Status and cost analysis of antimicrobial treatment of terminally ill patients with hematological malignancy in an acute hospital

ObjectiveTerminally ill patients with hematological malignancy tend to be treated aggressively. We aimed to clarify the status and costs of antimicrobial treatment of patients dying with hematological malignancies.MethodsThis retrospective study was conducted in a Japanese acute hospital between September 2010 and August 2015. A total of 141 patients who stayed for 14 days or longer and died in the hospital were investigated.ResultsThe median patient age was 67 years (range, 22–93). Most patients were treated with antibacterial, antifungal, and antiviral agents (98%, 75%, and 27% of the patients, respectively) in the last 14 days of their lives. The frequency of antibiotics used in the last 7 days did not differ from that of the week before.The median cost of antimicrobials was 245,000 JPY (2227 USD), which reflected 16% of the total medical costs spent over the last 14 days. A subgroup analysis of the patients according to care policy (aggressive care policy (A) and palliative care policy (P), respectively) showed that the total medical cost in group P in the last 7 days decreased from that of the preceding week; however, the cost of antimicrobials did not lessen even in the last 7 days.ConclusionsMost patients dying with hematological malignancy were treated with a broad spectrum of antimicrobials. It appeared to be difficult to reduce, let alone discontinue antimicrobial treatment even in patients treated according to the palliative care policy. The optimal use of antibiotics for hematological patients in their end-of-life should be discussed.     

Inequalities in the Distribution of Childhood Adversity From Birth to 11 Years

ObjectiveExposure to early adversity carries long term harmful consequences for children's health and development. This study aims to 1) estimate the prevalence of childhood adversity for Australian children from infancy to 10–11 years, and 2) document inequalities in the distribution of adversity according to socioeconomic position (SEP), Indigenous status, and ethnicity.MethodsAdversity was assessed every 2 years from 0–1 to 10–11 years in the nationally representative birth cohort of the Longitudinal Study of Australian Children (N = 5107). Adversity included legal problems; family violence; household mental illness; household substance abuse; harsh parenting; parental separation/divorce; unsafe neighborhood; family member death; and bullying (from 4 to 5 years). Adversities were examined individually and summed for a measure of multiple adversity (2+ adverse experiences).ResultsBy 10–11 years, 52.8% (95% confidence interval [CI] 51.0–54.7) of children had been exposed to 2 or more adversities. When combined with low SEP, children from ethnic minority and from Indigenous backgrounds had 4 to 8 times the odds of exposure to 2 or more adversities than children from higher SEP Anglo-Euro backgrounds, respectively (odds ratio [OR] 4.3, 95% CI 2.8–6.6 and OR 8.1, 95% CI 4.4–14.8). Ethnic minority and Indigenous children from higher SEP backgrounds had increased odds of exposure to multiple adversity than similarly advantaged Anglo-Euro children (OR 1.8, 95% CI 1.4–2.3 and OR 2.3, 95% CI 1.3–4.3, respectively).ConclusionsAddressing early adversity is a significant opportunity to promote health over the life course, and reduce health inequalities experienced by marginalized groups of children.     

A federal perspective on EAPs and emergency preparedness

Federal Employee Assistance Programs (EAPs) have a long history of intervention in emergency situations, and their role has expanded since September 11, 2001. There is considerable evidence on the importance of organizational factors such as social support in protecting disaster victims from the psychological effects of trauma. The authors recommend that EAPs become integrally involved in organizations' emergency planning processes, so that such supports can be built into all aspects of plans. EA professionals should function as organizational consultants, not simply as helpers who will eventually care for those affected. Two federally based case studies provide examples of EA professionals who have successfully used such an approach in their respective organizations.     

Anticipating Demand for Emergency Health Services due to Medication-related Adverse Events after Rapid Mass Prophylaxis Campaigns

Objectives: Mass prophylaxis against infectious disease outbreaks carries the risk of medication‐related adverse events (MRAEs). The authors sought to define the relationship between the rapidity of mass prophylaxis dispensing and the subsequent demand for emergency health services due to predictable MRAEs. Methods: The authors created a spreadsheet‐based computer model that calculates scenario‐specific predicted daily MRAE rates from user inputs by applying a probability distribution to the reported timing of MRAEs. A hypothetical two‐ to ten‐day prophylaxis campaign for one million people using recent data from both smallpox vaccination and anthrax chemoprophylaxis campaigns was modeled. Results: The length of a mass prophylaxis campaign plays an important role in determining the subsequent intensity in emergency services utilization due to real or suspected adverse events. A two‐day smallpox vaccination scenario would produce an estimated 32,000 medical encounters and 1,960 hospitalizations, peaking at 5,246 health care encounters six days after the start of the campaign; in contrast, a ten‐day campaign would lead to 41% lower peak surge, with a maximum of 3,106 encounters on the busiest day, ten days after initiation of the campaign. MRAEs with longer lead times, such as those associated with anthrax chemoprophylaxis, exhibit less variability based on campaign length (e.g., 124 out of an estimated 1,400 hospitalizations on day 20 after a two‐day campaign versus 103 on day 24 after a ten‐day campaign). Conclusions: The duration of a mass prophylaxis campaign may have a substantial impact on the timing and peak number of clinically significant MRAEs, with very short campaigns overwhelming existing emergency department (ED) capacity to treat real or suspected medication‐related injuries. While better reporting of both incidence and timing of MRAEs in future prophylaxis campaigns should improve the application of this model to community‐based emergency preparedness planning, these results highlight the need for coordination between public health and emergency medicine planning for infectious disease outbreaks to avoid preventable surges in ED utilization.     

