Effect of standing orders on paramedic scene time for trauma patients.

STUDY OBJECTIVE: To determine if a protocol change that allowed paramedics to perform certain procedures before base station contact (standing orders) would decrease scene time in trauma patients. DESIGN: Retrospective review of case series. SETTING: A single-tiered, all advanced life support emergency medical services system. INTERVENTION: Implementation with standing orders for invasive procedures. TYPE OF PARTICIPANTS: All physiologically unstable trauma patients transported to a Level I trauma center by ambulance. MEASUREMENTS AND MAIN RESULTS: One hundred ninety-seven patients met the inclusion criteria--87 before and 110 after the initiation of standing orders. Mean scene times for the control group (15.3 +/- 8.4 minutes) and for the standing orders group (15.1 +/- 7.6 minutes) were similar (P = .18). The power of the study to detect a two-minute difference in scene time was .92. Scene time was not influenced by mechanism of injury, and the number of procedures performed on patients was similar between the two groups. CONCLUSION: Standing orders did not decrease scene time in physiologically unstable trauma patients. Further study is necessary to delineate the factors that actually contribute to on-scene time and the factors that are important in determining whether standing orders or on-line medical contact should be used.     

Effect of inhalation times on exhaled NO

Recent work suggests that exhaled nitric oxide (eNO) can be divided into airway and alveolar components, using varying expiratory flow rates. It is known that higher values of eNO are found with lower expiratory flow rates, thought to be due to prolonged contact of the expirate with the bronchial epithelium. However, whether a prolonged inspiratory time could contaminate the alveolar signal with bronchial derived NO, by the same mechanism, is unknown. We aimed to study the effect, including repeatability, of inhalation time on eNO measurements performed at three different flow rates. We measured eNO in 21 children with asthma of different severity (no steroids, n = 2; inhaled corticosteroid (IC) dose up to 200 mcg/day, n = 3; IC up to 500 mcg/day, n = 3; IC >500 mcg/day, n = 6; IC >500 mcg/day and oral steroid, n = 7) and 24 normal adult controls at 50, 100, and 200 ml/s expiratory flow rate. The effect of either a rapid or a slow inhalation on measured eNO was studied at each flow rate. Furthermore, 12 asthmatic children and 12 adults had repeated measurements 1 hr apart. Repeatability within 1 day was assessed by calculating the single-determination standard deviation (SD) and 95% range. Our results showed that repeatability was equally good for the three expiratory flow rates, and inhalation time had no influence on the results. The inhalation maneuver does not influence eNO measurements using the variable expiratory flow technique.     

Effect of emergency physician burnout on patient waiting times

Burnout is common in emergency physicians. This syndrome may negatively affect patient care and alter work productivity. We seek to assess whether burnout of emergency physicians impacts waiting times in the emergency department. Prospective study in an academic ED. All patients who visited the main ED for a 4-month period in 2016 were included. Target waiting times are assigned by triage nurse to patients on arrival depending on their severity. The primary endpoint was an exceeded target waiting time for ED patients. All emergency physicians were surveyed by a psychologist to assess their level of burnout using the Maslach Burnout Inventory. We defined the level of burnout of the day in the ED as the mean burnout level of the physicians working that day (8:30 to the 8:30 the next day). A logistic regression model was performed to assess whether burnout level of the day was independently associated with prolonged waiting times, along with previously reported predictors. Target waiting time was exceeded in 7524 patients (59%). Twenty-six emergency physicians were surveyed. Median burnout score was 35 [Interquartile (24–49)]. A burnout level of the day higher than 35 was independently associated with an exceeded target waiting time (adjusted odds ratio 1.54, 95% confidence interval 1.39–1.70), together with previously reported predictors (i.e., day of the week, time of the day, trauma, age and daily census). Burnout of emergency physicians was independently associated with a prolonged waiting time for patients visiting the ED.     

Magnetoelastic standing waves induced in UO2 by microsecond magnetic field pulses

Magnetoelastic dilatometry of the piezomagnetic antiferromagnet UO₂ was performed via the fiber Bragg grating method in magnetic fields up to 150 T generated by a single-turn coil setup. We show that in microsecond timescales, pulsed-magnetic fields excite mechanical resonances at temperatures ranging from 10 to 300 K, in the paramagnetic as well as within the robust antiferromagnetic state of the material. These resonances, which are barely attenuated within the 100-µs observation window, are attributed to the strong magnetoelastic coupling in UO₂ combined with the high crystalline quality of the single crystal samples. They compare well with mechanical resonances obtained by a resonant ultrasound technique and superimpose on the known nonmonotonic magnetostriction background. A clear phase shift of π in the lattice oscillations is observed in the antiferromagnetic state when the magnetic field overcomes the piezomagnetic switch field Hc=−18 T. We present a theoretical argument that explains this unexpected behavior as a result of the reversal of the antiferromagnetic order parameter at Hc.

