Dx− and KS noncase (1): Sym+/Dx+ groups had worse mental and physical HRQOL outcomes than veterans in the KS noncase (2): Sym−/Dx+ and KS noncase (3): Sym−/Dx− groups (ps < 0.001). Individuals who met the CDC GWI severe criteria had worse mental and physical HRQOL outcomes than those meeting the CDC GWI mild-to-moderate or CDC noncases (ps < 0.001). For other outcomes, results followed a similar pattern. Relative to the less symptomatic comparison subtypes, veterans who met the Kansas symptom criteria, regardless of exclusionary conditions, and those who met the CDC GWI severe criteria experienced lower HRQOL and higher rates of depression, PTSD, and severe pain.

Background: Carotid blowout syndrome (CBS) is an infrequent but dangerous oncologic emergency that must be recognized due to a mortality rate that approaches 40% and neurologic morbidity that approaches 60%. Patients present with a variety of symptoms ranging from asymptomatic to frank hemorrhage, and appropriate recognition and management may improve their outcomes., Case Report: A man in his late 60s with squamous cell carcinoma of the oropharynx presented to the emergency department (ED) with hemoptysis and several episodes of post-tussive emesis with large clots. He had been cancer free for multiple years after treatment with chemotherapy and radiation to the neck. Evaluation revealed a necrotic tumor on the posterior pharynx on bedside laryngoscopy and an external carotid pseudoaneurysm that was stented by interventional radiology. The patient experienced recurrent hemorrhage several months later and opted for palliative measures and expired of massive hemorrhage in the ED on a subsequent visit. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: CBS can be fatal, and early suspicion and recognition are key to ensure that a threatened or impending carotid blowout are appropriately managed. Once carotid blowout is suspected, early resuscitation and consultation with interventional radiology and vascular surgery is warranted., (Copyright © 2021. Published by Elsevier Inc.)

This data-based cohort consisted of 26,508 (7%) United States veterans out of the 399,290 who tested positive for SARS-CoV-2 from 1 March to 10 September 2020. We aimed to assess the interaction of post-index vitamin D (Vit D) and corticosteroid (CRT) use on 30-day mortality among hospitalized and non-hospitalized patients with coronavirus disease 2019 (COVID-19). Combination Vit D and CRT drug use was assessed according to four multinomial pairs (-|+, -|-, +|+, +|-). Respective categorical effects were computed on a log-binomial scale as adjusted relative risk (aRR). Approximately 6% of veterans who tested positive for SARS-CoV-2 died within 30 days of their index date. Among hospitalized patients, a significantly decreased aRR was observed for the use of Vit D in the absence of CRTs relative to patients who received CRTs but not Vit D (aRR = 0.30; multiplicity corrected, p = 0.0004). Among patients receiving systemically administered CRTs (e.g., dexamethasone), the use of Vit D was associated with fewer deaths in hospitalized patients (aRR = 0.51) compared with non-hospitalized patients (aRR = 2.5) ( P -for-Interaction = 0.0071). Evaluating the effect of modification of these compounds in the context of hospitalization may aid in the management of COVID-19 and provide a better understanding of the pathophysiological mechanisms underlying this and future infectious disease outbreaks.

Introduction: The expanding use of immunotherapy and the growing population of patients with cancer has led to an increase in the reporting of immune related adverse events (irAEs). The emergency clinician should be aware of these emerging toxicities, some of which can be fatal. In this review we discuss the cardiotoxic side effects of immune checkpoint inhibitors (ICIs) and chimeric antigen receptor T-cell (CAR T-cell) therapy., Discussion: Recognizing the possible presentations of cardiotoxic irAEs is of utmost important as the diagnosis of cardiotoxicity associated with ICI and CAR T-cell can be difficult to make in the emergency department. The emergency clinician will have to presume the diagnosis and treat it without final confirmation in most cases. For this reason, if the diagnosis is suspected, early involvement of the cardiologist and oncologist is important to help guide management. Most irAEs will be treated with glucocorticoids, but in the case of CAR T-cell cardiotoxicity, Tocilizumab should be used as first line., Conclusion: Although cardiotoxicity is rare, it is often life-threatening. Treatment should be initiated as soon as the diagnosis is suspected, and early involvement of the cardiologist and oncologist is imperative for optimal treatment., Competing Interests: Declaration of Competing Interest DNL has received compensation for being a content expert for the Society of Immunotherapy of Cancer. DNL has also received compensation for multiple immunotherapy toxicity presentations from the PeerView Institute for Medical Education. The rest of the authors declare no conflicts of interest in this study., (Copyright © 2021 Elsevier Inc. All rights reserved.)