Coaching older adults discharged home from the emergency department: The role of competence and emotion in following up with outpatient clinicians

ObjectiveMotivating older adults to follow up with an outpatient clinician after discharge from emergency departments (ED) is beneficial yet challenging. We aimed to answer whether psychological needs for motivation and discrete emotions observed by care transition coaches would predict this behavioral outcome.MethodsCommunity-dwelling older adults following ED discharge were recruited from three EDs in two U.S. states. We examined home visit notes documented by coaches (N = 725). Retrospective chart reviews of medical records tracked participants’ health care utilization for 30 days.ResultsObserved knowledge-based competence predicted higher likelihood of outpatient follow-up within 30 days, while observed sadness predicted a lower likelihood of follow-up within seven days following discharge. Moreover, participants who demonstrated happiness were marginally more likely to have an in-person follow-up within seven days, and those who demonstrated knowledge-based competence were more likely to have an electronic follow-up within 30 days.ConclusionsKnowledge-based competence and emotions, as observed and documented in coach notes, can predict older adults’ subsequent outpatient follow-up following their ED-discharge.Practice implicationsIntervention programs might encourage coaches to check knowledge-based competence and to observe emotions in addition to delivering the content. Coaches could also customize strategies for patients with different recommended timeframes of follow-up.     

MicroRNA-1301 induces cell proliferation by downregulating ICAT expression in breast cancer

Breast cancer is one of the most common malignancies among gynecological diseases in the world and the long-term prognosis for breast cancer patients still remains dismal due to lack of effective early diagnosis biomarkers. Identifying sensitive and specific biomarkers in carcinogenesis may improve diagnostic and therapeutic strategies for this malignancy. Herein, we show that the expression of miR-1301 was markedly upregulated in breast cancer cell lines and tissues, and upregulation of miR-1301 enhanced, whereas downregulation of miR-1301 inhibited the proliferation of breast cancer cells in vitro. Furthermore, by biological approaches, we showed that miR-1301 directly targeted and suppressed ICAT expression, an important modulator of Wnt/β-Catenin pathway. These data suggests that miR-1301 may represent a novel therapeutic target of microRNA-mediated cell proliferation in breast cancer.     

Detecting central-venous oxygen desaturation without a central-venous catheter: Utility of the difference between invasively and noninvasively measured blood pressure

ObjectiveThe objective was to determine whether central-venous oxygen saturation (ScvO₂ < 70%) can be detected from the difference between invasively and noninvasively measured systolic blood pressure (BP) (ie, ΔBP defined as arterial BP minus noninvasive BP).MethodsThis is a cross-sectional study at a single medical and surgical intensive care unit in Japan. All hypotensive patients admitted to intensive care unit were eligible. Arterial BP was measured via a radial-artery catheter, and noninvasive BP on the same side was measured via a brachial cuff. ScvO₂ was measured by gas analysis of blood sampled from a central-venous chatheter (CVC). We calculate the area under the curve for ΔBP as an indicator of ScvO₂ < 70%.ResultsUsable data were obtained from the records of 111 patients. The median and interquartile range of ΔBP and ScvO₂ were − 4 mm Hg (− 11, 6) and 67% (60.9, 73.9), respectively. The area under the curve of ΔBP as an indicator of ScvO₂ < 70% was 0.81 (95% confidence interval [CI], 0.73-0.89). With a cutoff ΔBP of 0, sensitivity was 65.7% (95% CI, 53.1-76.8), specificity was 97.7% (95% CI, 88.0-99.8), and positive predictive value was 97.8 (95% CI, 88.2-99.9).ConclusionsΔBP can indicate whether ScvO₂ is lower than 70%. When that difference is greater than 0, ScvO₂ is very likely to be lower than 70%.     

Systematic review of the association of mastication with food and nutrient intake in the independent elderly

Substantial number of elderly people suffer from poor mastication, which is considered to have a detrimental effect on their dietary habits. However, the association between mastication and diet is far from conclusive. The objective of this systematic review was to assess the association of mastication with food and nutrient intake in the community dwelling elderly. We searched the PubMed, Web of Science, Cochrane Library, and Scirus databases to obtain information on the epidemiological studies in this research area. The included publications were analyzed for study design, main conclusions, and strength of evidence. A comprehensive quality assessment of all the included studies (28 cross-sectional and 7 intervention studies) was performed. In 22 of the 28 cross-sectional studies, elderly persons with better mastication and dentition reported significantly higher consumption of foods and intake of some nutrients than those with poorer oral health; however, the remaining studies showed no such differences. Five of the 7 intervention studies with an intervention involving the provision of new prostheses did not show significant improvement in food and/or nutrient intake. These discrepant findings suggest that masticatory ability explains only part of the variance in food and nutrient intake of the elderly. Two intervention studies with the combination of prosthetic treatment and dietary intervention produced changes in intake of foods such as fruits and vegetables.