Demographics and Outcomes of Pulmonary Hypertension Patients in United States Emergency Departments

Introduction: Pulmonary hypertension (PH) is a common, yet under-diagnosed, contributor to morbidity and mortality. Our objective was to characterize the prevalence of PH among adult patients presenting to United States (US) emergency departments (ED) and to identify demographic patterns and outcomes of PH patients in the ED.Methods: We analyzed the Nationwide Emergency Department Sample (NEDS) database, with a focus on ED patients aged 18 years and older, with any International Classification of Diseases, Clinical Modification (ICD)-9-CM or ICD-10-CM diagnosis code for PH from 2011 to 2015. The primary outcome was inpatient, all-cause mortality. The secondary outcomes were hospital admission rates and hospital length of stay (LOS).Results: From 2011 to 2015, in a sample of 121,503,743 ED visits, representing a weighted estimate of 545,500,486 US ED visits, patients with a diagnosis of PH accounted for 0.78% (95% confidence interval [CI], 0.75- 0.80%) of all US ED visits. Of the PH visits, 86.9% were admitted to the hospital, compared to 16.3% for all other ED visits (P <0.001). Likewise, hospital LOS and hospital-based mortality were higher in the PH group than for other ED patients (e.g., inpatient mortality 4.5% vs 2.6%, P < 0.001) with an adjusted odds ratio (aOR) of 1.34 (95% CI, 1.31–1.37). Age had the strongest association with mortality, with an aOR of 10.6 for PH patients over 80 years (95% CI, 10.06–11.22), compared to a reference of ages 18 to 30 years.Conclusion: In this nationally representative sample, presentations by patients with PH were relatively common, accounting for nearly 0.8% of US ED visits. Patients with PH were significantly more likely to be admitted to the hospital than all other patients, had longer hospital LOS, and increased risk of inpatient mortality

La innovación de tipo organizacional en las Empresas manufactureras de Cartagena de Indias

Este trabajo presenta un análisis de las innovaciones de tipo organizacional en lasempresas. La importancia del trabajo radica en la necesidad de estudiar un fenómenomoderno e importante en el momento para las empresas como es la innovación de tipoorganizacional. Lo que contribuye a conocer ¿el cómo? y ¿por qué? de este fenómenoorganizacional aportando nuevos elementos para el estudio de la innovación en el ámbitode las organizaciones. La metodología utilizada fue la de estudio de casos explicativos.Los resultados de este estudio muestran que las empresas del sector de petroquímicoplásticoaunque no poseen un modelo de gestión de innovación su sistema de calidadles ha permitido desarrollar su capacidad de innovación

What is a Freestanding Emergency Department? Definitions Differ Across Major United States Data Sources

Introduction: Despite the growing number of freestanding emergency departments (FSED) in the United States (US), FSED definitions differ across major US data sources of healthcare facilities and use. We compare these sources and propose a universal definition of FSED (and its two major types) to improve communications regarding these facilities and their patients.Methods: We collected definitions of FSEDs from 11 national data sources using their websites, email, and telephone communications. For each source, we asked how they define FSEDs, whether being open 24/7 is a requirement to be called an ED, and whether they maintain a dataset of FSEDs.Results: Definitions varied across the data sources. All sources recognize FSEDs in their definitions, regardless of type; only one (the National Health Intervew Survey) does not differentiate them from other EDs. Five of the 11 sources (45%) omit autonomous FSEDs from their definitions and do not separately identify satellite FSEDs from their affiliated hospitals. One source does separately identify satellite FSEDs from their affiliated hospitals, but also omits autonomous FSEDs. Furthermore, three of the 11 sources (27%) do not require being open 24/7, while all others (73%) employ this criterion. Six of the 11 (55%) maintain datasets of FSEDs using their definition.Conclusion: As FSEDs continue to change the landscape of emergency care, it is important that they also be represented in national ED data sources. The current differences in the definition of an FSED make it difficult to provide accurate and longitudinal analysis for these facilities and patients who receive services at these facilities. We propose a universal definition of FSEDs as described by both the American College of Emergency Physicians and the National Emergency Department Inventory. Implementing a standard definition would facilitate a more accurate representation of FSEDs in national data sources and enhance ongoing efforts to improve the quality of emergency care delivered in FSEDs

