BACKGROUND:Access to schedules, protocols, and learning materials needs to be convenient and fast. Smartphones have become the default pathway for information access. The purpose of this study was to understand the impact of a smartphone application (app) on residency workflow and education. METHODS:After app development, a survey was conducted before and after implementation using Likert scales.Student's t-test was used for analysis. RESULTS:Pre-app, 76 ​% of faculty did not know the resident on call compared to 50 ​% post implementation (p ​< ​0.01). Pre-app, management algorithms required internet search; post-app no searching was required (p ​< ​0.05). Post-app, a printed call schedule became unnecessary and hospital operator calls decreased from daily to occasionally for residents and almost never for faculty (p ​< ​0.01). CONCLUSIONS:A smartphone application has proven to be beneficial for consolidating resources and workflow to improve resident training and patient care.

Recent research suggests that mild traumatic brain injury (TBI) may exert deleterious effects on endogenous pain modulatory function, potentially underlying the elevated risk for persistent headaches following injury. Accumulating research also shows race differences in clinical and experimental pain, with African Americans (AA) generally reporting more severe pain, worse pain modulation, and greater pain sensitivity compared with Caucasians. However, race differences in pain-related outcomes following mild TBI have rarely been studied. The purpose of this study was to explore race differences in endogenous pain modulation, pain sensitivity, headache pain, and psychological factors among AA and Caucasian individuals with mild TBI in the first month following injury compared with healthy controls and across time. Patients with mild TBI were recruited from local emergency department trauma centers. Sixty-three participants with mild TBI (AAs: n = 23, Caucasians: n = 40) enrolled in this study and completed study sessions at 1-2 weeks and 1-month post-injury. Forty-one mild-TBI-free control participants (AAs: n = 11, Caucasians: n = 30), matched on age and sex, completed one study session. Assessments included a Headache Survey, Pain Catastrophizing Scale, Center for Epidemiological Studies-Depression Scale (CES-D), and quantitative sensory testing (QST) to measure endogenous pain modulatory function. QST included conditioned pain modulation (CPM) to measure endogenous pain inhibitory function and temporal summation (TS) of pain and pressure pain thresholds (PPTs) of the head to measure pain sensitization and sensitivity. Two-way analysis of variance (ANOVA) was used to determine whether the outcome measures differed as a function of race, mild TBI, and time. Mediation analysis was used to explore potential mediators for the race differences in headache pain intensity. The results showed that AA participants with mild TBI reported significantly greater headache pain and pain catastrophizing and exhibited higher pain sensitivity and worse pain modulation on QST compared with Caucasian participants with mild TBI. These same race differences were not observed among the healthy TBI-free control sample. The mediation analyses showed complete mediation for the relation between race and headache pain intensity by pain catastrophizing at 1-2 weeks and 1-month post-injury. Overall, the results of this study suggest that AAs compared with Caucasians are characterized by psychological and pain modulatory profiles following mild TBI that could increase the risk for the development of intense and persistent headaches following injury.

Background: Major Trauma Code 1 (TC1) activations require signi ficant resources to provide immediate treatment to potentially unstable, critically ill, patients. The Cribari Matrix Method (CMM) and Need For Trauma Intervention (NFTI) are two ways to determine over and undertriage in trauma. We studied the overtriage rate at a community level 1 trauma center using these two methods to determine the ef ficacy of the triage criteria in TC1 activations. Method: A retrospective review of all patients in the trauma registry of a level 1 American College of Surgeons trauma program from May to October 2021 was performed. Overtriage rates were determined using CMM and NFTI criteria. Results: The overtriage rate of 552 activations using CMM alone was 73%. CMM combined with NFTI resulted in a 56% overtriage rate. Conclusion: The Cribari method can be used to determine the effectiveness of a system's trauma code 1 criteria but cannot delineate which criteria should be reviewed.

Older adults commonly require special care and falling is a major reason for hospital admission. Identifying the cause of falls would help enable precautionary measures to be taken, which may reduce both injury and medical expenses. This study focuses on understanding underlying medical conditions or medicines associated with an increased risk of falls. Two datasets, one with trauma patient details and the other with fall-related admitted patient details, were analyzed to determine whether any relationship exists between falls and any underlying medical conditions and associated medications. Data visualization techniques and machine learning algorithms (e.g., SVC, Logistic Regression, and Naïve Bayes) have been used to study the cause of falls and whether they can be anticipated prior to their occurrence.

