An Analysis of Factors that Impact Utilization of Indianapolis Emergency Departments

Over 145 million Emergency Department (ED) visits occur annually in the United States. Policy makers continue to push for less ED visits for ambulatory sensitive conditions. The aim of this study was to explore the risk factors associated with being a frequent ED utilizer for low-acuity needs. This prospective survey study was conducted in two urban, level 1 trauma centers in Indianapolis, Indiana. The primary outcome was frequent ED utilization, defined as 4 or more visits in the past 12 months. Patient demographics, past ED visits, and primary care physician (PCP) utilization information were collected for 445 patients. A multivariate logistic regression model and Chi-square test were utilized to analyze associations between ED utilization and other factors. Of the 638 eligible ED patients, 445 were enrolled into the study. Patients were primarily female (274 females, 61.6%). Over half (55.1%) were African American and 36.4% were Caucasian. 291 (65.4%) patients stated they had a PCP, and 114 (25.6%) patients were frequent ED visitors. Having a PCP was not found to be associated with being a frequent ED visitor (p= 0.2978); however, patients with a higher Charlson Comorbidity Index score, experiencing unemployment, and with additional physicians besides a PCP were found to have higher odds of being a frequent ED visitor. Future research identifying additional factors that result in patients utilizing the ED for low-acuity needs is necessary

Effects of maternal depression on fetal health

Case Description Patient is a 27 years old pregnant (18 weeks) female with a past medical history of depression, post-traumatic stress disorder (PTSD), and military sexual trauma admitted for suicidal ideation with intent and plan. During admission, the patient refused all antidepressants after emesis on sertraline and prenatal vitamins. Patient was discharged after clinical stabilization and scheduled for follow-up outpatient. Conclusions Depression during pregnancy can have numerous adverse effects on mother as well as fetal and child development and thus treatment is of the utmost importance. Depression leads to alterations in the serotonin system and the HPA axis, as well as causes epigenetic changes to the infant glucocorticoid receptor gene. Changes in these pathways are most apparent during the second trimester and have downstream consequences leading to altered fetal heart rate variability, preterm birth, and low birth weight. Maternal depression can also lead to altered cortisol reactivity, and delayed motor and cognitive development in childhood. Furthermore, prevalence of depression varies throughout the pregnancy with depression more prevalent in the second and third trimesters. Clinical Significance Pregnant women are less likely to receive any mental health treatment for depression than their non-pregnant counterparts; 49% and 57% respectively, and screening for depression focuses on postpartum screening with few guidelines to screening during pregnancy. Due to the adverse effects on the fetus, maternal surveillance and treatment of depression during pregnancy is essential

Decision Making in Fertility Preservation Prior to Pursuing Curative Treatments for Sickle Cell Disease

AUTHORS: Angela Collins, MPH(1), Josey Noel(1), Olivia Abraham(1), Sydney Hornberger(1), Mahvish Rahim MD, MBA, MSCR(1,2), Seethal Jacob MD, MS, FAAP(1,2), Amanda Saraf DO(1,2). AFFILIATIONS: (1) Indiana University School of Medicine, Indianapolis, IN. (2) Department of Pediatrics, Riley Hospital for Children, Indianapolis, IN. ABSTRACT: RELEVANT BACKGROUND: Sickle cell disease (SCD) is one of the most commonly inherited hemoglobinopathies, often well controlled on Hydroxyurea (HU). Curative therapy options exist with stem cell transplant (SCT) and gene therapy. While both the underlying condition and routine therapy such as HU is thought to impact fertility, the chemotherapy used for both SCT and gene therapy can result in permanent sterility. Infertility can have a negative impact on long-term measures of quality of life. As a result, fertility preservation ought to be offered to all patients with SCD planning for curative treatment. Ovarian tissue cryopreservation and mature oocyte or embryo cryopreservation are fertility preservation options available for pre and postpubescent females respectively. Testicular tissue cryopreservation (TTC) is an experimental option for prepubescent males and sperm cryopreservation is utilized for postpubescent males. CASE DESCRIPTION: We present three cases of patients with SCD who pursued fertility preservation prior to receiving curative therapy with a myeloablative preparative regimen. Patient 1 is a prepubescent 8-year-old male with SCD controlled with HU who opted for TTC as fertility preservation prior to receiving a matched sibling SCT. Patient 2 is a 13-year-old male with SCD controlled with HU who opted for TTC following a failed sperm banking attempt prior to haploidentical SCT. Patient 3 is an 18-year-old female with SCD controlled with HU and Voxelator who opted to have eggs harvested prior to gene therapy. CLINICAL SIGNIFICANCE: As highlighted by these cases, continued research on safe and effective fertility preservation as well as counseling about both the impact of the underlying disease on fertility and treatment-related fertility risks is imperative to improve long-term quality of life measures. CONCLUSION: These patients demonstrate a need for further emphasis on fertility risk counseling in this patient population and ensuring that discussions regarding preservation options is standard of practice at every institution

North Atlantic Ocean Control on Surface Heat Flux at Multidecadal Timescale

Nearly 50 years ago Bjerknes1 suggested that the character of large-scale air–sea interaction over the mid-latitude North Atlantic Ocean differs with timescales: the atmosphere was thought to drive directly most short-term—interannual—sea surface temperature (SST) variability, and the ocean to contribute significantly to long-term—multidecadal—SST and potentially atmospheric variability. Although the conjecture for short timescales is well accepted, understanding Atlantic multidecadal variability (AMV) of SST2, 3 remains a challenge as a result of limited ocean observations. AMV is nonetheless of major socio-economic importance because it is linked to important climate phenomena such as Atlantic hurricane activity and Sahel rainfall, and it hinders the detection of anthropogenic signals in the North Atlantic sector4, 5, 6. Direct evidence of the oceanic influence of AMV can only be provided by surface heat fluxes, the language of ocean–atmosphere communication. Here we provide observational evidence that in the mid-latitude North Atlantic and on timescales longer than 10 years, surface turbulent heat fluxes are indeed driven by the ocean and may force the atmosphere, whereas on shorter timescales the converse is true, thereby confirming the Bjerknes conjecture. This result, although strongest in boreal winter, is found in all seasons. Our findings suggest that the predictability of mid-latitude North Atlantic air–sea interaction could extend beyond the ocean to the climate of surrounding continents