The antiferromagnetic (AFM) insulator uranium dioxide UO₂ has been the subject of extensive research during the last decades predominantly due to its widespread use as nuclear fuel in commercial power reactors (1). Besides efforts to understand the unusually poor thermal conductivity of UO₂, which impacts its performance as nuclear fuel (2), a recent magnetostriction study in pulsed magnetic fields up to 92 T uncovered linear magnetostriction in UO₂ (3), a hallmark of piezomagnetism.Piezomagnetism is characterized by the induction of a magnetic polarization by application of mechanical strain, which, in the case of UO₂, is enabled by broken time-reversal symmetry in the 3-k AFM structure that emerges below TN=30.8 K (4–7) and is accompanied by a Jahn–Teller distortion of the oxygen cage (8–11). This also leads to a complex hysteretic magnetoelastic memory behavior where magnetic domain switching occurs at fields around ±18 T at T=2.5 K. Interestingly, the very large applied magnetic fields proved unable to suppress the AFM state that sets in at TN (3). These earlier results provide direct evidence for the unusually high energy scale of spin-lattice interactions and call for further studies in higher magnetic fields.Here we present axial magnetostriction data obtained in a UO₂ single crystal in magnetic fields to 150 T. These ultrahigh fields were produced by single-turn coil pulsed resistive magnets (12, 13) and applied along the [111] crystallographic axis at various temperatures between 10 K and room temperature. At all temperatures, we observe a dominant negative magnetostriction proportional to H² accompanied by unexpectedly strong oscillations that establish a mechanical resonance in the sample virtually instantly upon delivery of the 102 T/μs pulsed magnetic field rate of change. The oscillations are long-lasting due to very low losses and match mechanical resonances obtained with a resonant ultrasound spectroscopy (RUS) technique (14). Mechanical resonances were suggested to explain anomalies in magnetostriction measurements during single-turn pulses (15, 16); however, their potential to elucidate magnetic dynamics was not explored so far. When the sample is cooled below room temperature, the frequencies soften, consistent with observations in studies of the UO₂ elastic constant c₄₄ as a function of temperature (17, 18).In the AFM state, i.e., T<30.8 K, the characteristic magnetic field sign switch in our single-turn coil magnet (a feature of destructive magnets) results in applied field values in excess of the UO₂ AFM domain switch field of Hc≈−18 T. This field sign switch exposes yet another unexpected result, namely, a π (180°) phase shift in the magnetoelastic oscillations. We use a driven harmonic oscillator and an analytical model to shed light on the origin of the observed phase shift.     

Effect of experimentally induced knee pain on standing balance in healthy older individuals

OBJECTIVE: Standing balance is impaired in older individuals with knee pain. The extent to which this impairment is due to the effects of pain itself or other pathophysiological aspects related to the underlying musculoskeletal condition causing the pain is unclear. To isolate the influence of pain, this study evaluated the effect of experimentally induced knee pain on standing balance in healthy older individuals. METHODS: We used a repeated-measures, within-subject design involving 12 healthy individuals aged 50-60 yr and with no history of knee pathology. Balance was tested during two randomly allocated experimental conditions: (i) control and (ii) knee pain induced by injection of hypertonic saline into the infrapatellar fat pad. Balance was measured using a computerized force platform under static and dynamic conditions as well as via the functional step test. RESULTS: Standing balance was not significantly altered by experimentally induced acute knee pain, nor was there any relationship between the severity of reported pain and balance scores. CONCLUSIONS: Impairments in balance associated with knee conditions such as osteoarthritis may be due to factors other than the sensation of pain. Thus, strategies designed to reduce pain in treatment of knee pathology may not necessarily lead to improvements in balance. Further research is required to determine the exact causes of balance impairment in individuals with knee joint pain and pathology.     

Effect of standing versus sitting position on spirometric indices in healthy subjects.

This study examined the effect of the standing versus the sitting position on spirometric indices in 94 healthy non-obese adult subjects (41 men and 53 women) with the order of testing randomised. On average all the spirometric indices examined, except the peak expiratory flow rate, were higher in the standing compared to the sitting position although the change was only significant at the 5% level for FEV1 in women. The fall in FEV1 with the change in position was statistically related to the ponderal index but not to age, height or the initial lung function level. A uniform posture for spirometry is recommended in epidemiological studies examining longitudinal trends in lung function, as well as in cross-sectional aetiological studies examining, for instance, the effects of environmental and/or occupational exposures. A uniform posture is also recommended for clinical studies which involve repeated measurements over time, for instance to measure the effect of treatment or the natural history of airways disease.     

