Potential use of leukocytosis and anion gap elevation in differentiating psychogenic nonepileptic seizures from epileptic seizures

Epileptic seizures (ES) and psychogenic nonepileptic seizures (PNES) can be difficult to differentiate from each other in the emergency department (ED) setting. We have previously shown that the anion gap (AG) can help differentiate between ES and PNES in the ED. In this study, we explored whether additionally considering leukocytosis can help better differentiate between ES and PNES. We screened a total of 1354 subjects seen in the ED of a tertiary care medical center; 27 PNES and 27 ES patients were identified based on clinical description and subsequent electroencephalography (EEG). Multivariable logistic regression analysis was used to model the association between ES, leukocytosis, and AG. Our results indicated that within 9 hours after the index event, serum AG (adjusted odds ratio [aOR] 2.07) and white blood cell (WBC) count (aOR 1.61) were both independently associated with ES. We derived an equation to help differentiate between ES and PNES: 1.5*AG+WBC. A score \u3e 24.8 indicated a \u3e 90% likelihood of ES. A score \u3c 15.5 indicated a \u3c 10% likelihood of ES (ie, the alternate diagnosis of PNES should be considered). This study for the first time provides evidence to help differentiate PNES and ES utilizing acidosis and leukocytosis

Infants Exposed To Homelessness: Health, Health Care Use, And Health Spending From Birth To Age Six

Homeless infants are known to have poor birth outcomes, but the longitudinal impact of homelessness on health, health care use, and health spending during the early years of life has received little attention. Linking Massachusetts emergency shelter enrollment records for the period 2008-15 with Medicaid claims, we compared 5,762 infants who experienced a homeless episode with a group of 5,553 infants matched on sex, race/ethnicity, location, and birth month. Infants born during a period of unstable housing resulting in homelessness had higher rates of low birthweight, respiratory problems, fever, and other common conditions; longer neonatal intensive care unit stays; more emergency department visits; and higher annual spending. Differences in most health conditions persisted for two to three years. Asthma diagnoses, emergency department visits, and spending were significantly higher through age six. While screening and access to health care can be improved for homeless infants, long-term solutions require a broader focus on housing and income

Gamification of a Digital Health Technology for Unmotivated Smokers: Concept and User-driven Development

Digital health technologies most often reach only those more motivated to engage, particularly when preventive health is targeted. To test whether gamification could be used to engage the unmotivated, we conceptualized “Take a Break” - a three-week technology-assisted challenge for smokers to compete in setting and achieving brief abstinence goals. Usability testing of the multi-technology Take a Break challenge was performed by a panel of smokers. These smokers were given 1) daily motivational messages, 2) brief “challenge quizzes” related to smoking behaviors, 3) a telehealth call to personalize their abstinence goal for the challenge and 4) a set “coping mini-games” to help manage cravings while attempting to achieve their brief abstinence goals. Fifth, a leaderboard “webApp” gave feedback on smokers’ participation compared to others engaged in the challenge, allowing for competition. We used usability testing to further refine the elements. Meaningful gamification was successful in engaging unmotivated smoker

Comparison of Diabetic Remission Rates following Roux en-Y Gastric Bypass and Longitudinal Sleeve Gastrectomy

Introduction: Bariatric surgery is being increasingly investigated as treatment for Type II Diabetes Mellitus (T2DM). As Sleeve Gastrectomy (SG) surpasses Roux-en-Y Gastric Bypass (RYGB) as the new standard in bariatric surgery, it is still unknown if its efficacy in achieving remission is comparable to RYGB. This study compared diabetic remission rates between SG and RYGB in order to identify the predictive factors for remission and the mechanisms of achieving remission. Methods: This was a retrospective cohort study comparing all diabetic patients undergoing RYGB and SG at an academic medical center from 1/1/11-7/1/15. Patients were followed preoperatively and at 6 week, 6 month, and 1, 2, and 3 year intervals. We defined diabetic remission as HbA1c under 7 without insulin or hypoglycemic use and excess body weight (EBW) as percent over ideal body weight. Data were analyzed using Cox analysis, Fisher’s Exact Tests, and Student T Tests. Results: During the study, 96 patients underwent RYGB and 89 underwent SG. Preoperatively, patients from both groups had similar age, weight, gender, preoperative weight loss, HbA1c at onset and at surgery, oral hypoglycemic use, insulin use, and HOMA2 parameters. At one year postoperatively, patients who underwent RYGB showed a statistically greater postoperative EBW loss (62% vs. 36% p \u3c 0.0001). Kaplan Meier analysis showed a significantly higher rate of remission, (83% vs. 66%) in patients who underwent SG (p=0.02). After using Cox analysis to account for differences in delta BMI (p=0.04), EBW loss (p=0.04), preoperative HOMA2 parameters (p=0.008-0.011), and preoperative factors such as HbA1c and insulin use (p=0.001 for both), there was no change in RYGB’s impact on diabetic remission compared to SG. Conclusion: Our results confirm that RYGB achieves a significantly greater rate of diabetic remission and a significantly higher weight loss than SG. Additionally, the difference in rate of diabetic remission is not explained by weight loss or preoperative predictors of less reversible diabetes (HOMA2 parameters, use of insulin). Identification of the factor(s) responsible for this differential effect on diabetes may afford opportunity for therapeutic intervention

