Opioid-induced respiratory depression (OIRD) remains a critical safety concern, particularly in older adults, yet timely, reliable detection methods are limited. Decline of pupillary unrest in ambient light (PUAL) has demonstrated potential as a marker of opioid effect in young adult subjects. We evaluated whether previously observed PUAL thresholds for high-risk opioid exposure in younger adults remain valid in 40-60-year-old subjects. Ten healthy volunteers 40–60 years of age underwent PUAL measurement at baseline and every 2.5 min during a 10-minute remifentanil infusion (0.2–0.3 µg/kg/min) and 25-minute recovery period. High-risk opioid exposure was defined primarily by modeled remifentanil effect-site concentration (CEREMI) threshold during infusion. Findings were then combined with previously collected data from 20 younger subjects (aged 20–39 years) undergoing an identical infusion protocol. PUAL declined consistently during infusion and increased toward baseline during recovery (p < 0.001). During infusion no significant difference in slope over time or CEREMI was observed between age groups, but during recovery a flatter slope was observed in older subjects (p = 0.016). PUAL reliably distinguished between high-versus low-risk opioid exposure during infusion (AUROC = 0.9833 [95

INTRODUCTION:Pupillary unrest in ambient light (PUAL) describes the fluctuation of pupil diameter observed in normal, awake subjects under typical levels of indoor light. PUAL becomes low to absent in young healthy subjects during opioid intoxication. We sought to determine the age-related distribution of PUAL values in a random sample of ambulatory participants. METHODS:Subjects ≥18 years of age were recruited. All were identified by age range (18-29, 30-49, 50-69, and ≥70), and surveyed for diabetes, beta-blocker use, and prior 24-hour opioid use. Relationship between mean PUAL, age group, comorbidity and opioid use were examined by Kruskal Wallis test, and PUAL and was modeled using stepwise multilevel linear regression, including diabetes, beta blocker use, prior 24-hour opioid use, autonomic dysfunction, and pupil diameter as fixed effects and subject as random effect. RESULTS:Among 150 subjects, 17 reported diabetes, 12 reported beta-blocker use, 14 reported prior 24-hour opioid use, and 120 reported no comorbid conditions. PUAL declined in higher age categories (by 0.0307, P < 0.001), with diabetes (by 0.0481, P = 0.025), and with beta-blocker use (by 0.0616, P = 0.005). Opioid related PUAL decline was observed, but statistical significance varied by model. Among healthy subjects, no PUAL value fell within range indicating high likelihood of opioid toxicity based on previous data from healthy subjects undergoing opioid infusion. CONCLUSION:PUAL declined in higher age groups, diabetes and beta-blocker use, conditions associated with impaired autonomic function, and with opioid use but significance varied depending on the chosen model.

AimTo determine the concurrent validity of the Warner Initial Developmental Evaluation of Adaptive and Functional Skills (WIDEA‐FS), a criterion‐specified questionnaire that assesses a child's adaptive skills in everyday contexts, and the Bayley Infant and Toddler Scales of Development, Third Edition (Bayley‐III).MethodIn a prospective cohort study, 431 WIDEA‐FS and Bayley‐III assessments were completed among 341 children, aged 10 to 36 months corrected age (158 females, 183 males; median [interquartile range] gestational age at birth 32wks [29–38]), monitored in a high‐risk neonatal intensive care unit follow‐up clinic.ResultsWIDEA‐FS scores were significantly associated with Bayley‐III scores in all domains. Lower scores on the WIDEA‐FS were significantly associated with an increased risk of adverse developmental performance on all Bayley‐III scales. The association was strongest for motor and language Bayley‐III scores when tested at <30 months of age, and for cognitive Bayley‐III scores when tested at ≥30 months of age.InterpretationThe WIDEA‐FS has concurrent validity with the Bayley‐III and may be a useful tool in high‐risk follow‐up settings.What this paper adds WIDEA‐FS mobility, communication, and social cognition domains are concurrently valid in infants at high‐risk for neurodevelopmental disability. Bayley‐III motor, language, and cognitive composite scores are concurrently valid in the same group. The WIDEA‐FS mobility and communication domains may be most clinically useful in children <30 months.