BACKGROUND:The American Society for Gastrointestinal Endoscopy and Society of American Gastrointestinal and Endoscopic Surgeons provide guidelines for managing suspected common bile duct (CBD) stones. We sought to evaluate adherence to the guidelines among patients with choledocholithiasis and/or acute biliary pancreatitis (ABP) and to evaluate the ability of these guidelines to predict choledocholithiasis. METHODS:We prospectively identified patients undergoing same-admission cholecystectomy for choledocholithiasis and/or ABP from 2016 to 2019 at 12 United States medical centers. Predictors of suspected CBD stones were very strong (CBD stone on ultrasound; bilirubin >4 mg/dL), strong (CBD > 6 mm; bilirubin ≥1.8 to ≤4 mg/dL), or moderate (abnormal liver function tests other than bilirubin; age >55 years; ABP). Patients were grouped by probability of CBD stones: high (any very strong or both strong predictors), low (no predictors), or intermediate (any other predictor combination). The management of each probability group was compared with the recommended management in the guidelines. RESULTS:The cohort was comprised of 844 patients. High-probability patients had 64.3% (n = 238/370) deviation from guidelines, intermediate-probability patients had 29% (n = 132/455) deviation, and low-probability patients had 78.9% (n = 15/19) deviation. Acute biliary pancreatitis increased the odds of deviation for the high- (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.06-2.8; p = 0.03) and intermediate-probability groups (OR, 1.6; 95% CI, 1.07-2.42; p = 0.02). Age older than 55 years (OR, 2.19; 95% CI, 1.4-3.43; p < 0.001) also increased the odds of deviation for the intermediate group. A CBD greater than 6 mm predicted choledocholithiasis in the high (adjusted OR (aOR), 2.16; 95% CI, 1.17-3.97; p = 0.01) and intermediate group (aOR, 2.78; 95% CI, 1.59-4.86; p < 0.001). Any very strong predictor (aOR, 2.43; 95% CI, 1.76-3.37; p < 0.0001) and both strong predictors predicted choledocholithiasis (aOR, 2; 95% CI, 1.35-2.96; p < 0.001). CONCLUSION:Almost 45% of patients with suspected CBD stones were managed discordantly from the American Society for Gastrointestinal Endoscopy and Society of American Gastrointestinal and Endoscopic Surgeons guidelines. We believe these guidelines warrant revision to better reflect the ability of the clinical variables at predicting choledocholithiasis. LEVEL OF EVIDENCE:Therapeutic/Care Management; Level IV.

When matched for sex and age, patients with CKD or ESRD did not exhibit higher incidence of CVA or cognitive decline. However, depression disproportionately affected these patients.

Ambient humidity demonstrated a robust and resilient effect on kidney function. Higher humidity corresponded to a reduction in estimated GFR across all stages of CKD and within stages. Other climate factors exhibited no effect. A possible mechanism is the decrease in evaporative cooling leading to additional sweat loss, reduced plasma volume, and a lower blood pressure gradient in the glomerulus.

Outcomes from ipsilateral breast tumor recurrence

Background Colonic stenting has emerged as preferred palliative treatment for left sided malignant obstructions. It shortens hospital stays, decreases healthcare cost, reduces permanent stoma rates, and expedites the start of chemotherapy. The role of stenting as a bridge-to-surgery remains unsettled. Data source For this paper the recommendations of the American and European society of gastroenterology and colorectal surgery were reviewed. We will discuss the benefits and risks of stenting in palliative setting and as bridge-to-surgery. Quality of life, hospital stay, and health care cost will also be considered. Conclusion Non-traversable colon masses during endoscopy are considered a risk factor of development of intestinal obstruction but preventive stent placement in patients without obstructive symptoms is not recommended. The risk of technical or clinical failure is significant at 25%. If stent placement allows neoadjuvant chemotherapy, it may increase the rate of R0 resections. Perforations may raise local recurrence and mortality rates.