Differences in Complication Rates Between Roux-en-Y Gastric Bypass and Longitudinal Sleeve Gastrectomy

Introduction: Sleeve Gastrectomy (SG) has surpassed Roux-en-Y Gastric Bypass (RYGB) as the most commonly performed bariatric operation. Though the beneficial effect of SG on Type 2 Diabetes Mellitus is less than that of RYGB, it is perceived to have a lower complication rate. The purpose of this study was to quantify the complication rates between of SG and RYGB in a severely obese diabetic population. Methods: This was a retrospective cohort study that included all diabetic patients undergoing RYGB and SG at an academic medical center from January 1, 2011 to July 1, 2015. Patients were followed at 6 week, 6 month, 1 year, 2 year, and 3 year postoperatively. Outpatient and emergency visits were identified in the EMR system. Continuous data was analyzed using Student T tests and discrete data was analyzed using Fisher’s Exact Test. We defined early complications as those occurring within 30 days postoperatively, and late complications as those after 30 days. Results: A total of 96 patients underwent RYGB and 89 underwent SG. The groups were concurrent and similar with regards to preoperative demographic factors such as age, gender, Hgb-A1c, HOMA2 parameters, excess body weight, BMI, and diabetic medication use. In terms of early complications, the rate of hemorrhage requiring transfusion was higher in the SG group compared to RYGB (10.1% vs. 3.1%, p=0.073). Postoperative length of stay was lower in the SG group (m=1.7 d vs. m=2 d, p=0.02), but the early readmission rate was also higher in the SG group (7.9% vs. 2.1%, p=0.09). For late postoperative complications, there were 4 anastomotic ulcer perforations and one case of internal hernia in the RYGB group. There were 6 late postoperative reoperations in the RYGB group (6% vs. 0%, p=0.03). In addition, 13 patients underwent 16 total upper endoscopies in the RYGB group (13.5% vs. 0%, p=0.0002). The cumulative rate of early and late interventions was higher in the RYGB group (20% vs. 3.4%, p=0.0005). Conclusions: While the rate of early postoperative complication is similar between SG and RYGB, the need for late intervention is higher after RYGB. The cumulative need for reintervention (early and late) is higher after RYGB. This may explain the shift from Roux-en-Y Gastric Bypass to Sleeve Gastrectomy as the most commonly performed bariatric intervention

The Effect of Oral Antibiotics on the Development of Community Acquired Clostridium Difficile Colitis in Medicare Beneficiaries

Clostridium difficile infection (CDI) is increasingly prevalent among community dwelling Americans. Older Americans are particularly vulnerable to community-acquired Clostridium difficile (CACD), in part to increasing use of antibiotics. We studied the association between outpatient antibiotics and CACD among Medicare beneficiaries. Case-control study utilizing a 5% sample of Medicare beneficiaries (2009-2011). Patients with CACD severe enough to warrant hospitalization were identified by a primary diagnosis code for CDI and no exposure to a healthcare environment within 90-days of admission. 1,514 CACD cases were matched to ten controls each on birth year and sex. Potential controls with exposure to healthcare environment were excluded. Outpatient oral antibiotic exposure was classified into three groups: ≤30 days, 31-60 days, or 61-90 days prior to case subject’s index admission. Metronidazole and Vancomycin were excluded because they are used to treat CDI. Multivariable models were utilized to determine the independent effect of antibiotics on the development of CACD while controlling for several patient associated characteristics. Cases of CACD had more outpatient antibiotic exposure in each time period examined: ≤30 days = 40.0% vs 8.4%; 31-60 = 10.7% vs 5.0%; and 61-90 = 5.5% vs 4.4% (all p-values \u3c 0.05). Subjects exposed to antibiotics ≤30 days prior to admission had a markedly higher risk of being admitted with CACD compared with those not exposed (OR 8.09, 95% CI 7.13, 9.19). Similarly, subjects taking antibiotics 31-60 days and 61-90 days prior to admission had increased risk of CDI admission (OR 3.65, 95% CI 3.02, 4.41) and (OR 2.06, 95% CI 1.61, 2.63) respectively. Recent exposure to outpatient oral antibiotics increases the risk of CACD among community dwelling elderly with the risk persisting as long as 90 days after exposure. Inappropriate antibiotic usage must be minimized and older Americans who require outpatient antibiotic treatment may warrant close observation for signs of CDI

The contributions of focused attention and open monitoring in mindfulness-based cognitive therapy for affective disturbances: A 3-armed randomized dismantling trial