About 25-35% of United States veterans who fought in the 1990-1991 Gulf War report several moderate or severe chronic systemic symptoms, defined as Gulf War illness (GWI). Thirty years later, there is little consensus on the causes or biological underpinnings of GWI. The Gulf War Era Cohort and Biorepository (GWECB) was designed to investigate genetic and environmental associations with GWI and consists of 1343 veterans. We investigate candidate gene-toxicant interactions that may be associated with GWI based on prior associations found in human and animal model studies, focusing on SNPs in or near ACHE , BCHE , and PON1 genes to replicate results from prior studies. SOD1 was also considered as a candidate gene. CDC Severe GWI, the primary outcome, was observed in 26% of the 810 deployed veterans included in this study. The interaction between the candidate SNP rs662 and pyridostigmine bromide (PB) pills was found to be associated with CDC Severe GWI. Interactions between PB pill exposure and rs3917545, rs3917550, and rs2299255, all in high linkage disequilibrium in PON1 , were also associated with respiratory symptoms. These SNPs could point toward biological pathways through which GWI may develop, which could lead to biomarkers to detect GWI or to better treatment options for veterans with GWI.

Background: The accurate detection of cancer-associated venous thromboembolism (VTE) can avoid unnecessary diagnostic imaging or laboratory tests., Objective: We sought to determine clinical and cancer-related risk factors of VTE that can be used as predictors for oncology patients presenting to the emergency department (ED) with suspected VTE., Methods: We retrospectively analyzed all consecutive patients who presented with suspicion of VTE to The University of Texas MD Anderson Cancer Center ED between January 1, 2009, and January 1, 2013. Logistic regression models were used to identify risk factors that were associated with VTE. The ability of these factors to predict VTE was externally validated using a second cohort of patients who presented to King Hussein Cancer Center ED between January 1, 2009, and January 1, 2016., Results: Cancer-related covariates associated with the occurrence of VTE were high-risk cancer type (odds ratio [OR] 3.64 [95% confidence interval {CI} 2.37-5.60], p < 0.001), presentation within 6 months of the cancer diagnosis (OR 1.92 [95% CI 1.62-2.28], p < 0.001), active cancer (OR 1.35 [95% CI 1.10-1.65], p = 0.003), advanced stage (OR 1.40 [95% CI 1.01-1.94], p = 0.044), and the presence of brain metastasis (OR 1.73 [95% CI 1.32-2.27], p < 0.001). When combined, these factors along with other clinical factors showed high prediction performance for VTE in the external validation cohort., Conclusions: Cancer risk group, presentation within 6 months of cancer diagnosis, active and advanced cancer, and the presence of brain metastases along with other related clinical factors can be used to predict VTE in patients with cancer presenting to the ED., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Accurate risk stratification of pulmonary embolism (PE) can reduce unnecessary imaging. We investigated the extent to which the American College of Physicians (ACP) guideline for evaluation of patients with suspected PE could be applied to cancer patients in the emergency department of a comprehensive cancer center., Materials and Methods: Data from cancer patients who underwent CT pulmonary angiography (CTPA) between August 1, 2015, and October 31, 2015, were collected. We assessed each patient's diagnostic workup for its adherence to the ACP guideline in terms of clinical risk stratification and age-adjusted d-dimer level and the degree to which these factors were associated with PE., Results: Of the 380 patients identified, 213 (56%) underwent CTPA indicated per the ACP guideline, and 78 (21%) underwent CTPA not indicated per the guideline. Only one of the patients who underwent nonindicated CTPA had a PE. Fifty-seven patients underwent unnecessary d-dimer evaluation, and 71 patients with negative d-dimer test results underwent nonindicated CTPA. PEs were found in 6 of 108 (6%) low-risk patients, 22 of 219 (10%) intermediate-risk patients, and 13 of 53 (25%) high-risk patients. The ACP guideline had negative predictive value of 99% (95% confidence interval: 93%-100%) and sensitivity of 97% (95% confidence interval: 86%-100%) in predicting PE., Conclusion: The ACP guideline has good sensitivity for detecting PE in cancer patients and thus can be applied in this population. Compliance with the ACP guideline when evaluating cancer patients with suspected PE could reduce the use of unnecessary imaging and laboratory studies., (Copyright © 2019 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Multiple drugs of a new class of cancer treatments called immune checkpoint inhibitors, which work by enabling the immune system to attack tumour cells, have been approved for a variety of indications in recent years. Immune checkpoints, such as cytotoxic T-lymphocyte antigen-4 and programmed death-1, are part of the normal immune system and regulate immune activation. Treatment with inhibitors of these checkpoints can significantly improve response rates, progression-free survival and overall survival of patients with cancer; it can also result in adverse reactions that present similarly to other conditions. These immune-mediated adverse reactions (IMARs) are most commonly gastrointestinal, respiratory, endocrine or dermatologic. Although patients' presentations may appear similar to other types of cancer therapy, the underlying causes, and consequently their management, may differ. Prompt recognition is critical because, with appropriate management, most IMARs resolve and patients can continue receiving immune checkpoint inhibitor treatment. Rarely, these IMARs may be life-threatening and escape detection from the usual evaluations in the emergency environment. Given the unusual spectrum and mechanism of IMARs arising from immune checkpoint inhibitors, emergency departmentED staff require a clear understanding of the evaluation of IMARs to enable them to appropriately assess and treat these patients. Treatment of IMARs, most often with high-dose steroids, differs from chemotherapy-related adverse events and when possible should be coordinated with the treating oncologist. This review summarises the ED presentation and management of IMARs arising from immune checkpoint inhibitors and includes recommendations for tools and resources for ED healthcare professionals., Competing Interests: Competing interests: JV-U reports consulting fees from Bristol-Myers Squibb. No other authors have commercial, financial or other relationships in any way related to the subject of this article to disclose, per ICMJE conflict of interest guidelines. Outside the submitted work, GD reports clinical trial support from Bristol-Myers Squibb, Nektar, Regeneron, Viralytics, Dynavax, OncoSec and Merck. DK reports personal fees and non-financial support from Bristol-Myers Squibb., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Code status discussions form an important part of advance care planning (ACP) as it enables physicians to respect the patient's wishes for end-of-life care. However, in some cases, code status discussions can be challenging causing the physician to go against the patient's wishes and the code of medical ethics. This is especially true in an emergency setting. In this paper, we will discuss three cases of advanced cancer patients, where code status discussions posed challenges to healthcare providers., Case Reports: In the first case, the patient was a 26-year-old male diagnosed with advanced osteosarcoma. Code status was discussed with him, while he was still functional, wherein he agreed to a do-not-resuscitate (DNR) order. However, at the time of end-of-life care, despite of previous code status agreement, the patient's mother insisted on full code. As a result, the DNR order was reverted and the patient was intubated. The second case discusses an 83-year-old female patient with metastatic gastric cancer. Code status was extensively discussed with the patient and her son who agreed to sign a DNR order. This case posed a challenge because when the patient's condition deteriorated, her son demanded cardioversion and other aggressive treatment measures without any chest compressions or intubation. In the third case, the patient was a 40-year-old woman with advanced metastatic adenocarcinoma with neuroendocrine features of the parotid. On admission to the ED, as per the patient's wishes expressed by her husband, a DNR/DNI order was placed. However, this order had to be reverted when the patient's aunt and sister opposed vehemently to the DNR/DNI order., Conclusion: The three cases demonstrate the challenges that can arise in the implementation of code status order in the ED as it pertains for end-of-life care. In any scenario, respecting the patient's wishes and adherence to the code of medical ethics take precedence over any familial objections arising difficulties with coping.

Background: Docetaxel, a lipophilic drug, is indicated for castration-resistant metastatic prostate cancer. Most men with such disease would have had androgen-deprivation therapy, which decreases muscle and increases body fat. Obesity and body composition changes may influence the outcomes of docetaxel therapy., Methods: We conducted a retrospective review of 333 patients with metastatic prostate cancer treated with docetaxel at a comprehensive cancer center between October 7, 2004 and December 31, 2012. Body composition parameters were measured based on the areas of muscle and adipose tissues in the visceral and subcutaneous compartments on CT images at L3-4 levels. Dose calculations, toxicity and adverse reaction profiles, and overall survival were analyzed., Results: Obese patients were younger at the diagnosis of prostate cancer and had a shorter duration from diagnosis to docetaxel therapy. Analysis of body composition found that a high visceral fat-to-subcutaneous fat area ratio (VSR) was associated with poor prognosis but a high visceral fat-to-muscle area ratio (VMR) and high body mass index were associated with increased duration from starting docetaxel to death, allowing such men to catch up with patients with normal body mass index in overall survival from cancer diagnosis to death. Cox proportional hazard regression showed that age ≥65 years, high VSR, abnormal serum alkaline phosphatase, and >10% reduction of initial dosage were significant predictors of shorter time between starting docetaxel and death, and that high VMR, obesity, and weekly regimens were significant predictors of longer survival after docetaxel., Conclusion: Obese and overweight patients may benefit more from weekly docetaxel regimens using the reference dosage of 35 mg/m2 without empirical dosage reduction.