Intensive care unit (ICU) admission does not appear to confer a survival benefit - and may in fact harm - patients with equivocal ICU needs. Furthermore, allocating ICU beds to patients without sustained ICU needs may indirectly harm patients most likely to benefit from ICU admission by contributing to protracted ED boarding, during which time it may be difficult to provide optimal care. We developed and implemented a team-based model to improve care for critically ill patients boarding in the ED, while simultaneously identifying patients for entry into a pathway providing a brief period of intensive critical care interventions, re-evaluating the need for ICU admission, and downgrading as appropriate.

OBJECTIVES: The healthcare burden of autoimmune hepatitis (AIH) in the United States has not been characterized. We previously showed that AIH disproportionately affects people of color in a single hospital system. The current study aimed to determine whether the same disparity occurs nationwide. METHODS: We analyzed hospitalizations with a primary discharge diagnosis corresponding to the ICD-9 code for AIH in the National Inpatient Sample between 2008 and 2012. For each racial/ethnic group, we calculated the AIH hospitalization rate per 100,000 population and per 100,000 all-cause hospitalizations, then calculated a risk ratio compared to the reference rate among whites. We used multivariable logistic regression models to assess for racial disparities and to identify predictors of in-hospital mortality during AIH hospitalizations. RESULTS: The national rate of AIH hospitalization was 0.73 hospitalizations per 100,000 population. Blacks and Latinos were hospitalized for AIH at a rate 69% (P<0.001) and 20% higher (P<0.001) than whites, respectively. After controlling for age, gender, payer, residence, zip code income, region, and cirrhosis, black race was a statistically significant predictor for mortality during AIH hospitalizations (odds ratio (OR) 2.81, 95% confidence interval (CI) 1.43, 5.47). CONCLUSIONS: Hospitalizations for AIH disproportionately affect black and Latino Americans. Black race is independently associated with higher odds of death during hospitalizations for AIH. This racial disparity may be related to biological, genetic, environmental, socioeconomic, and healthcare access and quality factors.

A major cause of ED crowding is the inability to move admitted patients from the ED to inpatient beds. When inpatient beds are full, bed capacity can be increased by using alternative care area (ACA) beds. ACA beds were previously designated disaster plan beds and located in inpatient hallways, cardiac catheterization lab, and endoscopy. Our objective was to examine the effect of ACA bed policy on several patient safety and quality outcomes: transfers to Intensive Care Unit (ICU), mortality, 72-hour hospital re-admission, hospital acquired infections (HAI), and falls. Retrospective cohort study of all patients (age >18 years) admitted to a non-ICU bed from the ED at a single, urban, academic hospital with an ED volume of >70,000/year. Exclusion criteria: patients who went from the ED to a procedure or operating room, or had psychiatric admission. In 2015, a new hospital policy allowed use of ACA beds when standard inpatient beds were full for patients who did not have altered level of consciousness or dementia, gastrointestinal bleed, bowel obstruction, oxygen requirement >4 liters, contact or airborne isolations, neutropenic precautions, or presence of nasogastric tube or drain. The ACA beds were used primarily from September to March of each fiscal year. Patient data was extracted from the electronic medical record for 3 study periods: pre-intervention, when ACA beds were rarely used 9/2014-3/2015; transition period, which had increased ACA bed utilization 9/2015-3/2016; and intervention period, which had steady use of ACA beds 9/2016-3/2017. The ACA bed utilization and patient outcomes for the study periods were compared in unadjusted and multivariable analyses. In the latter, we controlled for age, sex, telemetry as inpatient, and ED triage Emergency Service Index level. We also performed an instrumental variable analysis using study period as the instrument and the same covariates. To illustrate the need for adjustment, we reported unadjusted relative risk differences between ACA beds and standard beds. The study included 16,855 patients, of whom 622 patients (3.7%) were admitted to ACA beds. Comparing the 3 study periods, significant differences were: increased number of ACA beds, decreased transfers to ICU, and decreased HAI. Changes in hospital mortality, 72-hour readmission, and falls were not statistically significant. Multivariable regression and the instrumental variable analysis showed no increased risk of major adverse outcomes associated with ACA bed use. In the instrumental variable analysis, statistically significant differences between ACA beds and standard beds were: decreased transfers to ICU -9.7% (95% CI: -18.1, -1.3) and HAI -13.4 (95% CI: -21, -5.8). As expected, unadjusted comparison of ACA beds and standard beds showed large relative risk differences (Table). Admitting ED patients to ACA beds was not associated with increased transfers to ICU, mortality, 72-hour re-admission to the hospital, hospital acquired infections, and falls.Tabled 1Pre-Intervention n= 5505Transition n= 5601Intervention n= 5749P-valueUnadjusted Relative Risk DifferenceAdjusted Relative Risk DifferenceACA Beds14 (0.3%)71 (1.3%)537 (9.3%)<0.001Safety and Quality OutcomesTransfers to ICU337 (6.1%)294 (5.3%)281 (4.9%)0.01-29.5% (95% CI: -52.6, 4.9)-9.7% (95% CI: -18.1, -1.3)Mortality151 (2.7%)151 (2.7%)137 (2.4%)0.43-69.9% (95% CI: -87.5, -27.7)-1.7% (95% CI: -7.6, 4.2)72-hour readmission838 (15.2%)823 (14.7%)828 (14.4%)0.46-20% (95% CI: -35.6, -0.7)-3.7% (95% CI: -17.1, 9.7)Hospital acquired infections252 (4.6%)247 (4.4%)199 (3.5%)0.006-42.7% (95% CI: -65.4, -5)-13.4 (95% CI: -21, -5.8)Falls51 (0.9%)67 (1.2%)47 (0.8%)0.11-35.2% (95% CI: -75.9, 74.3)-0.6% (95% CI: -4.4, 3.1) Open table in a new tab