Introduction: In 2019, the American Society for Gastrointestinal Endoscopy revised their 2010 guidelines for predicting choledocholithiasis (CDL). We sought to compare the predictive ability of the 2 versions and evaluate the relative importance of each clinical predictor. Methods: We performed a post-hoc analysis of prospectively collected patients undergoing same-admission cholecystectomy for CDL and/or acute biliary pancreatitis (ABP) from 2016 to 2019 at 12 US medical centers. Patients were divided by likelihood of CDL (high, intermediate, low) using the 2010 and 2019 criteria. Recursive partitioning was used to model the predicted probability of CDL (pCDL) using the clinical predictors from 2010 (M1) and 2019 (M2). Patients with no clinical predictors served as controls. Results: There were 736 patients meeting inclusion criteria. The pCDL in M2 was greater than M1 for high (0.74 vs 0.68, p < .0001) and intermediate likelihood patients (0.5 vs 0.46, p < .0001) and lower for low-likelihood patients (0.45 vs 0.36, p < .0001). In M1, there was no difference in pCDL between a dilated CBD and bilirubin >4 (0.64 vs 0.67, p = 0.1). Comparing all predictors in both models, sonographic CBD stones had the highest pCDL except for bilirubin >4 + dilated CBD in M2 (0.76 vs 0.74, p = 0.1). Compared with controls, pCDL was significantly higher for all clinical predictors except ABP (M1) and age > 55 years (M1 and M2). Conclusion: The 2019 guidelines are associated with higher pCDL for patients with high and intermediate likelihood of CDL. Removing age as a clinical predictor could simplify risk stratification without compromising guideline accuracy.

Approximately 19% of American adults age ≥ 65 years are taking an antidepressant medication. Prescriptions are more common among adults who do not engage in regular exercise and those who have experienced a fall. A sedentary lifestyle and antidepressant use may compound the risk of falling, but data are limited. PURPOSE: To examine the effect of antidepressant use on fall risk in older adults. METHODS: We analyzed patients from a Level 1 trauma center in an urban-suburban setting. Patients age ≥ 65 years who experienced a fall-related injury constituted the study sample (N = 615). We collected their demographic information, conducted a medical history, documented poor balance, lightheadedness, and cognitive struggles, recorded the use of antidepressants, and tabulated previous fall-related admissions. Holding all demographic and diagnostic variables constant, a logistic regression tested the effect of antidepressant use on the odds that patients had been admitted multiple times in the past for falls. We then tracked patients forward for 8 months, tabulated future falls, and repeated the logistic regression prospectively, holding the same predictors constant. Lastly, we conducted a Poisson regression to measure the effect of antidepressant use on the total number of falls (retrospective and prospective), using the same set of predictors. RESULTS: Subjects were 80.0 ± 9.1 years old; 31.1% were taking an antidepressant medication; the most common class was SSRIs (22.4%). In the retrospective logistic regression (pseudo R2 = 0.170; p < 0.001), the use of antidepressants associated with a 59% increase in the odds of sustaining multiple previous falls (p < 0.001; 95% CI of OR: 1.10 - 2.29). The prospective logistic regression (pseudo R2 = 0.111; p < 0.001) showed antidepressant use to predict a 104% increase in the odds of a future fall (p < 0.001; 95% CI of OR: 1.42 - 2.95). The Poisson regression (p < 0.001) predicted an 18% increase in the total number of falls when taking an antidepressant (p = 0.002; 95% CI of IRR: 1.06 - 1.31). CONCLUSION: The use of antidepressants appears to increase fall risk in this population. Physicians may consider advising at-risk patients to participate in controlled exercise to decrease the need for prescriptions while simultaneously lowering the likelihood of falls.

