Duration of patients’ visits to the hospital emergency department

Background Length of stay is an important indicator of quality of care in Emergency Departments (ED). This study explores the duration of patients’ visits to the ED for which they are treated and released (T&R). Methods Retrospective data analysis and multivariate regression analysis were conducted to investigate the duration of T&R ED visits. Duration for each visit was computed by taking the difference between admission and discharge times. The Healthcare Cost and Utilization Project (HCUP) State Emergency Department Databases (SEDD) for 2008 were used in the analysis. Results The mean duration of T&R ED visit was 195.7 minutes. The average duration of ED visits increased from 8 a.m. until noon, then decreased until midnight at which we observed an approximately 70-minute spike in average duration. We found a substantial difference in mean duration of ED visits (over 90 minutes) between Mondays and other weekdays during the transition time from the evening of the day before to the early morning hours. Black / African American patients had a 21.4-minute longer mean duration of visits compared to white patients. The mean duration of visits at teaching hospitals was substantially longer than at non-teaching hospitals (243.8 versus 175.6 minutes). Hospitals with large bed size were associated with longer duration of visits (222.2 minutes) when compared to hospitals with small bed size (172.4 minutes) or those with medium bed size (166.5 minutes). The risk-adjusted results show that mean duration of visits on Mondays are longer by about 4 and 9 percents when compared to mean duration of visits on non-Monday workdays and weekends, respectively. Conclusions The duration of T&R ED visits varied significantly by admission hour, day of the week, patient volume, patient characteristics, hospital characteristics and area characteristics

Vulnerability of Subsistence Systems Due to Social and Environmental Change: A Case Study in the Yukon-Kuskokwim Delta, Alaska

Arctic Indigenous communities have been classified as highly vulnerable to climate change impacts. The remoteness of Arctic communities, their dependence upon local species and habitats, and the historical marginalization of Indigenous peoples enhances this characterization of vulnerability. However, vulnerability is a result of diverse historical, social, economic, political, cultural, institutional, natural resource, and environmental conditions and processes and is not easily reduced to a single metric. Furthermore, despite the widespread characterization of vulnerability, Arctic Indigenous communities are extremely resilient as evidenced by subsistence institutions that have been developed over thousands of years. We explored the vulnerability of subsistence systems in the Cup’ik village of Chevak and Yup’ik village of Kotlik through the lens of the strong seasonal dimensions of resource availability. In the context of subsistence harvesting in Alaska Native villages, vulnerability may be determined by analyzing the exposure of subsistence resources to climate change impacts, the sensitivity of a community to those impacts, and the capacity of subsistence institutions to absorb these impacts. Subsistence resources, their seasonality, and perceived impacts to these resources were investigated via semi-structured interviews and participatory mapping-calendar workshops. Results suggest that while these communities are experiencing disproportionate impacts of climate change, Indigenous ingenuity and adaptability provide an avenue for culturally appropriate adaptation strategies. However, despite this capacity for resiliency, rapid socio-cultural changes have the potential to be a barrier to community adaptation and the recent, ongoing shifts in seasonal weather patterns may make seasonally specific subsistence adaptations to landscape particularly vulnerable.Les collectivités autochtones de l’Arctique sont classées comme étant fortement vulnérables aux incidences du changement climatique. L’éloignement des collectivités de l’Arctique, leur dépendance des espèces et des habitats locaux de même que la marginalisation historique des peuples autochtones intensifient cette vulnérabilité. Toutefois, la vulnérabilité est le résultat de conditions et de processus divers sur le plan historique, social, économique, politique, culturel, institutionnel, environnemental et des ressources naturelles. Il est difficile d’attribuer la vulnérabilité à un seul aspect. Malgré cette vaste caractérisation de la vulnérabilité, les collectivités autochtones de l’Arctique sont extrêmement résilientes, comme en attestent les modes de subsistance qui se sont développés au fil de milliers d’années. Nous avons exploré la vulnérabilité des systèmes de subsistance du village cup’ik de Chevak et du village yup’ik de Kotlik du point de vue des dimensions saisonnières fortes de la disponibilité des ressources. Dans le contexte des récoltes de subsistance des villages autochtones de l’Alaska, la vulnérabilité peut être déterminée au moyen de l’exposition des ressources de subsistance aux incidences du changement climatique, de la sensibilité d’une collectivité à ces incidences et de la capacité des institutions de subsistance à absorber ces incidences. Les ressources de subsistance, leur saisonnalité et les incidences perçues de ces ressources ont été étudiées au moyen d’entrevues semi-structurées et d’ateliers participatifs d’établissement de calendrier. Selon les résultats, bien que ces collectivités soient aux prises avec des incidences disproportionnées de changement climatique, l’ingéniosité et l’adaptabilité des Autochtones pavent le chemin à des stratégies d’adaptation convenant à leur culture. Cependant, malgré cette capacité de résilience, les changements socioculturels accélérés ont la possibilité de faire obstacle à l’adaptation collective, sans compter que la variation continue des tendances climatiques saisonnières peut rendre les adaptations de subsistance saisonnières au paysage particulièrement vulnérables

The impact of the abuse-deterrent reformulation of extended-release T OxyContin on prescription pain reliever misuse and heroin initiation