Purpose: To determine if endoscopic Helicobacter pylori and peptic ulcer disease prevalence has changed over an 11-year period in a rural region., Methods: Current endoscopic records were reviewed and compared with similar data obtained over a time period 11 years earlier at the same institution with regard to H. pylori status, endoscopic findings, microscopic pathologic findings, and medication use., Results: There were 251 records reviewed in the current study group (mean age 52.8 years, 59.0% female) and 263 in the previous group (mean age 60.1 years, 56.7% female). H. pylori was positive in 17 (6.8%) in the current study and 173 (65.8%) in the earlier study (P <.0001). Peptic ulcer disease (PUD) was present in 14 (5.6%) in the current study and in 102 (38.8%) in the earlier study (P <.0001). H. pylori was positive in 1 of the 14 PUD patients (7.1%) in the current study and in 78 of 102 (76.5%) in the previous study (P <.0001)., Conclusions: Endoscopic H. pylori prevalence in our rural locality has decreased substantially over the past decade and may reflect local overall prevalence trends, although underestimation is likely due to widespread prior noninvasive H. pylori diagnosis and treatment. Endoscopic PUD also has decreased precipitously, possibly related to changes in regional H. pylori characteristics and prolific use of antisecretory agents. Changing geographic trends regarding acid-peptic disease may prompt modification of diagnostic approach and treatment., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Medical oversight is a fundamental component of every emergency medical services (EMS) system. The quality of physician medical direction has a significant impact upon the system and patient outcome. The lead agency for the state EMS system is a principal facet of our emergency care system, and the state EMS medical director is a vital component within this comprehensive network. The selection of an experienced, qualified physician for the provision of state EMS medical direction is a critical decision. This resource document provides a snapshot of the status of state EMS medical direction in our nation in 2007 and a projection of the achievable benchmarks for the role of the state EMS medical director in the future. As an informational resource, this tool will assist state EMS officials, legislators, laypersons, and partners within the emergency care system to comprehend, create or improve, and support the state EMS medical director position within their jurisdictions.

Objective: To compare the efficacy and safety of faropenem medoxomil, 300 mg twice daily for seven or ten days, with cefuroxime axetil 250 mg twice daily for ten days in adults with acute bacterial sinusitis (ABS)., Study Design and Setting: Prospective, double-blinded, phase III trial with entry criteria consistent with FDA/IDSA guidelines for diagnosis of ABS. Primary efficacy parameter was clinical response at 7 to 21 days posttherapy., Results: One thousand ninety-nine subjects were randomized and treated; 861 were efficacy valid. Clinical cure rates were 80.3% for seven days of faropenem, 81.8% for ten days of faropenem, and 74.5% for 10 days of cefuroxime axetil. The incidence of adverse events and premature discontinuations were similar for the three treatment regimens., Conclusions: Seven- and ten-day faropenem medoxomil regimens were similar (noninferior) to a ten-day cefuroxime axetil regimen based on clinical response in patients with ABS., Significance: A seven-day course of faropenem medoxomil 300 mg twice-daily regimen is a promising alternative for treatment of ABS.

Changes in the scope of any health care construction project are inevitable. They happen for a number of reasons, including pressure from doctors and staff. While some are justified by factors that influence space requirements, such as changing market needs, new physicians or new technology, others inflate the cost of a construction project without adding significant benefits.

Removal of fallopian tubes and ovaries through the laparoscope is a safe and efficient alternative to laparotomy. Seventeen patients undergoing this procedure are described. This approach should be considered for those patients requiring adnexal surgery provided that the operator is skilled in multiple puncture laparoscopy.

Compared the effects of play on the psychosocial adjustment of 46 children hospitalized for acute illness, who were placed in one of four groups: therapeutic play, diversionary play, verbal support, and no treatment. Ratings of psychological adjustment included self-report, as well as nurse and parent ratings. Children in the therapeutic play condition evidenced a significant reduction in self-reported hospital fears. Parent ratings were not affected by therapeutic treatments; rather, parents in all four groups rated their children less anxious from pre- to posttesting. Results are discussed in terms of methodological considerations that have affected outcomes in this type of research.