This study examined the impact of case management on hospital service use, hospital costs, homelessness, substance abuse, and psychosocial problems in frequent users of a public urban emergency department (ED). Subjects were 53 patients who used the ED five times or more in 12 months. Utilization, cost, and psychosocial variables were compared 12 months before and after the intervention. The median number of ED visits decreased from 15 to 9 (P <.01), median ED costs decreased from $4,124 to $2,195 (P < .01) and median medical inpatient costs decreased from $8,330 to $2,786 (P < .01). Homelessness decreased by 257% (P < .01), alcohol use by −22% (P = .05) and drug use by −26% (P < .05). Linkage to primary care increased 74% (P < .01). Fifty-four percent of medically indigent subjects obtained Medicaid (P .01). There was a net cost savings, with each dollar invested in the program yielding a $1.44 reduction in hospital costs. Thus, case management appears to be a cost-effective means of decreasing acute hospital service use and psychosocial problems among frequent ED users. (Am J Emerg Med 2000;18:603–608.

Immediate aggressive fluid resuscitation of a child with life-threatening hemorrhagic shock provides the difference between life and death. Obtaining venous access in the hypovolemic child sometimes is difficult and time consuming. In order to evaluate the benefit of prehospital administration of intraosseous fluids into the tibial bone marrow as a method of gaining quick access to the systemic circulation and in resuscitating victims from severe hypovolemic shock, 13 puppies weighing 4.6 to 10 kg were subjected to progressive, controlled exsanguination until their mean arterial pressure (MAP) was 20% or less of their baseline MAP for 5 minutes (maxishock). Then an 18-gauge intraosseous needle was inserted into the tibial bone marrow and lactated Ringer's solution was infused at 300 mm Hg of pressure until a volume three times the blood loss had been administered. The MAP, central venous pressure, arterial blood gases, hematocrit, serum lactate, and urine output were recorded at 10, 20, 30, 45, 60, 90, and 120 minutes after the onset of maxishock. At the end of the experiment the left lung of each animal was sent to the pathology department to investigate the possibility of bone marrow emboli. The results were compared with a group of control dogs with maxishock and no treatment, and a group of dogs with maxishock treated with a canine military antischock trousers inflated to 50 to 55 mm Hg and no fluids. The average needle insertion time was 16 seconds; the rate of infusion of fluids varied from a maximum of 25.7 mL/min to a minimum of 4.5 mL/min, with a mean of 10.6 mL/min. The overall survival, recovery of MAP, urine output, and lactic acid clearance were significantly better in the group of dogs treated with intraosseous fluids when compared with the other two groups. We conclude that the emergency administration of intraosseous fluids in both safe and efficacious in the initial resuscitation of hypovolemic shock when the intravenous route in the field is unavailable.