Achenbach Syndrome: A Classic Presentation of a Not-So-Common Condition

Also called “acute idiopathic blue finger” or “paroxysmal finger hematoma,” Achenbach syndrome is a benign collection of findings that is often mistaken for more serious conditions. Characteristically presenting with discrete unexplained bruising or discoloration of the volar aspect of one or two fingers, it is a diagnosis that physicians should include on their differential given its innocuous course and excellent outcomes, without need for invasive testing or intervention. The purpose of this case report therefore is to increase awareness of this rare condition, especially among emergency department physicians and internists, in order to minimize the incidence of unnecessary testing, procedures, and psychological burden

The Correlation Between Perceptions of Safety and Perceived Stress Among Residents of the Somerset Neighborhood of Kensington, Philadelphia

Background: The Somerset neighborhood of Kensington, Philadelphia is affected by economic, environmental, and social issues that come with disinvestment. The average median income for Somerset is $26,015 per year which is much lower than Philadelphia’s city-wide income of$36, 957. This study evaluated the connection between perceptions of safety and perceived stress among residents of the Somerset neighborhood. Methods: This study was a secondary data analysis from a cross-sectional study in the Somerset neighborhood. The data included self-reported surveys from Somerset residents that were completed at their homes. The surveys were completed using an electronic (tablet) format which took approximately 20 to 30 minutes to complete. Trained members of the neighborhood collected the data from July to December 2017. We used SPSS to quantify relationships between perceptions of safety and perceived stress using Spearman’s Rank Order Correlation for each of our 12 perceptions of safety variables and stress. Our final model was created using a multivariable linear regression model. Results: We had 328 adults with an average age of 48 years old in our study sample. We found that most of the residents were female, 35.3% were Latino, predominantly single, and mainly employed full-time. Additionally, over half of the residents owned their home and 16 years was the average amount of time lived in the neighborhood. We found that the average score on the stress scale was a 5.18 (range 0-16). In our final model, we found 4 variables to be statistically significant (α= .10) age, years lived in the community, police should spend more time working with community members and groups to solve problems, and members of my community are interested in crime prevention activities. Discussion: Overall, the mean stress levels were lower than we expected. We found associations between demographics and perceptions of safety variables specifically, as age increased, stress decreased and as the years lived in the community increased, stress increased. Our results also indicated as police spent more time working with community members and as crime prevention activities increased in the community, stress decreased. The strongest predictor of stress was the variable: “police should spend more time working with community members and groups to solve problems.” Collaborations between police officers and community members have the potential to improve health and may also help residents feel safer and less stressed in the neighborhood

Understanding Differences in Medical Versus Surgical Patients Alerted by the Modified Early Warning Score (MEWS) at Jefferson Hospital

An Early Warning Score (EWS) is a risk-management tool to identify patients experiencing clinical deterioration early, therefore allowing timely treatment to occur. Although EWS scores are recommended for all in-patients, more data is available for patients under general medical services compared to surgical services. This study aims to understand differences between medical versus surgical in-patients who receive a red alert from the Modified Early Warning Score (MEWS) at Jefferson hospital. Patients who received a red MEWS alert during admission and discharged between June 2017 to March 2018 (N=812) were categorized as medical or surgical patients. Patient characteristics were compared using an independent samples t-test (age, alert count) or chi-square test (sex, race, admission source, insurance). Patient outcomes were compared using a binary logistic regression (in-hospital mortality, RRT, sepsis diagnosis, ICU transfer, intubation, discharge to hospice) or a Cox regression model (length of stay), controlling for age, sex, and race. Compared to medical patients, surgical patients were younger by 2.7 years (p=0.026) and more likely to have a Commercial and/or Medicare category of insurance (OR=1.568, p=0.005). Surgical patients were more likely to have ICU transfer (OR=1.487, p=0.013) and intubation post-alert (OR=2.470, p=0.006), while less likely to be discharged early (HR=0.675,

The Association Between Opioid-Related Industry Payments and Opioid Prescribing at the Individual and Ecological Level in Pennsylvania