OBJECTIVE: Mindfulness-based cognitive therapy (MBCT) includes a combination of focused attention (FA) and open monitoring (OM) meditation practices. The aim of this study was to assess both short- and long-term between- and within-group differences in affective disturbance among FA, OM and their combination (MBCT) in the context of a randomized controlled trial. METHOD: One hundred and four participants with mild to severe depression and anxiety were randomized into one of three 8-week interventions: MBCT (n = 32), FA (n = 36) and OM (n = 36). Outcome measures included the Inventory of Depressive Symptomatology (IDS), and the Depression Anxiety Stress Scales (DASS). Mixed effects regression models were used to assess differential treatment effects during treatment, post-treatment (8 weeks) and long-term (20 weeks). The Reliable Change Index (RCI) was used to translate statistical findings into clinically meaningful improvements or deteriorations. RESULTS: All treatments demonstrated medium to large improvements (ds = 0.42-1.65) for almost all outcomes. While all treatments were largely comparable in their effects at post-treatment (week 8), the treatments showed meaningful differences in rapidity of response and pattern of deteriorations. FA showed the fastest rate of improvement and the fewest deteriorations on stress, anxiety and depression during treatment, but a loss of treatment-related gains and lasting deteriorations in depression at week 20. OM showed the slowest rate of improvement and lost treatment-related gains for anxiety, resulting in higher anxiety in OM at week 20 than MBCT (d = 0.40) and FA (d = 0.36), though these differences did not reach statistical significance after correcting for multiple comparisons (p\u27s = .06). MBCT and OM showed deteriorations in stress, anxiety and depression at multiple timepoints during treatment, with lasting deteriorations in stress and depression. MBCT showed the most favorable pattern for long-term treatment of depression. CONCLUSIONS: FA, OM and MBCT show different patterns of response for different dimensions of affective disturbance. TRIAL REGISTRATION: This trial is registered at (v NCT01831362); www.clinicaltrials.gov

Impact of Pre-Injury Warfarin Use Among Medicare Beneficiaries With Head Trauma

Introduction: The effect of warfarin on outcomes of head injured patients remains controversial. Yet more than 2 million Americans, many of them elderly, are started on warfarin annually. Meanwhile, with the aging US population, elderly Americans are becoming an increasingly large proportion of head injured patients. We studied a national cohort of Medicare beneficiaries with head injuries to determine the effects of pre-injury warfarin on outcomes. Methods: A retrospective review of a 5% random sample of Medicare claims data (2009-2010) was performed for enrollees with at least 1 year of Medicare eligibility. Head injury cases were identified using ICD-9 codes for intracranial hemorrhage with or without accompanying skull fractures. Using Part D prescription drug claims, warfarin exposure was defined as \u3e2 warfarin prescriptions filled within 60 days prior to injury. Characteristics and outcomes (mortality, length of stay (LOS), ICU LOS) between warfarin users and patients not on warfarin (non-users) were compared using univariate tests of association. Multivariable models adjusting for patient characteristics, concomitant torso injuries/long-bone fractures, and need for ICU care were conducted to measure the independent effect of warfarin on in-hospital mortality. Results: We identified 3,420 head injured patients,6.6% of whom were treated with warfarin. Warfarin users were more likely to be female (74.2%vs.65.6%, p Conclusion: Anticoagulation with warfarin increases risk of mortality after head injury nearly two fold in Medicare beneficiaries even after adjusting for other risk factors. As new, more difficult to reverse, agents are introduced for chronic anticoagulation this problem may be exacerbated. Physicians should exercise caution when initiating chronic anticoagulation in patients over the age of 65

Quadrimodal Distribution of Death after Trauma: Predictors of Death in the Fourth Peak

Introduction: Patterns of death after trauma are changing due to diagnostic and treatment advances. We examined mortality in critically injured patients at risk of death after discharge. Methods: We reviewed all critically injured (Injury Severity Score≥25 AND death in Emergency Room , death within 24hrs, OR ICU admission\u3e24hrs) adults (age≥18) admitted to a Level 1 trauma center (01/01/2000-12/31/2010) and determined death post-discharge (Social Security Death Index) of patients discharged alive. We compared demographics, injury data, and critical care resource utilization between those who died during follow-up and survivors using univariate tests and Cox proportional hazards models. Results: Of 1,695 critically injured patients, 1135 (67%) were discharged alive. As of 05/1/2012, 977 (58%) index survivors were alive (median follow-up 62mos (IQR35,96)). Of 158 deaths post-discharge, 75 (47%) occurred within the first year. Patients who died post-discharge had longer hospital (24dys (IQR13,38) vs. 17dys (IQR10,27)) and ICU LOS (17dys (IQR6,29) vs. 8dys (IQR4,19)) and were more likely to undergo tracheostomies (36.1% vs. 15.6%, p16dys increased risk of death at one year (HR1.94 (1.22,3.06)) and by the end of follow-up (HR2.19 (1.58,3.04)) compared to shorter ICU stays. Conclusion: We propose the first year after discharge as the fourth peak of trauma related mortality. Duration of ICU LOS during index hospitalization is associated with post-discharge mortality