More than 130 million Americans visit emergency departments each year. Between 1996 and 2009, there was a 13-fold increase in documentation of obesity as the principal diagnosis. Fewer than 25% of these patients meet ACSM recommendations for aerobic and resistance exercise, and no more than a third are counseled on exercise behavior. For exercise counselling to become standard practice, we must improve the nature of reporting. PURPOSE: To examine how obesity is documented in a clinical setting and estimate its effect on patient outcomes. METHODS: We conducted a chart review of two patient samples over a 4-year period (2012-2015). Both samples were drawn from a single institution; 768 were treated at the trauma center (TC) and 2,106 were treated at the emergency department (ED). All patients in both samples were between 15 and 85 years of age and had a Glasgow Coma Scale score ≥ 14. We evaluated obesity reporting and the consequences of obesity on patient outcomes using logistic, linear, and negative binomial regressions as appropriate. RESULTS: In both samples, documenting of obesity increased each year (p < 0.001). In the TC group, 3.3% of patients were documented as obese in 2012, 9.4% in 2013, 30.0% in 2014, and 24.3% in 2015. In the ED sample, 1.1% of patients were documented as obese in 2012, 7.0% in 2013, 29.6% in 2014, and 34.0% in 2015. In 2014 and 2015, when reporting was sufficient, obese patients had lower oximetry (p = 0.020), higher heart rate (p = 0.010), higher systolic (p = 0.006) and diastolic (p = 0.027) blood pressure, more myocardial infarctions (p = 0.014), and higher rates of hypertension (p = 0.007) and diabetes (p < 0.001). Controlling or age, sex, and injury severity, patients categorized as obese cost $31 k more to the patient (p = 0.005) and $16 k more to the hospital (p = 0.002). Holding sex and age constant, the odds of experiencing a myocardial infarction were 3.1-fold higher in obese patients (p = 0.006) and the odds of being diagnosed with diabetes were 3.0-fold higher (p < 0.001). CONCLUSIONS: Obesity is a strong predictor of patient outcomes in both trauma and emergency medicine. These findings delineate the obesity trends in patient samples and emphasize the importance for obesity interventions using information from clinical settings. Physicians are well-positioned to emphasize exercise guidelines to patients.

BACKGROUND:Antimicrobial guidance for common bile duct (CBD) stones is limited. We sought to examine the effect of antibiotic duration on infectious complications in patients with choledocholithiasis and/or gallstone pancreatitis. METHODS:We performed a post hoc analysis of a prospective, observational, multicenter study of patients undergoing same admission cholecystectomy for choledocholithiasis and gallstone pancreatitis between 2016 and 2019. We excluded patients with cholangitis and/or cholecystitis. Patients were divided into groups based on duration of antibiotics: prophylactic (<24 hours) or prolonged (≥24 hours). We analyzed these two groups in the preoperative and postoperative periods. Outcomes included infectious complications, acute kidney injury (AKI), and hospital length of stay (LOS). RESULTS:There were 755 patients in the cohort. Increasing age, CBD diameter, and a preoperative endoscopic retrograde cholangiopancreatography (odds ratio, 1.91; 95% confidence interval, 1.34-2.73; p < 0.001) significantly predicted prolonged preoperative antibiotic use. Increasing age, operative duration, and a postoperative endoscopic retrograde cholangiopancreatography (odds ratio, 4.8; 95% confidence interval, 1.85-13.65; p < 0.001) significantly predicted prolonged postoperative antibiotic use. Rates of infectious complications were similar between groups, but LOS was 2 days longer for patients receiving overall prolonged antibiotics (p < 0.0001). Patients with AKI received two more days of overall antibiotic therapy (p = 0.02) compared with those without AKI. CONCLUSION:Rates of postoperative infectious complications were similar among patients treated with a prolonged or prophylactic course of antibiotics. Prolonged antibiotic use was associated with a longer LOS and AKI. LEVEL OF EVIDENCE:Therapeutic, Level IV.