Objective: to understand how industry payments related to opioid products are associated with opioid prescribing in Pennsylvania. Methods: we merged the Open Payments data, Medicare Part D public use file, and Dartmouth Hospital Atlas of Health Care Hospital Service Areas from 2015 to analyze relationships between opioid related payments and opioid prescribing. We used a binomial regression model to investigate individual-level trends and a log-linear model to investigate Hospital Service Area-level trends. We mapped the distribution of opioid-related payments in Pennsylvania using GIS software. Results: One additional payment to a physician was associated with 4.2% higher opioid-prescribing rate (OR = 1.0418, 95% CI 1.0416-1.0420, Chi-Square(1) = 122678, p Conclusions: We found a positive association between opioid-related payments to physicians and opioid prescribing. Policy makers and administrators should consider revising rules related to pharmaceutical company marketing tactics and promote judicious opioid prescribing

A Case of Bartonella Endocarditis and Torrential Aortic Regurgitation Leading to Cardiac Arrest

Infective endocarditis can be difficult to diagnose, especially when blood culture-negative. We describe a case of a patient who presented with signs and symptoms of new, acute decompensated heart failure who was found to have culture-negative endocarditis, a large, mobile aortic valve mass, and torrential aortic regurgitation. Although the patient remained clinically stable during early admission and was planned for surgical correction of the valvular pathology, he suffered abrupt clinical decompensation which resulted in cardiac arrest. Postmortem serologies were found to be positive for Bartonella henselae and Bartonella quintana

Predictors of Youth Suicide: A U.S. Survey

Background: The suicide rate in the youth population of the United States has increased by over 50% in the last 10 years. Other countries have markedly reduced suicide rates through investment in research, education and treatment. The United States has been slow in implementing suicide prevention measures and U.S. data on suicide and risk factors remains limited. Objective: The aim of this research is to better understand the risk factors and warning signs for suicide in the youth population. This information could inform the development of prevention strategies to reduce the suicide rate in this population. Methods: Data was collected nationally from survivors of a suicide attempt, the ‘self’ dataset, and family members of those lost to suicide, the ‘other’ dataset. Data were collected on demographics and warning signs observed in 431 individuals aged 8 to 24 years. SAS statistics software was used to generate descriptive statistics and chi-squared tests were performed to compare the warning signs identified by survivors with those identified by family members. Results: The results showed that overall the individuals who had attempted or died from suicide were white (87.24%), male (62.18%), single (50.81%) in school (63.81%) and living at home with their families (85.15%). 80.51% identified as heterosexual and 19.49% as LGBTQ+. Almost a third had made previous suicide attempts (28.77%) and of those 66.94% had made 1 or 2 attempts. 67.52% had ever received psychiatric treatment but, of those, only 53.61% were receiving treatment at the time of the suicide or attempt. 32.71% had a history of suicide in their family and behavior changes were noticed in 59.16% of individuals. Overall the most commonly identified warning signs were emotional misery/pain (45.71%), insomnia (34.75) and hopelessness (34.57%). There were statistically significant differences in prevalence seen between the ‘self’ and ‘other’ datasets in 28 of the 42 warning signs. Conclusions: This research provides an overview of the most at-risk individuals in the youth population. It highlights that warning signs are not easy to identify in others so if there are concerns about an individual, conversations must be had to ascertain their mental state and provide help as needed. More research is needed to further evaluate and understand this topic

Normalized Healthcare Utilization Among Refugees Resettled in Philadelphia, 2007-2016

Background/Purpose: About 70,000 new refugees are resettled in the United States each year, of which approximately 600 are resettled in Philadelphia. This project seeks to better understand the patterns of healthcare utilization, including primary care, emergency, and hospitalization, among refugees resettled in Philadelphia, PA, between 2007 and 2016. Methods: Demographic and healthcare utilization data for 1,144 refugees seen at Jefferson Family Medical Associates were compiled from the Jefferson Longitudinal Refugee Health Registry. Descriptive statistics were used to describe the demographic characteristics of the refugee population. Negative binomial count regressions were used to test for significant correlations between major demographic variables and healthcare utilization. Results: Refugees had an average of 7.24 (SD = 9.35) and a median of 4 primary care visits. Visits rates were highest during the first eight months post resettlement and declined significantly after expiration of Refugee Medical Assistance. Country of origin and year of arrival were significantly associated with differing rates of healthcare utilization. Discussion: Overall, refugees utilized primary healthcare services at a slightly higher rate than the U.S. average. There are differences in utilization among various sub-populations within the refugee community. Future studies should further explore these differences in healthcare utilization patterns among recently resettled refugees