Effect of standing on ventricular parasystole: shortening of the parasystolic cycle length.

OBJECTIVE: To investigate the effect of standing on the parasystolic cycle length in cases of "true" ventricular parasystole. METHODS: Parasystolic cycle length and sinus cycle length were measured during lying and standing in eight men with true ventricular parasystole. These cycle lengths were also measured after exercise in the lying position. RESULTS: In all cases, parasystolic cycle length and sinus cycle length both shortened on standing, by a mean of 6.4% and 17.8%, respectively, compared to lying. In all cases, the rate of shortening of the parasystolic cycle length was less than that of the sinus cycle length. Parasystolic cycle length was prolonged after exercise, in contrast to a shortening of the sinus cycle length. CONCLUSIONS: Influences on the parasystolic cycle length are not always in the same direction as on the sinus cycle length. This suggests that the effect of autonomic changes on parasystolic rhythm is not always parallel to that on sinus rhythm.     

Effect of do-not-resuscitate orders on hospitalization of nursing home residents evaluated for lower respiratory infections

OBJECTIVES: To determine resident and facility characteristics associated with do-not-resuscitate (DNR) orders and to test the effect of DNR orders on hospitalization of acutely ill nursing home (NH) residents with lower respiratory tract infections (LRIs). DESIGN: Prospective cohort. SETTING: Thirty-six NHs (almost 4,000 residents) in central and eastern Missouri in the Missouri Lower Respiratory Infection study. PARTICIPANTS: NH residents with a LRI (n=1031). MEASUREMENTS: Data were obtained from new Minimum Data Set evaluations, resident examination, and chart review. Associations between resident, physician, and facility characteristics and the presence of a DNR order and hospitalization within 30 days from evaluation for an LRI were analyzed. RESULTS: Sixty percent of subjects had a DNR order, and 2% had a do-not-hospitalize order. Resident characteristics associated with a DNR order included older age, white race, having a surrogate decision-maker, NH residence for longer than 3 years, and more-impaired cognition. Residents with DNR orders were more likely to live in facilities with more licensed beds, a lower proportion of Medicaid recipients, and a higher prevalence of influenza vaccination. After controlling for potential confounders, residents with a DNR order before the acute illness episode were significantly less likely to be hospitalized (adjusted odds ratio=0.69, 95% confidence interval=0.49-0.97). CONCLUSION: DNR orders independently reduce the risk of hospitalization for LRI and may function as a marker for undocumented care limitations or as a mandate to limit care (unrelated to resuscitation) in NH residents with LRI.     

替米沙坦不同服药时间对非杓型伴清晨高血压患者疗效的对比研究

目的探讨替米沙坦不同服药时间对非杓型伴清晨高血压患者24h动态血压监测各参数及血管内皮功能的影响。方法选择2014年9月~2015年12月贵州医科大学附属医院心内科就诊的原发性轻中度高血压患者80例,随机分为清晨服药组40例(07:00~09:00口服替米沙坦80 mg,1次/d)和夜晚服药组40例(19:00~21:00口服替米沙坦80mg,1次/晚),疗程12周。比较2组治疗后动态血压监测参数、血压模式、血管性血友病因子(von Willebrand factor,vWF)及高敏C反应蛋白(hypersensitive C-reactive protein,hs-CRP)水平的变化。结果与清晨服药组比较,夜晚服药组治疗后夜间平均收缩压、夜间平均舒张压、清晨平均收缩压、清晨平均舒张压水平明显降低,差异有统计学意义(P0.05)。与清晨服药组比较,夜晚服药组治疗后vWF和hs-CRP水平明显降低[(148.3±11.4)%vs(162.4±12.1)%,(2.9±0.5)mg/L vs(3.6±0.6)mg/L,P0.05]。结论夜晚服用替米沙可降低非杓型伴清晨高血压患者的夜间及清晨血压水平、优化血压模式,并降低vWF、hs-CRP水平,而改善血管内皮功能。     

Effect of elapsed time after standing up on orthostatic blood pressure change in the elderly

The effect of time elapsed after standing on the orthostatic change in blood pressure was investigated. The study subjects were recruited from 237 community-dwelling elderly residents free from any history of cardiovascular disease and not on medication. Basal blood pressure was determined by averaging two determinations of supine blood pressure measured with an automatic oscillometric blood pressure recorder after resting for more than 10 minutes. Orthostatic change in systolic blood pressure (SBP) was determined as more than a 10% increase or decrease in SBP after standing. In the total population, maximum change in SBP was observed at 1 minute after standing-up. However, 8.4% and 7.2% of subjects showed abnormal increase or decrease in SBP only after 3 minutes. These results suggests that orthostatic dysregulation of blood pressure could be evaluated by measuring at 1 minute after standing up. However, if abnormal variation of blood pressure was not observed at 1 minute after standing up, repeated measurement at 3 minutes would be necessary.     