Abstract. Objective:. The purpose of this study was to determine whether self-reported physical activity (PA) in the first month after mild traumatic brain injury (mTBI) predicts endogenous pain modulatory function and pain catastrophizing at 1 to 2 weeks and 1 month after injury in patients with mTBI. Methods:. Patients with mild traumatic brain injury completed study sessions at 1 to 2 weeks and 1 month after injury. Assessments included a headache survey, Pain Catastrophizing Scale, International Physical Activity Questionnaire-Short Form, and several quantitative sensory tests to measure endogenous pain modulatory function including conditioned pain modulation (CPM), temporal summation, and pressure pain thresholds of the head. Hierarchical linear regressions determined the relationship between the PA variables (predictors) and pain catastrophizing and pain modulation variables (dependent variables) cross-sectionally and longitudinally, while controlling for potential covariates. Results:. In separate hierarchical regression models, moderate PA, walking, and total PA at 1 to 2 weeks after injury predicted pain inhibition on the CPM test at 1 month, after controlling for significant covariates. In addition, a separate regression revealed that minutes sitting at 1 month predicted CPM at 1 month. Regarding predicting pain catastrophizing, the regression results showed that sitting at 1 to 2 weeks after injury significantly predicted pain catastrophizing at 1 month after injury. Conclusion:. Greater self-reported PA, especially moderate PA, 1 to 2 weeks after injury longitudinally predicted greater pain inhibitory capacity on the CPM test at 1 month after injury in patients with mTBI. In addition, greater sedentary behavior was associated with worse pain inhibition on the CPM test and greater pain catastrophizing at 1 month after injury.

Depression affects approximately 1.5% of American adults and incidence increases with age (5% of adults over 60). Incidence of dementia and psychiatric diseases also increase with age. Deeper understanding of contributing factors can aid in the prevention and treatment of these disorders. PURPOSE: To identify cardiovascular abnormalities that may underlie these illnesses. METHODS: 2,306 hospital patients were evaluated for cardiovascular and cognitive health. Demographic information, anthropometric values, clinical tests, and diagnostic history were collected. Independent variables were heart rate, blood pressure, and diagnosis of hypertension. Dependent variables were depression, dementia, cerebrovascular accidents, and psychiatric disorders. Descriptive statistics characterized the sample. Logistic regressions tested the effect of the cardiovascular predictors on cerebral and psychological outcomes. Significance was set at P < 0.05. RESULTS: 23 patients had depression, 115 were diagnosed with dementia, 92 experienced a cerebrovascular accident, and 161 had a psychiatric illness. Patients with hypertension were diagnosed with depression 120% more frequently (P = 0.045); 56% of depressed patients were hypertensive. Among patients with depression, there was a 264% increase in the odds of a dementia diagnosis (P = 0.006). In patients with dementia, systolic blood pressure (SBP) was 13 mmHg (9%) higher (P < 0.001), pulse pressure was 13 mmHg (23%) higher (P < 0.001), and heart rate was 7 bpm (8%) lower (P < 0.001). Patients with hypertension were diagnosed with dementia 379% more frequently than normotensive patients (P < 0.001). A diagnosis of hypertension also corresponded to 436% higher incidence of cerebrovascular accidents (P < 0.001). Controlling for age, there was a 2.2-fold increase in the odds of an adverse event in patients with dementia (P = 0.005). However, patients with psychiatric disorders had SBP that was 5 mmHg (4%) lower (P = 0.018); similarly, pulse pressure was 5 mmHg (7%) lower (P = 0.007). CONCLUSIONS: These findings support the hypothesis that cardiovascular deterioration coincides with increased risk for depression and neurocognitive issues. Aerobic exercise training oriented toward improved cardiovascular health likely reduces adverse events and psychological decline.

Falls are one of the leading causes of death for adults aged 65 and up. Due to the increase of falls in older adults and the severity of the resulting injuries, medical costs spent on treating affected patients are high; therefore, it is imperative to derive models that can predict falls in older adults and identify contributing factors that can be used to determine preventive methods and reduce costs. In this study, a test suite of four supervised machine learning models was created to predict falls using a fall risk dataset consisting of 593 patients and 764 internal and external features. After the training and testing phases were completed, a ten-fold cross-validation was performed to confirm the results which demonstrated accuracies of 80% and above for making predictions using the testing dataset. The results demonstrated that the model with the highest accuracy is the one that uses the support vector machine. It predicted 87% of falls correctly and had an area under the curve of 0.86. Additionally, the most significant feature in the dataset was the total number of medications which was selected along with 29 other features that were primarily prescription medications. Based on these findings, we assert that patients who take prescription medications that may result in cognitive impairment are at high risk for falls.