Latitude, Sunlight, Vitamin D, and Childhood Food Allergy/Anaphylaxis

Vitamin D is widely known for its role in bone metabolism, but this sterol hormone also has important immunomodulatory properties. Vitamin D is produced by the conversion of D3 in the skin following UVB exposure, or after ingestion of D2 or D3. At the extremes of latitude, there is insufficient UVB intensity in the autumn and winter months for adequate synthesis of vitamin D to occur. Growing evidence implicates vitamin D deficiency in early life in the pathogenesis of nonskeletal disorders (e. g., type 1 diabetes and multiple sclerosis) and, more recently, atopic disorders. Several studies have reported higher rates of food allergy/anaphylaxis or proxy measures at higher absolute latitudes. Although causality remains to be determined, these studies suggest a possible role for sunlight and/or vitamin D in the pathogenesis of food allergy/anaphylaxis

La innovación de tipo organizacional en las empresas manufactureras de Cartagena de Indias

Este trabajo presenta un análisis de las innovaciones de tipo organizacional en las empresas. La importancia del trabajo radica en la necesidad de estudiar un fenómeno moderno e importante en el momento para las empresas como es la innovación de tipo organizacional. Lo que contribuye a conocer ¿el cómo? y ¿por qué? de este fenómeno organizacional aportando nuevos elementos para el estudio de la innovación en el ámbito de las organizaciones. La metodología utilizada fue la de estudio de casos explicativos. Los resultados de este estudio muestran que las empresas del sector de petroquímicoplásticoaunque no poseen un modelo de gestión de innovación su sistema de calidad les ha permitido desarrollar su capacidad de innovaciónEstructura organizacional; diseño organizacional; innovación organizacional, innovación no tecnológica

Near-universal hospitalization of US emergency department patients with cancer and febrile neutropenia

IMPORTANCE: Febrile neutropenia (FN) is the most common oncologic emergency and is among the most deadly. Guidelines recommend risk stratification and outpatient management of both pediatric and adult FN patients deemed to be at low risk of complications or mortality, but our prior single-center research demonstrated that the vast majority (95%) are hospitalized. OBJECTIVE: From a nationwide perspective, to determine the proportion of cancer patients of all ages hospitalized after an emergency department (ED) visit for FN, and to analyze variability in hospitalization rates. Our a priori hypothesis was that >90% of US cancer-associated ED FN visits would end in hospitalization. DESIGN: Analysis of data from the Nationwide Emergency Department Sample, 2006-2014. SETTING: Stratified probability sample of all US ED visits. PARTICIPANTS: Inclusion criteria were: (1) Clinical Classification Software code indicating cancer, (2) diagnostic code indicating fever, and (3) diagnostic code indicating neutropenia. We excluded visits ending in transfer. EXPOSURE: The hospital at which the visit took place. MAIN OUTCOMES AND MEASURES: Our main outcome is the proportion of ED FN visits ending in hospitalization, with an a priori hypothesis of >90%. Our secondary outcomes are: (a) hospitalization rates among subsets, and (b) proportion of variability in the hospitalization rate attributable to which hospital the patient visited, as measured by the intra-class correlation coefficient (ICC). RESULTS: Of 348,868 visits selected to be representative of all US ED visits, 94% ended in hospitalization (95% Confidence Interval [CI] 93-94%). Each additional decade of age conferred 1.23x increased odds of hospitalization. Those with private (92%), self-pay (92%), and other (93%) insurance were less likely to be hospitalized than those with public insurance (95%, odds ratios [OR] 0.74-0.76). Hospitalization was least likely at non-metropolitan hospitals (84%, OR 0.15 relative to metropolitan teaching hospitals), and was also less likely at metropolitan non-teaching hospitals (94%, OR 0.64 relative to metropolitan teaching hospitals). The ICC adjusted for hospital random effects and patient and hospital characteristics was 26% (95%CI 23-29%), indicating that 26% of the variability in hospitalization rate was attributable to which hospital the patient visited. CONCLUSIONS AND RELEVANCE: Nearly all cancer-associated ED FN visits in the US end in hospitalization. Inter-hospital variation in hospitalization practices explains 26% of the limited variability in hospitalization decisions. Simple, objective tools are needed to improve risk stratification for ED FN patients