The effect of do-not-resuscitate orders on physician decision-making

The effect of do-not-resuscitate (DNR) orders on physicians' decisions to provide life-prolonging treatments other than cardiopulmonary resuscitation (CPR) for patients near the end of life was explored using a cross-sectional mailed survey. Each survey presented three patient scenarios followed by 10 treatment decisions. Participants were residents and attending physicians who were randomly assigned surveys in which all patient scenarios included or did not include a DNR order. Response to three case scenarios when a DNR order was present or absent were measured. Response from 241 of 463 physicians (52%) was received. Physicians agreed or strongly agreed to initiate fewer interventions when a DNR order was present versus absent (4.2 vs 5.0 (P =.008) in the first scenario; 6.5 vs 7.1 (P =.004) in the second scenario; and 5.7 vs 6.2 (P =.037) in the third scenario). In all three scenarios, patients with DNR orders were significantly less likely to be transferred to an intensive care unit, to be intubated, or to receive CPR. In some scenarios, the presence of a DNR order was associated with a decreased willingness to draw blood cultures (91% vs 98%, P =.038), central line placement (68% vs 80%, P =.030), or blood transfusion (75% vs 87%, P =.015). The presence of a DNR order may affect physicians' willingness to order a variety of treatments not related to CPR. Patients with DNR orders may choose to forgo other life-prolonging treatments, but physicians should elicit additional information about patients' treatment goals to inform these decisions.     

Antimicrobials in acute exacerbations of chronic obstructive pulmonary disease - An analysis of the time to next exacerbation before and after the implementation of standing orders

OBJECTIVE:

To compare the mean time to next exacerbation in patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) before and after the implementation of standing orders.

SETTING:

Tertiary care hospital, Halifax, Nova Scotia, Canada.

POPULATION STUDIED:

The records of 150 patients were analyzed, 76 were in the preimplementation group, 74 in the postimplementation group.

INTERVENTION:

The management and outcomes of patients admitted with an acute exacerbation of COPD before and after the implementation of standing orders were compared.

DESIGN:

A retrospective chart review.

MAIN RESULTS:

There was no difference in the mean time to next exacerbation between treatment groups (preimplementation group: 310 days, postimplementation group: 289 days, P=0.53). Antibiotics were used in 90% of the cases (preimplementation group: 87%, postimplementation group: 93%). The postimplementation group had a 20% increase in the use of first-line agents over the preimplementation group. Overall, first-line agents represented only 37% of the antibiotic courses.

CONCLUSIONS:

The implementation of standing orders encouraged the use of first-line agents but did not influence subsequent symptom resolution, length of hospital stay, or the infection-free interval in patients with acute exacerbations of COPD.Key Words: Antibiotics, Chronic obstructive pulmonary disease, ExacerbationIn Canada, chronic obstructive pulmonary disease (COPD) is a major health issue affecting over 750,000 people and the fourth ranked cause of mortality (1,2). Worldwide, it is the second most common chronic noncommunicable disease and the only leading cause of death that is increasing in prevalence (1,3,(4). The inpatient mortality associated with COPD exacerbations ranges from 3% to 4% (5). Each year, over 52,000 hospital admissions and 16,000 deaths in Canada are attributed to COPD (1,6). At our institution, Queen Elizabeth II Health Sciences Centre, COPD exacerbations are the third leading cause for admissions to the internal medicine service (preceded by pneumonia and congestive heart failure) (7).In patients with COPD, acute infectious exacerbations are the most common precipitating factor leading to hospitalization and the most common cause of death (8-10). Up to 80% of acute exacerbations of COPD are due to respiratory infections, with 50% to 70% of these caused by bacteria and only 10% to 30% caused by viruses (11-13). In September 2000, standing orders for patients with a COPD exacerbation were implemented at our institution (Figures ​(Figures11 and ​and2),2), with the rationale that prompt institution of optimal care, including controlled oxygenation and maximum bronchodilation, anti-inflammatory, and antibiotic therapy, would improve outcomes. The antibiotic choice included as first-line agents were trimethoprim/sulfamethoxazole (TMP/SMX) and doxycycline hyclate. Second-line agents were azithromycin dihydrate, amoxicillin trihydrate/clavulanate pottasium, cefuroxime sodium, and ciprofloxacin. It was our intent to assess the impact of these orders on clinical outcome (time to next exacerbation, clinical symptomatology), antimicrobial outcome (culture eradication), and resource utilization (antimicrobial use) via a quality assurance retrospective chart review.Open in a separate windowFigure 1Physician standing orders for acute exacerbations of chronic obstructive pulmonary disease (COPD) implemented at the Queen Elizabeth II Health Sciences Centre in September 2000-front page, emphasizing use of first-line antibiotics. ABG Arterial blood gas; ac Before meals; BID Twice a day; BP Blood pressure; C&S Culture and sensitivity; CAP Community-acquired pneumonia; CrCl Creatinine clearance; Fi0₂ Fraction of inspired oxygen; Ht Height; HR Heart rate; IV Intravenous; MDI Metered dose inhaler; PRN As requried; RMO Requisition made out; RR Rate of respiration; Wt WeightOpen in a separate windowFigure 2Physician standing orders for acute exacerbations of chronic obstructive pulmonary disease (COPD) implemented at the Queen Elizabeth II Health Sciences Centre in September 2000-back page, with second line antibiotic options. CrCl Creatinine clearance; DS Double Strength; HCNS Home care Nova Scotia; IBW Ideal body weight; po By mouth; Scr Serum creatinine; TMP Sulfa Trimethoprim/sulfamethoxazole     

General anesthetic versus light sedation: Effect on pediatric endoscopy wait times

BACKGROUND:

Wait times are an important measure of health care system effectiveness. There are no studies describing wait times in pediatric gastroenterology for either outpatient visits or endoscopy. Pediatric endoscopy is performed under light sedation or general anesthesia. The latter is hypothesized to be associated with a longer wait time due to practical limits on access to anesthesia in the Canadian health care system.

OBJECTIVE:

To identify wait time differences according to sedation type and measure adverse clinical outcomes that may arise from increased wait time to endoscopy in pediatric patients.

METHODS:

The present study was a retrospective review of medical charts of all patients <18 years of age who had been assessed in the pediatric gastroenterology clinic and were scheduled for an elective outpatient endoscopic procedure at McMaster Children’s Hospital (Hamilton, Ontario) between January 2006 and December 2007. The primary outcome measure was time between clinic visit and date of endoscopy. Secondary outcome measures included other defined waiting periods and complications while waiting, such as emergency room visits and hospital admissions.

RESULTS:

The median wait time to procedure was 64 days for general anesthesia patients and 22 days for patients who underwent light sedation (P<0.0001). There was no significant difference between the two groups with regard to the number of emergency room visits or hospital admissions, both pre- and postendoscopy.

CONCLUSIONS:

Due to the lack of pediatric anesthetic resources, patients who were administered general anesthesia experienced a longer wait time for endoscopy compared with patients who underwent light sedation. This did not result in adverse clinical outcomes in this population.     

Antimicrobials in acute exacerbations of chronic obstructive pulmonary disease - An analysis of the time to next exacerbation before and after the implementation of standing orders.

OBJECTIVE: To compare the mean time to next exacerbation in patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) before and after the implementation of standing orders. SETTING: Tertiary care hospital, Halifax, Nova Scotia, Canada. POPULATION STUDIED: The records of 150 patients were analyzed, 76 were in the preimplementation group, 74 in the postimplementation group. INTERVENTION: The management and outcomes of patients admitted with an acute exacerbation of COPD before and after the implementation of standing orders were compared. DESIGN: A retrospective chart review. MAIN RESULTS: THERE WAS NO DIFFERENCE IN THE MEAN TIME TO NEXT EXACERBATION BETWEEN TREATMENT GROUPS (PREIMPLEMENTATION GROUP: 310 days, postimplementation group: 289 days, P=0.53). Antibiotics were used in 90% of the cases (preimplementation group: 87%, postimplementation group: 93%). The postimplementation group had a 20% increase in the use of first-line agents over the preimplementation group. Overall, first-line agents represented only 37% of the antibiotic courses. CONCLUSIONS: The implementation of standing orders encouraged the use of first-line agents but did not influence subsequent symptom resolution, length of hospital stay, or the infection-free interval in patients with acute exacerbations of COPD.