Nurse-Initiated Treatment Reduces Costs for Acute Asthma in a Pediatric Emergency Department

Standardized emergency department (ED) pathways can improve care delivery to children with acute asthma, though their impact on hospitalization and costs is unclear. An Acute Asthma Care Pathway (AACP) that facilitates nurse initiation of treatment was implemented at a tertiary care pediatric ED using standard quality improvement methodology. The impact of implementation was assessed using process control methodology and multivariable time series analyses between pre- and post-implementation periods. Provision of a steroid within 30 minutes and 60 minutes of arrival increased by 21 and 22 percentage points respectively, IV magnesium sulfate administration increased by 30 percentage points, the proportion hospitalized decreased from 44.8% to 32.2%, and mean direct costs per patient decreased from $2,663 to$2,303 (13.5%). In multivariable analysis, these improvements remained significant. Implementation of the AACP improved timeliness of treatment, hospitalization, and direct costs of children receiving ED treatment for acute asthma

Evaluation of a standard provision versus an autonomy promotive exercise referral programme: rationale and study design

Background The National Institute of Clinical Excellence in the UK has recommended that the effectiveness of ongoing exercise referral schemes to promote physical activity should be examined in research trials. Recent empirical evidence in health care and physical activity promotion contexts provides a foundation for testing the utility of a Self Determination Theory (SDT) -based exercise referral consultation. Methods/Design Design: An exploratory cluster randomised controlled trial comparing standard provision exercise on prescription with a Self Determination Theory-based (SDT) exercise on prescription intervention. Participants: 347 people referred to the Birmingham Exercise on Prescription scheme between November 2007 and July 2008. The 13 exercise on prescription sites in Birmingham were randomised to current practice (n=7) or to the SDT-based intervention (n=6). Outcomes measured at 3 and 6-months: Minutes of moderate or vigorous physical activity per week assessed using the 7-day Physical Activity Recall; physical health: blood pressure and weight; health status measured using the Dartmouth CO-OP charts; anxiety and depression measured by the Hospital Anxiety and Depression Scale and vitality measured by the subjective vitality score; motivation and processes of change: perceptions of autonomy support from the advisor, satisfaction of the needs for competence, autonomy, and relatedness via physical activity, and motivational regulations for exercise. Discussion This trial will determine whether an exercise referral programme based on Self Determination Theory increases physical activity and other health outcomes compared to a standard programme and will test the underlying SDT-based process model (perceived autonomy support, need satisfaction, motivation regulations, outcomes) via structural equation modelling. Trial registration The trial is registered as Current Controlled trials ISRCTN07682833

Power Law versus Exponential State Transition Dynamics: Application to Sleep-Wake Architecture

BACKGROUND: Despite the common experience that interrupted sleep has a negative impact on waking function, the features of human sleep-wake architecture that best distinguish sleep continuity versus fragmentation remain elusive. In this regard, there is growing interest in characterizing sleep architecture using models of the temporal dynamics of sleep-wake stage transitions. In humans and other mammals, the state transitions defining sleep and wake bout durations have been described with exponential and power law models, respectively. However, sleep-wake stage distributions are often complex, and distinguishing between exponential and power law processes is not always straightforward. Although mono-exponential distributions are distinct from power law distributions, multi-exponential distributions may in fact resemble power laws by appearing linear on a log-log plot. METHODOLOGY/PRINCIPAL FINDINGS: To characterize the parameters that may allow these distributions to mimic one another, we systematically fitted multi-exponential-generated distributions with a power law model, and power law-generated distributions with multi-exponential models. We used the Kolmogorov-Smirnov method to investigate goodness of fit for the "incorrect" model over a range of parameters. The "zone of mimicry" of parameters that increased the risk of mistakenly accepting power law fitting resembled empiric time constants obtained in human sleep and wake bout distributions. CONCLUSIONS/SIGNIFICANCE: Recognizing this uncertainty in model distinction impacts interpretation of transition dynamics (self-organizing versus probabilistic), and the generation of predictive models for clinical classification of normal and pathological sleep architecture