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In this double-blind randomized trial, adults with persistent symptoms following non-stroke brain injury received 40 hyperbaric oxygen (HBO2) sessions or 40 sham sessions over 12 weeks. Three months later, all were offered 40 unblinded HBO2 sessions. Participants completed the Neurobehavioral Symptom Inventory (NSI) at baseline, 13 weeks (after 40 chamber sessions), 6 months, 9 months (after the second chamber series), and 12 months, with prime outcome at 13 weeks, and additional questionnaires, neuropsychological tests, and functional measures. We enrolled 49 participants and analyzed 47 due to drop-out/exclusion (26 males, 40 with traumatic brain injury). Baseline NSI was 35.9 +/- 15.8 in the HBO2 group (n = 26) and 30.7 +/- 16.9 in the sham group (n = 21) (p = 0.28). Mean 13-week change scores were 10.6 +/- 10.6 (HBO2 group) and 3.6 +/- 5.9 (sham group) (mean difference 7.0, 95% CI 1.7-12.3, p = 0.01). The HBO2 group improved on measures of olfaction, anxiety, sleep difficulties, and vestibular complaints. Both groups reported improvements in depression, headaches, PTSD symptoms, physical quality of life, and degree to which difficulties interfere with daily life. With an additional 40 HBO2 sessions, the original HBO2 group reported additional improvements on NSI at 12 months. Only 15 original sham participants completed the second chamber series, limiting conclusions from that data.
Introduction: Diabetic kidney disease (DKD) represents a substantial burden on the Veterans Health Administration (VHA). We calculated the cost of DKD care for US Veterans from the healthcare system perspective. Methods: Veterans with type 2 diabetes (T2D) in 2015-2021 were identified using diagnosis codes, prescription records, and problem lists. We identified prevalent and incident DKD stages based on urine albumin, urine protein, and eGFR, and following the Kidney Disease Improving Global Outcome definitions. Aggregate all-cause monthly healthcare costs per patient for managing each DKD stage (ie, stages 1 through 5) were estimated by summing patient-level VHA costs in incident DKD stages from January 2018 until December 2021. Summary statistics include descriptive median and interquartile ranges of per-patient per-month [PPPM] cost. All costs were inflated to 2022 US dollars (USD) based on the Consumer Price Index of all items for urban consumers. Results and Conclusion: Out of two million US Veterans with T2D, we identified 401,214 DKD patients with 1+ incident stage progression in the follow-up period. Median PPPM all-cause healthcare cost increased exponentially from $748 at Stage 1 to $2,661 at Stage 5 (Figure). Interventions targeting patients with rapid DKD progression could markedly decrease the burden of DKD in US Veterans. Disclosure K.Kim: Research Support; Renalytix, GRAIL (acquired by Illumina in 2021), AstraZeneca. J.L.Crook: None. C.S.Lu: None. R.E.Nelson: None. H.Nyman: None. J.Lafleur: Research Support; Renalytix, Genentech, Inc., Novartis Pharmaceuticals Corporation.
OBJECTIVES:Few surveys have focused on physician moral distress, burnout, and professional fulfilment. We assessed physician wellness and coping during the COVID-19 pandemic. DESIGN:Cross-sectional survey using four validated instruments. SETTING:Sixty-two sites in Canada and the United States. SUBJECTS:Attending physicians (adult, pediatric; intensivist, nonintensivist) who worked in North American ICUs. INTERVENTION:None. MEASUREMENTS AND MAIN RESULTS:We analysed 431 questionnaires (43.3% response rate) from 25 states and eight provinces. Respondents were predominantly male (229 [55.6%]) and in practice for 11.8 ± 9.8 years. Compared with prepandemic, respondents reported significant intrapandemic increases in days worked/mo, ICU bed occupancy, and self-reported moral distress (240 [56.9%]) and burnout (259 [63.8%]). Of the 10 top-ranked items that incited moral distress, most pertained to regulatory/organizational ( n = 6) or local/institutional ( n = 2) issues or both ( n = 2). Average moral distress (95.6 ± 66.9), professional fulfilment (6.5 ± 2.1), and burnout scores (3.6 ± 2.0) were moderate with 227 physicians (54.6%) meeting burnout criteria. A significant dose-response existed between COVID-19 patient volume and moral distress scores. Physicians who worked more days/mo and more scheduled in-house nightshifts, especially combined with more unscheduled in-house nightshifts, experienced significantly more moral distress. One in five physicians used at least one maladaptive coping strategy. We identified four coping profiles (active/social, avoidant, mixed/ambivalent, infrequent) that were associated with significant differences across all wellness measures. CONCLUSIONS:Despite moderate intrapandemic moral distress and burnout, physicians experienced moderate professional fulfilment. However, one in five physicians used at least one maladaptive coping strategy. We highlight potentially modifiable factors at individual, institutional, and regulatory levels to enhance physician wellness.
Rationale: Care of emergency department (ED) patients with pneumonia can be challenging. Clinical decision support may decrease unnecessary variation and improve care. Objectives: To report patient outcomes and processes of care after deployment of electronic pneumonia clinical decision support (ePNa): a comprehensive, open loop, real-time clinical decision support embedded within the electronic health record. Methods: We conducted a pragmatic, stepped-wedge, cluster-controlled trial with deployment at 2-month intervals in 16 community hospitals. ePNa extracts real-time and historical data to guide diagnosis, risk stratification, microbiological studies, site of care, and antibiotic therapy. We included all adult ED patients with pneumonia over the course of 3 years identified by International Classification of Diseases, 10th Revision discharge coding confirmed by chest imaging. Measurements and Main Results: The median age of the 6,848 patients was 67 years (interquartile range, 50-79), and 48% were female; 64.8% were hospital admitted. Unadjusted mortality was 8.6% before and 4.8% after deployment. A mixed effects logistic regression model adjusting for severity of illness with hospital cluster as the random effect showed an adjusted odds ratio of 0.62 (0.49-0.79; P < 0.001) for 30-day all-cause mortality after deployment. Lower mortality was consistent across hospital clusters. ePNa-concordant antibiotic prescribing increased from 83.5% to 90.2% (P < 0.001). The mean time from ED admission to first antibiotic was 159.4 (156.9-161.9) minutes at baseline and 150.9 (144.1-157.8) minutes after deployment (P < 0.001). Outpatient disposition from the ED increased from 29.2% to 46.9%, whereas 7-day secondary hospital admission was unchanged (5.2% vs. 6.1%). ePNa was used by ED clinicians in 67% of eligible patients. Conclusions: ePNa deployment was associated with improved processes of care and lower mortality. Clinical trial registered with www.clinicaltrials.gov (NCT03358342).