The introduction of abuse-deterrent OxyContin in 2010 was intended to reduce its misuse by making it more tamper resistant. However, some studies have suggested that this reformulation might have had unintended consequences, such as increases in heroin-related deaths. We used the 2005–2014 cross-sectional U.S. National Survey on Drug Use and Health to explore the impact of this reformulation on intermediate outcomes that precede heroin-related deaths for individuals with a history of OxyContin misuse. Our study sample consisted of adults who misused any prescription pain reliever prior to the reformulation of OxyContin (n = 81,400). Those who misused OxyContin prior to the reformulation were considered the exposed group and those who misused other prescription pain relievers prior to the reformulation were considered the unexposed group. We employed multivariate logistic regression under a difference-in-differences framework to examine the effect of the re- formulation on five dichotomous outcomes: prescription pain reliever misuse; prescription pain reliever use disorder; heroin use; heroin use disorder; and heroin initiation. We found a net reduction in the odds of pre- scription pain reliever misuse (OR:0.791, p \u3c 0.001) and heroin initiation (OR:0.422, p = 0.011) after the reformulation for the exposed group relative to the unexposed group. We found no statistically significant effects of the reformulation on prescription pain reliever use disorder (OR: 0.934, p = 0.524), heroin use (OR: 1.014p = 0.941), and heroin use disorder (OR: 1.063, p = 0.804). Thus, the reformulation of OxyContin appears to have reduced prescription pain reliever misuse without contributing to relatively greater new heroin use among those who misused OxyContin prior to the reformulation

Data Quality from a Community-Based, Water-Quality Monitoring Project in the Yukon River Basin

This paper examines the quality of data collected by the Indigenous Observation Network, a community-based water-quality project in the Yukon River Basin of Alaska and Canada. The Indigenous Observation Network relies on community technicians to collect surface-water samples from as many as fifty locations to achieve their goals of monitoring the quality of the Yukon River and major tributaries in the basin and maintaining a long-term record of baseline data against which future changes can be measured. This paper addresses concerns about the accuracy, precision, and reliability of data collected by non-professionals. The Indigenous Observation Network data are examined in the context of a standard data life cycle: plan, collect, assure, and describe; as compared to professional scientific activities. Field and laboratory protocols and procedures of the Indigenous Observation Network are compared to those utilized by professional scientists. The data of the Indigenous Observation Network are statistically compared to those collected by professional scientists through a retrospective analysis of a set of water-quality parameters reported by all three projects over a number of years. No statistical differences were found among the three projects for pH, Calcium, Magnesium, or Alkalinity, although statistically significant differences were found for Sodium, Chloride, Sulfate, and Potassium concentrations. The statistical differences found were small and likely not significant in terms of interpreting the data for a variety of uses. Our results suggest that Indigenous Observation Network data are of high quality, and with consistent protocols and participant training, community based monitoring projects can collect data that are accurate, precise, and reliable

PEG−peptide conjugates

The remarkable diversity of the self-assembly behavior of PEG−peptides is reviewed, including self-assemblies formed by PEG−peptides with β-sheet and α-helical (coiled-coil) peptide sequences. The modes of self-assembly in solution and in the solid state are discussed. Additionally, applications in bionanotechnology and synthetic materials science are summarized

Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

BACKGROUND: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care. METHODS: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries. RESULTS: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries. CONCLUSIONS: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. STUDY REGISTRATION: ISRCTN5181700

The impact of surgical delay on resectability of colorectal cancer: An international prospective cohort study

AIM: The SARS-CoV-2 pandemic has provided a unique opportunity to explore the impact of surgical delays on cancer resectability. This study aimed to compare resectability for colorectal cancer patients undergoing delayed versus non-delayed surgery. METHODS: This was an international prospective cohort study of consecutive colorectal cancer patients with a decision for curative surgery (January-April 2020). Surgical delay was defined as an operation taking place more than 4 weeks after treatment decision, in a patient who did not receive neoadjuvant therapy. A subgroup analysis explored the effects of delay in elective patients only. The impact of longer delays was explored in a sensitivity analysis. The primary outcome was complete resection, defined as curative resection with an R0 margin. RESULTS: Overall, 5453 patients from 304 hospitals in 47 countries were included, of whom 6.6% (358/5453) did not receive their planned operation. Of the 4304 operated patients without neoadjuvant therapy, 40.5% (1744/4304) were delayed beyond 4 weeks. Delayed patients were more likely to be older, men, more comorbid, have higher body mass index and have rectal cancer and early stage disease. Delayed patients had higher unadjusted rates of complete resection (93.7% vs. 91.9%, P = 0.032) and lower rates of emergency surgery (4.5% vs. 22.5%, P < 0.001). After adjustment, delay was not associated with a lower rate of complete resection (OR 1.18, 95% CI 0.90-1.55, P = 0.224), which was consistent in elective patients only (OR 0.94, 95% CI 0.69-1.27, P = 0.672). Longer delays were not associated with poorer outcomes. CONCLUSION: One in 15 colorectal cancer patients did not receive their planned operation during the first wave of COVID-19. Surgical delay did not appear to compromise resectability, raising the hypothesis that any reduction in long-term survival attributable to delays is likely to be due to micro-metastatic disease

Outcomes from elective colorectal cancer surgery during the SARS-CoV-2 pandemic

This study aimed to describe the change in surgical practice and the impact of SARS-CoV-2 on mortality after surgical resection of colorectal cancer during the initial phases of the SARS-CoV-2 pandemic

Elective cancer surgery in COVID-19-free surgical pathways during the SARS-CoV-2 pandemic: An international, multicenter, comparative cohort study

PURPOSE As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19–free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. PATIENTS AND METHODS This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19–free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). RESULTS Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19–free surgical pathways. Patients who underwent surgery within COVID-19–free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19–free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score–matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19–free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76). CONCLUSION Within available resources, dedicated COVID-19–free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks